Inadvertent endobronchial intubation with nasogastric tube. Occurrence after head and neck surgery

Monitoring Feeding Tube Placement

The purpose of this literature review is to describe currently available bedside methods to determine feeding tube placement. Described first are methods used at the time of blind insertion to distinguish between gastric and respiratory placement and gastric and small-bowel placement. Discussed next are methods used after feedings are initiated to determine if the tube has remained in the desired position in the gastrointestinal tract. Some of the methods are research-based, whereas others are opinion-based. The level of accuracy of the methods discussed in the review varies widely. No sure non-radiographic method exists to differentiate between respiratory, esophageal, gastric, and small bowel placement of blindly inserted feeding tubes in the fed or unfed state. However, a combination of some of the simpler and more accurate methods may be used to guide feeding tube placement during insertion and help identify the point at which an abdominal radiograph is most likely to confirm the desired location. In addition, methods described in this review can help determine when a radiograph is needed to confirm that a feeding tube has remained in the correct position after the initiation of feedings. Minimizing the number of radiographs taken to assure correct tube placement is important, especially in young children and in the critical care setting where the need for radiographs for other reasons is common.

A case of a ‘lost’ nasogastric tube

Objectives:

To present the case of a ‘lost’ nasogastric tube and to highlight the importance of imaging and/or chest X-ray after nasogastric tube insertion, especially in unreliable patients.

Case report:

A 50-year-old man, undergoing radiotherapy treatment for squamous cell carcinoma of the tongue base, was admitted for pain control and nasogastric tube feeding. This patient required multiple nasogastric tubes over a two-week period. The patient repeatedly denied pulling the nasogastric tube out and we were unable to establish the exact mode of nasogastric tube removal. On one such occasion another tube was inserted and a check X-ray showed two feeding tubes; the latest one was lying in the left main bronchus and the old nasogastric tube was observed in the oesophagus, with its upper end jutting above the hypopharynx. It was apparent that the patient had somehow cut the tube and swallowed it.

Conclusion:

This case not only illustrates the importance of flexible nasendoscopy and/or chest X-ray for checking the position of the nasogastric tube, but also highlights that some patients are not tolerant of nasogastric tubes. The use of nasogastric tubes should be avoided in these patients to prevent any self-inflicted injury.

Methods and complications of nasoenteral intubation

Nasoenteral intubation is among the most common procedures performed by clinicians across all medical specialties. The most common technique for nasoenteral intubation is blind passage, as it does not require the use of sophisticated or expensive medical equipment. Unfortunately, blind placement too frequently results in trauma and is a source of significant morbidity and mortality. It is apparent that altered mental status, a preexisting endotracheal tube, and critical illness put a patient in a higher risk group for malposition and complications. Nasoenteral intubation should be attempted only with an understanding of the possibility for difficult placement and the potential complications that can arise from trauma or malposition.

Development of a clinical practice guideline for testing nasogastric tube placement

PURPOSE

A Perth metropolitan hospital group standardized changes to nasogastric tube placement, including removal of the "whoosh test" and litmus paper, and introduction of pH testing.

DESIGN AND METHODS

Two audits were conducted: bedside data collection at a pediatric hospital and a point-prevalence audit across seven hospitals.

RESULTS

Aspirate was obtained for 97% of all tests and pH was < or = 5.5 for 84%, validating the practice changes. However, patients on continuous feeds and/or receiving acid-inhibiting medications had multiple pH testing fails.

PRACTICE IMPLICATIONS

Nasogastric tube placement continues to present a challenge for those high-risk patients on continuous feeds and/or receiving acid-inhibiting medications.

Certification of staff nurses to insert enteral feeding tubes using a research-based procedure

Nutrition Support Nurse Clinicians at a Central Texas tertiary care facility have developed a research-based nasoenteric feeding tube insertion procedure that minimizes the potential for inadvertent passage of a feeding tube containing a stylet into the respiratory tract and maximizes placement of the feeding tube in the desired gastric or duodenal location. The first 79 staff nurses to be certified to use the technique had a 90% duodenal placement success rate under supervision. No bedside feeding tube insertion complications have been noted since the initiation of the certification program 6 years ago. This article describes the feeding tube insertion technique used in the certification process and the research on which it is based.

Use of a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral feeding tubes

This study was conducted to determine the reliability and validity of using a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral tubes in nonmechanically ventilated patients. It was anticipated that on inhalation, tubes properly placed in the gastric region would yield positive readings owing to positive gastric pressures. Conversely, tubes that were inadvertently placed in the pulmonary system should yield negative pressure readings owing to the negative pulmonary pressures that exist on inhalation. Forty-six subjects were enrolled in the study. Of those, 44 had positive gauge readings, and x-ray results showed that these nasoenteral tubes were in the gastric region. Two patients had negative gauge readings, and the x-rays for both of these subjects demonstrated that the nasoenteral tubes were in the pulmonary system. Thus, the findings were consistent with what was anticipated. Despite the small sample size, the results of this study indicate that this method of assessing nasoenteral tube placement may be a safe, reliable, and cost-effective method of differentiating gastric from pulmonary tube placement in this patient population.

pH testing of feeding-tube aspirates to determine placement

Although radiologic confirmation of tube placement remains the "gold standard," there is growing evidence that pH testing of feeding-tube aspirates can reduce (although not totally eliminate) reliance on x-rays used for this purpose. This article describes that evidence and tells how it was obtained. Reducing the number of x-rays needed to confirm tube position can have far-reaching financial benefits.