Tension pneumothorax and pneumomediastinum after nasogastric tube insertion

[Prevalence of mucosal injuries during flexible endoscopic evaluation of swallowing in the presence of a nasogastric tube]

BACKGROUND

The flexible endoscopic evaluation of swallowing (FEES) is an established low-risk examination method to assess the risk of penetration or aspiration in patients with dysphagia. FEES might be more difficult or of higher-risk when a nasogastric tube is in place.

OBJECTIVE

This study aims to identify whether the prevalence of mucosal lesions is higher when the endoscopy is carried out with a nasogastric tube in place. Pre-existing mucosal lesions were also documented.

METHODS

In a retrospective, monocentric study, a total of 918 FEES procedures routinely performed in hospitalized patients of a university hospital from January 2014 to March 2019 were evaluated. Mucosal lesions were identified and characterized for descriptive statistics.

RESULTS

In the video material analysed here, no endoscopy-related injuries were identified. However, pre-existing mucosal lesions, which often occurred as multiple lesions, were detected in 48.6% of the endoscopies. Further analysis showed that these pre-existing lesions were not worsened by the endoscopy performed.

CONCLUSION

The results demonstrate that transnasal flexible endoscopy is a safe, low-risk examination method, even in patients with a nasogastric tube. A very high number of pre-existing mucosal lesions were found, which is probably related to the previous insertion of the nasogastric tube. Due to the high number of pre-existing lesions, strategies should be developed to minimize injuries when placing nasogastric tubes.

Nasogastric tube insertion difficulty in a patient with a large goiter: A case report

Airway management under anesthesia is given special attention in patients who have large goiters. Nasogastric tube insertion may be difficult in intubated patients with large goiters. Several methods have been proposed to facilitate the insertion of nasogastric tubes in patients with endotracheal intubation; however, a standard insertion method has not been established. A 33-year-old man was admitted to our otolaryngology department for right thyroid lobectomy to remove a larger goiter. A thyroid computed tomography scan revealed a huge cystic mass with tracheal displacement. Although difficult intubation was expected, endotracheal intubation was performed successfully. An anesthesiologist attempted nasogastric tube insertion via the right nostril; however, this was not successful. Next, an angiography catheter was placed in a nasogastric tube, and the nasogastric tube was gently inserted with the patient’s neck in mild flexion. This attempt also failed. Finally, the nasogastric tube was gently inserted via anterior displacement of the cricoid cartilage. The nasogastric tube advanced up to 60 cm. Surgery was performed, and the patient was discharged with no complications on postoperative day 8.

Nasogastric/nasoenteric tube-related adverse events: an integrative review

Objective:

to analyze in the scientific literature the evidence on nasogastric/nasoenteric tube related adverse events in adult patients.

Method:

integrative literature review through the search of publications in journals indexed in PubMed/MEDLINE, CINAHL, LILACS, EMBASE and Scopus, and hand searching, was undertaken up to April 2017.

Results:

the sample consisted of 69 primary studies, mainly in English and published in the USA and UK. They were divided in two main categories and subcategories: the first category refers to Mechanical Adverse Events (respiratory complications; esophageal or pharyngeal complications; tube obstruction; intestinal perforation; intracranial perforation and unplanned tube removal) and the second alludes to Others (pressure injury related to fixation and misconnections). Death was reported in 16 articles.

Conclusion:

nasogastric/nasoenteric tube related adverse events are relatively common and the majority involved respiratory harm that resulted in increased hospitalization and/or death. The results may contribute to healthcare professionals, especially nurses, to develop an evidence-based guideline for insertion and correct positioning of bedside enteral tubes in adult patients.

