To the Editor:
We have read with interest the excellent letter of Dr. Rampaul and colleagues (CHEST; July 1999) regarding the "breathing bag" sign in the early diagnosis of tracheoesophageal fistula (TEF) in patients receiving positive pressure ventilation. The phasic inflation and deflation of the nasogastric bag with respiratory excursions is reported by them as not previously described.
In our experience, we described in 1996 a preexisting unrecognized TEF in an acute respiratory failure patient that was discovered at the moment of starting positive pressure ventilation. Only a few cases of asymptomatic TEF presenting immediately for the first time in patients receiving positive pressure ventilation have been previously reported during surgical general anesthesia,[3-5] but not among adult ICU patients. We were also able to see this breathing bag sign in our patient and were tempted to describe it in the same way as Rampaul and colleagues. However, we found in one of these previous reports that Dakaraju and colleagues in 1974 had already described how "the polythene bag, which had been placed over the end of the nasogastric tube, ballooned out each time the lungs were inflated" in a 20-year-old woman receiving mechanical ventilation with a previously undiagnosed esophagobronchial fistula.
TEF associated with mechanical ventilation is an uncommon clinical problem, and making an early accurate diagnosis is quite difficult in most cases. After intubation, clinical manifestations of TEF are frequently air leak around the cuff and gastric distention. Massive gastric distention in intubated patients has been reported as an early marker for the defective airway, and this finding should alert that a communication may exist between the airway and the GI tract, and the need for a prompt appropriate diagnostic evaluation. Auscultation over the abdomen can reveal air movement synchronous with the respiratory action. Synchronous gurgling in the trachea and stomach is often present. In one patient reported by Ng et al, the left upper quadrant of the abdomen was noticed to distend during the application of positive pressure and to deflate during expiration, in a similar way as the polythene bag at the end of the nasogastric robe has been reported.[1,3]
Because abdominal distention is a common finding in as many as 50% of patients placed on mechanical ventilation, comparative analysis of gases from the stomach, ventilator, and room air have been also proposed as a simple supporting tool for the bedside clinical diagnosis of TEF in patients receiving mechanical ventilation who experience marked abdominal distention. However, we would agree along with Dr. Rampaul and coworkers that breathing bag sign might be considered a simpler method, and also a clue to the early diagnosis of TEF in patients receiving positive pressure ventilation.
Nicolas Serrano, MD, FCCP Maria-Luisa Mora, MD, PhD Hospital Universitario de Canarias Intensive Care Unit Universidad de La Laguna Tenerife, Spain
Correspondence to: Nicholas Serrano, MD, FCCP, Hospital Universitario de Canarias, Universidad de La Laguna, Intensive Care Unit, 38320 La Laguna, Tenerife, Spain; e-mail: firstname.lastname@example.org
 Rampaul RS, Naraynsingh V, Dean VS. Traeheoesophageal fistula following blunt chest trauma: diagnosis in the ICU; the "breathing bag" sign [letter]. Chest 1999; 116:267
 Serrano N, Cortes JL. An unusual presentation of tracheoesophageal fistula. Intensive Care Med 1996; 22:717-718
 Dakaraju P, Mansfield RE, Shatapathy P. Undiagnosed congenital oesophago-bronchial fistulas in adults and older children: accidental discovery under anesthesia in eases of bronchiectasis. Anesthesia 1974; 29:169-174
 Milliken RA, Pratilas V. An unusual presentation of a respiratory-oesophageal communication. Anesthesiol Rev 1975; 2:21-23
 Ng TY, Kirimli BI, Datta TD. Unrecognized tracheo-oesophageal fistula. Anesthesia 1977; 32:31-33
 Tessler S, Kupfer Y, Lerman A, et al. Massive gastric distention in the intubated patient: a marker for a defective airway. Arch Intern Med 1990; 150:318-320
 Kovitz KL, Siebens A, Brower RG. Diagnosis of tracheoesophageal fistula by analysis of gastric air. Chest 1993; 104:641-642
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