Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care

Abstract

Purpose of review: This article reviews the thoracic complications from malpositioned blindly inserted nasogastric feeding tubes in mechanically ventilated patients in intensive care and the methods to check the position and promote safe placement of the feeding tubes. Recent findings: Malpositioned feeding tubes are not included in risk management databases. The reported incidence is 1-3% and more than half occur in mechanically ventilated patients. Eighty three mechanically ventilated patients were reported with malpositioned nasogastric tubes and 66% of them developed serious thoracic complications. Pneumothoraces accounted for 80% of thoracic complications that were evenly distributed between tubes with and without stylet. Repeated misplacements appear to increase the risk. Non-radiological confirmation of the position of the tube has suboptimal performance. Protocols to place feeding tubes and new technology are promising candidates. Summary: Malpositioned nasogastric feeding tubes are underreported and associated with serious thoracic complications in mechanically ventilated patients. We need more data to answer whether we can afford to prevent them

Post‐operative iatrogenic pneumothorax and associated mortality: lessons learnt

“…Incidence of thoracic complications following NGT insertion is reported between 1 and 3% with the majority of these being pneumothoraces and is more common in mechanically ventilated patients . NGTs are more likely to be malpositioned in the right rather than left tracheobronchial tree, which is unsurprising given that the right bronchial tree is more vertical and wider.…”

Tension pneumothorax secondary to nasojejunal feeding tube misplacement in a mechanically ventilated dog

“…Potential reasons for the higher incidence in this patient population are the absence of a gag reflex in anaesthetised patients, the size of the feeding tube and the supine position of the patient. In mechanically ventilated patients, the presence of a cuffed endotracheal tube may give the operator a false sense of security that the tube will not pass into the tracheobronchial tree, but in a report of 55 cases of malpositioned feeding tubes in intubated human patients, the operator reported a sensation of resistance to tube passage in only 9% of cases . In our clinical case, the use of a narrow‐bore enteral feeding tube with a stylet, combined with the presence of a large‐volume, low‐pressure cuffed endotracheal tube, may explain why the clinician did not feel increased resistance when pushing the feeding tube past the endotracheal tube's cuff and multiple attempts of insertion were made.…”

Lavage through malpositioned nasogastric tube: a cause of concern

“…There are four radiological signs that indicate the right position of NGT; 1) NGT path follows the oesophagus, 2) the tube bisects the carina, 3) tube crosses the diaphragm in the middle and 4) tip of the tube lies below the left hemi diaphragm. 6 Few more methods are available to control the correct position of the tube: measurement of billirubin in the aspirate and endoscopy, however in day to day practice these methods did not find broad acceptance and still the chest x-ray after the NGT placement remains the gold standard.…”