Pulmonary Parenchymal Perforation as a Complication of Placement of a Nasoenteric Tube

Abstract

To the Editor: Nowadays, alimentation is an important aspect of the management of severely ill patients. Therapeutic use of nasogastric feeding dates back at least to John Hunter in the 1790s.1Randall HT The history of enteral nutrition.in: Rombeau JL Caldwell MD Enteral and tube feeding. WB Saunders, Philadelphia1984: 7-10Google Scholar The development of small-diameter catheters for nasoduodenal intubation has facilitated enteral feeding. The incidence of nasotracheal intubation and subsequent pulmonary complications is poorly documented. The misplacement of a nasoenteric feeding tube into the tracheobronchial tree has been reported infrequently relative to the common use of these tubes in clinical practice. From June 1983 to December 1991, 3, 875 patients were admitted to our intensive care unit. Placement of a feeding tube was attempted in 2,106 cases. In two patients, a 70-year-old woman admitted for treatment of acute respiratory failure due to pneumonia and an 80-year-old man admitted for treatment of head trauma, a nasogastric tube for nutritional support was misplaced in the pleural space (Fig 1). A chest tube had to be placed, and mechanical ventilation was required in both cases. The patients died of lung infection. Feeding tubes are frequently thin plastic catheters. Because the tube is relatively flexible, it coils easily, and passage of its tip into the duodenum may be difficult. To obviate this problem, the feeding tube is now packaged with a stiff monofilament core that may be inserted into the tube to make it more rigid. Patients at risk for pulmonary parenchymal perforation due to a nasoenteric tube misplacement are those who are neurologically depressed, who are unable to gag, or who have previously undergone multiple nasogastric intubations.2Scheinbaum KR Bakal CW Jacobson HG Chest pain in a debilitated postoperative patient.Chest. 1991; 100: 1447-1448Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Time-consuming procedures for avoiding nasotracheal intubation have been advocated but require the assistance of a variety of specialists.3Roubenoff R Ravich WJ Pneumothorax due to nasogastric feeding tubes: report of four cases, review of the literature and recommendations for prevention.Arch Intern Med. 1989; 149: 184-188Crossref PubMed Scopus (99) Google Scholar Our experience, as well as that reported in the literature, suggests that a routine chest x-ray film should be obtained and cautiously evaluated before starting tube feeding.4Scholten DJ Wood TL Thompson DR Pneumothorax from nasoenteric feeding tube insertion: a report of five cases.Am Surg. 1986; 52: 381-385PubMed Google Scholar Moreover, a change in clinical status (such as restlessness, increasing shortness of breath, or deteriorating blood gas values) after tube insertion should raise the suspicion that the feeding tube is malpositioned.5Hendry PJ Bronchopleural complications of nasogastric feeding tubes.Crit Care Med. 1986; 14: 892-894Crossref PubMed Scopus (66) Google Scholar Until 1989 only 106 cases of this complication had been reported.3Roubenoff R Ravich WJ Pneumothorax due to nasogastric feeding tubes: report of four cases, review of the literature and recommendations for prevention.Arch Intern Med. 1989; 149: 184-188Crossref PubMed Scopus (99) Google Scholar Recently, Scheinbaum et al2Scheinbaum KR Bakal CW Jacobson HG Chest pain in a debilitated postoperative patient.Chest. 1991; 100: 1447-1448Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar published another case. It seems likely that there is a great disparity between the number of incidents reported and the actual occurrence.