Using Video-Assisted Laryngoscope (GlideScope®) to Insert a Nasogastric Tube and Prevent Pneumothorax From Incorrectly Inserted Nasogastric Tubes

When indicated, nasogastric tubes (NGT) are often inserted blindly, and the positioning is later confirmed using a chest X-ray (CX-ray). This case describes the blind insertion of an NGT in an 85-year-old nonverbal woman with advanced dementia who developed a pneumothorax (PTX) following NGT insertion. The patient had sepsis due to pneumonia and an infected decubitus ulcer. Because the patient had difficulty swallowing, NGT insertion was blindly performed by a house staff resident, and the tube entered the left lung. A portable bedside CX-ray was performed post-insertion and confirmed that the NGT was in the left lung, with left-sided PTX. An immediate CT of the chest revealed a partial collapse of the left lung. The patient was placed on a nonrebreather mask with 80% oxygen, and immediate insertion of a chest tube (12 Fr catheter) resulted in a subcomplete resolution of the PTX on the left side, with remaining apical PTX. Because an NGT was still required to feed the patient, we used a video-assisted laryngoscope (VAL) to assist with the insertion of the NGT the second time and prevent insertion in the incorrect location. We encourage physicians to consider the insertion of NGT under direct observation using VAL.

Inadvertent insertion of a nasogastric tube into the brain: case report and review of the literature

The inadvertent insertion of a nasogastric tube (NGT) into the brain of a trauma patient with skull base fractures is reported. A 52-year-old male with head trauma was referred following a car accident with an NGT in situ. Serosanguineous fluid was withdrawn from the NGT, which was considered to be an indication of gastrointestinal bleeding, and cold saline lavage was performed. Skull X-rays revealed intracranial position and coiling of the NGT and pneumocranium. The NGT was immediately removed manually. The patient finally went through neurosurgical operation because of an extradural hematoma, with normal postoperative course and outcome.

Colonoscopic versus nasogastric fecal transplantation for the treatment of Clostridium difficile infection: a review and pooled analysis

BACKGROUND

Fecal microbiota transplantation (FMT) has been demonstrated to be highly effective for the treatment of recurrent Clostridium difficile infection (CDI). However, the best route of administration has not been established. We present a pooled analysis of the reported cases of CDI treated with FMT via colonoscopy or nasogastric tube (NGT) to evaluate treatment efficacy.

METHODS

PubMed was searched for English-written articles published up to December 2011. Studies that reported cases of FMT for recurrent CDI using either colonoscopy or NGT-guided fecal infusion were reviewed.

RESULTS

A total of 182 patients from 12 published studies were identified; 148 patients received FMT via colonoscopy (colonoscopy group) and 34 patients received FMT via NGT (NGT group). The median age in the colonoscopy group as compared with the NGT group was 72 and 82 years, respectively. There were differences regarding pre-FMT treatment for CDI; 134 patients (90.5 %, 134/148) received lavage with/without antibiotic in the colonoscopy group and 34 patients (100.0 %, 34/34) received antibiotic without lavage in the NGT group, P < 0.001. A higher stool volume was used for FMT in the colonoscopy group (121 patients, 81.8 %, used 100-400 ml) than in the NGT group (33 patients, 97.0 %, used <100 ml), P < 0.001. The treatment efficacy did not differ significantly; 93.2 % (138/148) success for the colonoscopy group as compared to 85.3 % success (29/34) for the NGT group, P = 0.162. Recurrence of CDI after FMT was also similar in both the colonoscopy group (8/148 5.4 %) versus the NGT group (2/34, 5.9 %), P = 1.000.

CONCLUSIONS

Despite procedural differences, FMT via colonoscopy or NGT appears to be highly effective and safe for the management of recurrent CDI.

Case series: Tension pneumothorax complicating narrow-bore enteral feeding tube placement

Frequently, narrow-bore feeding tubes are placed in critically ill hospitalized patients without difficulty. However, due to the simplicity and relative ease of bedside placement of feeding tubes, complications, including life threatening, are often minimized. We report 3 cases of severe pleuropulmonary complications after routine bedside placement of a narrow-bore enteral feeding tubes and a review of the literature. These episodes have not only prompted our adoption of a new policy specifying the routine use of ultrasound to guide feeding tube placement in obtunded or mechanically ventilated patients but also offer recommendations post-removal of misplaced feeding tubes.

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.

Inadvertent insertion of a nasogastric tube into both main bronchi of an awake patient: a case report

The use of nasogastric tube is desirable for the short-term administration of calories when oral feeding is not possible. Although the insertion of nasogastric tubes has been described as being easy this is not without risks. An unusual case of malpositioning of a fine bore nasogastric tube into both main bronchi in a patient that was awake is reported. Respiratory complications of misplaced nasogastric tubes and the importance of a check chest x-ray following tube placement are discussed.

Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis

Nasogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. We report a case of fatal hemorrhagic shock immediately after nasogastric tube insertion in a patient undergoing debridement by video-assisted thoracoscopic surgery for mediastinitis. Emergency endoscopy showed that the bleeding came from the nasogastric tube which had perforated the esophagus and possibly tore an intrathoracic large vessel. The nasogastric tube insertion was considered to have directly produced the perforation because no esophageal perforation had been found on preoperative endoscopy. Factors contributing to the risk of esophageal perforation in this case included coexisting mediastinitis, surgical manipulation, endotracheal intubation, inability to cooperate during general anesthesia, and repetitive advancement of the nasogastric tube. Prompt clamping of the nasogastric tube or delayed insertion after failed attempts might have improved the outcome. This report illustrates the complication of massive bleeding that can occur immediately after misplaced insertion of a nasogastric tube. Extraordinary care should be taken to avoid misplacement of the nasogastric tube during insertion.

A simple technique for nasogastric feeding tube insertion

Nasogastric tubes are increasingly used in the management of a diverse group of patients who generally require short-term enteral feeding. Various techniques of insertion have been described emphasizing the fact that as yet there is no simple and safe method. Nasogastric intubation in head and neck cancer patients may be especially difficult following radiotherapy due to difficulties in swallowing secondary to edema, mucositis, abnormal anatomy and altered sensation. In this paper, we describe a simple technique that evolved from experience of passing enteral feeding tubes in head and neck cancer patients. The feeding tube is inserted through the appropriate nasal cavity, and at 21 cm (8 inches) from the anterior nares in the average adult (corresponding to a few millimeters above the arytenoids), the patient is asked to vocalize by saying 'eeeee' in a high pitched tone. The tube is then advanced into the esophagus while the patient is vocalizing. This technique has been successfully carried out in 22 consecutive patients, thereby avoiding the use of more invasive methods.

Intrapleural nasogastric tube insertion

A misplaced fine-bore nasogastric tube (NGT) might enter the bronchial tree. Pleural puncture and intrapleural passage of the tube is very uncommon but the location can often be inferred from the frontal chest radiograph. Following recognition of a NGT within the pleural space, progress films should be carefully screened for complications, particularly pneumothorax. This is often not done by staff involved in the monitoring of such patients because the staff frequently do not recognize the signs of intrapleural NGT insertion.

[Pneumomediastinum and bilateral tension pneumothorax as a complication of oxygen therapy using a nasal cannula]

We report the case of a patient who developed a subcutaneous and submucosal emphysema in association with a pneumomediastinum, a bilateral pneumothorax and a pneumoperitoneum. This complication was secondary to oxygen supply via a nasal cannula, which allowed a wrong submucosal pathway previously, created by the traumatic placement of a nasogastric tube. The evolution was uneventful. We comment the pathophysiological mechanism of such a complication and propose simple actions to prevent the reproduction.

Fatal hydrothorax due to misplacement of a nasoenteric feeding tube

Blind nasoenteric intubation was attempted in a patient with chronic parkinsonism. The tube was inadvertently misplaced and penetrated the left pleural cavity. The next day, the patient developed cardiopulmonary arrest during dietary supplement infusion. This complication ultimately led to the patient's death. We have reviewed the known complications of nasoenteric tube placement and conclude that difficult insertion in patients at risk from tube misplacement should be followed by chest radiography to confirm the correct placement of the tube before nutritional support is started.

Intracranial placement of a nasogastric tube after severe craniofacial trauma

Complications of intracranial placement of a nasogastric tube in patients with complex facial and skull base fractures are infrequent, though the associated morbidity and mortality are high. In such situations some authors advocate craniotomy to allow removal of the tube in several linear segments under direct visualization. Others advise tube removal nasally under antibiotic coverage. We present a case of complex craniofacial fracture in which a nasogastric tube was positioned intracranially 48 hours after admission. The tube was quickly removed through the nose, and the patient was discharged without neurologic problems.