Noninvasive ventilation and intubation.

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.2 Massive gastric distention in intubated patients has been reported as an early marker for the defective airway,6 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,5 the left upper quadrant of the abdomen was noticed to distend during the application of positive pressure and to deflate during expiration,5 in a similar way as the polythene bag at the end of the nasogastric tube 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.7 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.