A 65-year-old man was admitted to the Intensive Care Unit (ICU) for invasive mechanical ventilation after a significant intraventricular bleed. When his nasogastric tube (NGT) was accidentally removed, a new NGT was inserted blind. The pH of the thick green aspirate was under five and so enteral feeding was restarted. However, the patient subsequently deteriorated with rapidly worsening respiratory failure and invasive ventilation was required. An X-ray revealed misplacement of the NGT into the right lung with consolidation, pleural effusion, and pneumothorax. This highlights that indirect techniques to check NGT position (e.g., air insufflation and abdominal auscultation, aspirate appearance and pH) are unreliable. Even X-ray only detects misplacement after the event and mistakes have occurred because previous X-rays from the same patient have erroneously been reviewed. Only real-time visualization can prevent bronchopulmonary misplacement and the associated risks of pneumothorax and microbial contamination. The authors’ current practice is therefore to use laryngoscopy, endoscopy, or fluoroscopy for insertion of all NGT in patients in ICU with impaired airway protective reflexes.
Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2:25-8.
Sparks DA, Chase DM, Coughlin LM, Perry E. Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: A critical review. JPEN J Parenter Enteral Nutr 2011;35:625-9.
National Health Service (NHS) Improvement. Initial Placement Checks for Nasogastric and Orogastric Tubes: Resource Set. NHS Improvement; 2016. Available from: https://www.improvement.nhs. uk/uploads/documents/Resource_set__Initial_placement_checks_for_ NG_tubes_1.pdf. [Last accessed on 2017 May 10].
Lamont T, Beaumont C, Fayaz A, Healey F, Huehns T, Law R, et al. Checking placement of nasogastric feeding tubes in adults (interpretation of X ray images): Summary of a safety report from the National Patient Safety Agency. BMJ 2011;342:d2586.
Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: Review of safe practice. Interact Cardiovasc Thorac Surg 2005;4:429-33.
Bercik P, Schlageter V, Mauro M, Rawlinson J, Kucera P, Armstrong D. Noninvasive verification of nasogastric tube placement using a magnet-tracking system: A pilot study in healthy subjects. JPEN J Parenter Enteral Nutr 2005;29:305-10.
Rajendram R, Popat M. Placement of a gastric tube using a flexible intubating fibrescope. Anaesthesia 2012;67:545-6.
Kelly G, Lee P. Nasendoscopically-assisted placement of a nasogastric feeding tube. J Laryngol Otol 1999;113:839-40.
Mizzi A, Cozzi S, Beretta L, Greco M, Braga M. Real-time image-guided nasogastric feeding tube placement: A case series using Kangaroo with IRIS Technology in an ICU. Nutrition 2017;37:48-52.