Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk

Complicated placement of a nasogastric tube in the gastric mucosa: A case report and literature review

Nasogastric tubes (NGTs) are commonly used in the intensive care unit (ICU) and are often inserted blindly at the bedside. Previous studies have highlighted various complications associated with NGT misplacement, including epistaxis, pneumothorax and even fatal perforations. To reduce the incidence of complications, guidelines recommend confirming the correct position of the NGT through radiography, pH testing, end-expiratory carbon dioxide monitoring, ultrasonography, etc. Herein, we present the case of a 78-year-old man who experienced sudden dyspnoea, was brought to the ICU and subsequently developed gastrointestinal bleeding following improper NGT placement. In this patient, air was rapidly injected down the NGT while auscultating for a 'whooshing sound' over the epigastrium. However, the correct position of the NGT was eventually confirmed by X-ray. Urgent upper gastrointestinal endoscopy revealed an oesophagogastric submucosal tunnelling of the NGT. This case emphasizes that auscultation may be unreliable and no longer encouraged. Additionally, various verification methods may not detect such rare complications related to NGT placement, making it necessary to focus on the emerging clinical manifestations following NGT insertion. Moreover, gaining further insight into the history of gastrointestinal diseases in patients may be beneficial. RELEVANCE TO CLINICAL PRACTICE: This case underscores the importance of noting resistance during a blind nasogastric tube (NGT) insertion in the intensive care unit (ICU). Additionally, the 'whooshing testing' for tube placement verification is not recommended. Although radiographic confirmation remains the gold standard, it may not effectively identify rare complications. Furthermore, emerging clinical signs (such as the abnormal nature of the gastrointestinal decompression drainage fluid, hypotension and anaemia) after insertion may suggest NGT misalignment. Finally, in urgent ICU settings, the patient's history of gastrointestinal disease should not be overlooked, as it can lead to complications such as gastrointestinal bleeding.

Feeding tube safety: National guidance ignores the 'elephant in the room'

BackgroundNational guidance attempts to prevent tubes remaining undetected and being used when misplaced in the respiratory tract. The 'elephant in the room' is that this guidance detects misplacement too late to prevent most pneumothoraces and pneumonias.ObjectiveReview risks of undetected and detected respiratory or oesophageal tube misplacements and how 'in-procedure' methods of determining tube position might reduce them.MethodsTube misplacement risk was compared for different methods of checking tube position. Data were obtained from UK NHS England (NHSE), a literature search between 1986 and 12/07/2024 using CINAHL, Embase, Medline and Emcare and from a local database.ResultsPost-procedure pH or X-ray checks on tube position have failed to prevent a rising incidence of undetected respiratory misplacements (NEVER events) (0.013%). Worse, current checks cannot prevent the 0.52% of placements that lead to in-procedure pneumothorax, constituting 97% of lung complications. In addition, pH may fail to prevent aspiration risk from oesophageal misplacement. Conversely, pneumothorax-risk would be reduced to 0.021% by using a supplementary mid-procedure CO2 check or to 0.005% with expert guided tube placement (both p < 0.0001). Guided tube placement can additionally pre-empt oesophageal-related complications, but its safety is expert-dependent, with higher rates of undetected misplacement and pneumothorax in low-use Cortrak centres (0.10%) than expert centres (0%, p < 0.009).ConclusionThe high health burden from feeding tube-related complications could be almost eliminated if regulatory authorities recommended a mid-procedure CO2 check for respiratory placement or expert guided tube placement, alongside mandates for the necessary training.

A biologically transparent illumination device is more useful in children for detecting the position of the nasogastric tube in the stomach

PURPOSE

The study aimed to evaluate the efficacy of the Biologically Transparent Illumination (BTI) device for confirming the correct placement of nasogastric (NG) tubes in children, as an alternative to X-ray, which exposes patients to radiation.

METHODS

In this prospective observational study, 106 pediatric patients (ages 0-16) undergoing NG-tube insertion after general anesthesia were evaluated. The BTI catheter was used to emit bio-permeable red light from the NG tube, which was then visually confirmed in the cervical, thoracic, and epigastric regions. X-ray confirmed NG-tube placement in all patients. The ethics committee approved the study.

RESULTS

The average patient age was 3.8 years, with a male-to-female ratio of 72:34. BTI was successfully detected in the epigastric area in 105 of 106 patients, with one 9-year-old patient having unclear BTI visibility. X-ray confirmed NG-tube placement in the stomach for all patients, resulting in a BTI sensitivity of 99%. The mean NG-tube insertion time was 38 s, and the mean abdominal thickness was 9.8 mm.

CONCLUSIONS

The BTI device proved to be a safe and effective method for NG-tube placement in children, offering a radiation-free alternative with 100% successful placement when BTI was detected in the epigastric area.

An externally validated guide to anatomical interpretation using a direct-vision ('IRIS') feeding tube

BACKGROUND & AIMS

Most of the 11.5 million feeding tubes placed annually in Europe and the USA are placed 'blind'. This carries a 1.6% risk that these tubes will enter the lung and 0.5% cause pneumothorax or pneumonia regardless of whether misplacement is identified prior to feeding. Tube placement by direct vision may reduce the risk of respiratory or oesophageal misplacement. This study externally validated whether an 'operator guide' would enable novice operators to differentiate the respiratory and alimentary tracts.

METHODS

One IRIS tube was placed in each of 40 patients. Novice operators interpreted anatomical position using the built-in tube camera. Interpretation was checked from recorded images by consultant gastroenterologists and end-of-procedure checks using pH or X-ray checked by Radiologists and a consultant intensivist.

RESULTS

The 40 patients were a median of 68y (IQR: 56-75), 70% male, mostly medical (65%), conscious (67.5%) and 70% had no artificial airway. Three tubes were removed due to failed placement. In the remaining 37 placements, novice operators identified the airway in 17 (45.9%) and airway + respiratory tract in 19 (51.4%), but redirected all these tubes into the oesophagus. By using direct vision to reduce the proportion of tubes near the airway or in respiratory tract from 0.514 to 0, operator discrimination between the respiratory and alimentary tracts was highly significant (0.514 vs 0: p < 0.0001, power >99.9% when significance = 0.05). In addition, organ boundaries (respiratory tract vs oesophagus, oesophagus vs stomach, stomach vs intestine) were identified in 100%.

CONCLUSIONS

Novice operators, trained using the guide, identified all respiratory misplacements and accurately interpreted IRIS tube position. Guide-based training could enable widespread use of direct vision as a means to prevent tube-related complications.