Sir, A 50-year-old man with oral carcinoma was transferred to our ICU from the radiotherapy ward with a complaint of sudden respiratory distress. History indicated that the patient developed severe coughing, choking and difficulty in breathing after nasogastric tube placement. On arrival, he was awake, extremely restless and unable to maintain saturation on room air. His heart rate was 130 bpm and BP was 130/87 mmHg, with rapid and shallow respiration. Auscultation showed bilateral coarse crepts. We decided to intubate the patient. On laryngoscopy, the nasogastric tube was seen entering the vocal cords [Figure 1]. We removed the tube with a Magill's forcep and, to our surprise, about 16 cm length of it was lying inside the trachea. After 3 days of mechanical ventilation, he was transferred back to the ward after extubation and proper nasogastric tube placement, which was later confirmed by chest Xray. Nasogastric tube inside the glottis Insertion of feeding tubes although stated to be easy is not without complications, although the problem is underreported.[1] The rate of malposition of feeding tubes into the trachea and distal airways ranges from 2 to 2.5%.[1,2] Sorokin and Gottlieb (2006)[1] reported 50 cases of nasogastric tube malposition into the right or left bronchus out of 2000 tube insertions over a period of 4 years, with two mortalities. The complications are more frequently seen in the elderly, mentally unsound, neurologically impaired and critically ill patients,[3] with occasional reports in awake patients.[4] Failure to recognize a malpositioned feeding tube may lead to serious injuries to the tracheo-bronchial pleural tract, such as pneumothorax, pleural-effusion and even death.[4] Therefore, radiographic confirmation must be done before starting nutrition. Most case reports of malposition are with the use of narrow bore tubes with stiff inner guide wire.[5] In contrast, in our patient, the complication occurred with a wide bore 16F soft tube. In this patient, the tube was inserted by an inexperienced resident and the position was confirmed by auscultation only, which is often fallacious. Fortunately, no feeding or medication was instilled into the tube. Reporting such events will make the clinicians aware about the potential morbidity and mortality associated with such a simple procedure often done unsupervised by junior staff and nurses. Further, this may lead to formulation of a plan to contain this problem and, thus, enhance the safety. 1. Sorokin R, Gottlieb JE. Enhancing patient safety during feeding-tube insertion.a review of more than 2000 insertions. JPEN J Parenter Enteral Nutr. 2006;30:440–5. [PubMed] [Google Scholar] 2. 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. [PMC free article] [PubMed] [Google Scholar] 3. Methany NA, Meert KL, Clouse RE. Complications related to feeding tube placement. Curr Opin Gastroenterol. 2007;23:178–82. [PubMed] [Google Scholar] 4. Thomas B, Cummin D, Falcone RE. Accidental pneumothorax from a nasogastric tube. N Engl J Med. 1996;335:1325. [PubMed] [Google Scholar] 5. Takwoingi YM. Inadvertent insertion of a nasogastric tube into both main bronchi of an awake patient: a case report. Cases J. 2009;2:6914. [PMC free article] [PubMed] [Google Scholar] Chapter 10. Tubes and Devices A nasogastric (NG) tube is a hollow flexible plastic or silicone tube inserted through a nare, past the nasopharynx, oropharynx and into the stomach or the upper portion of the small intestine (the later referred to as naso-jejunum). NG tubes are used for feeding, gastric decompression, or gastric lavage. An NG tube used for feeding is usually softer and has a smaller lumen than tubes used for gastric suctioning / decompression. NG feeding tubes are used for patients who may have swallowing difficulties or require additional nutritional supplements. Placement of blindly inserted enteral tubes must be verified by x-ray before initial use for feedings or medication administration (Bourgault et al., 2014). Blindly inserted means there has not been direct visualization that the tube in the correct position. Sometimes normal peristalsis is interrupted (i.e., post op, in association with certain conditions). In these situations a naso gastric tube is used for gastric decompression. Removal of gastric contents can be done either by gravity or by being connected to a suction pump. In these situations, the NG tube is used to relieve gastric distention and in doing so prevent nausea and vomiting. In the event a patient swallows toxic substances, a nasogastric tube can be inserted and used to lavage or wash the stomach of its contents. NG tubes for these purposes generally have a larger lumen than tubes used for feeding purposes (Perry et al., 2018). Sometimes referred to as a Salem Sump or Levin, these tubes are double lumen. The main lumen is attached to suction, the second lumen acts as an air vent which prevents suctioning of gastric mucosa when the stomach is empty. When working with people who have nasogastric tubes, remember the following care measures:
Checklist 80 outlines the steps for inserting a nasogastric tube.
Special Considerations with NG Tubes:
Watch the video Insertion of a NG Tube developed by Renée Anderson and Wendy McKenzie (2018) of Thompon Rivers University School of Nursing. Removing a NG TubeA NG tube should be removed if it is no longer required. The process of removal is usually very quick. Prior to removing the NG tube, verify physician orders. If the NG tube is ordered to remove gastric contents, the physician’s order may state to “trial” clamping the tube for a number of hours to see if the patient tolerates oral intake or their own accumulation of gastric secretions prior to the tube removal. During the trial, the patient should not experience any nausea, vomiting, or abdominal distension. If they do experience these things, simply reattach the NG to suction. To review how to remove a NG tube, refer to Checklist 81.
Critical Thinking Exercises
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