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Potential Complications of Nasogastric Tube Placement

Clinician's Brief (Capsule)

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Nasogastric tube (NGT) placement is generally considered technically straightforward, although complications are possible. This study reported 2 canine cases in which NGTs were inadvertently advanced into the lung, resulting in iatrogenic pneumothorax. In both patients, an NGT was introduced through the nostril and advanced to the level of the gastric lumen using standard anatomic landmarks.

Right lateral chest radiographs confirmed proper placement before the tube was advanced further. In both cases, the NGT was assumed to be correctly positioned in the distal esophagus. Negative pressure was obtained on NGT aspiration. Coughing was not noted; however, further attempts to advance the tube were met with resistance. The NGT in case 1 was immediately withdrawn, but after subsequent attempt at placement, a right lateral thoracic radiograph revealed intrapleural NGT positioning with pneumothorax. The patient went into cardiorespiratory arrest but was successfully resuscitated and treated for pneumothorax. Case 2 developed respiratory distress and pneumothorax and was stabilized by thoracentesis.

These cases illustrated complications from NGT placement using a standard procedure. Critically ill and sedated patients may not exhibit a cough reflex. Obtaining negative pressure on NGT aspiration may not rule out tracheopulmonary placement, and routine radiography may not identify a problem. The authors proposed a modified Roubenoff and Ravich 2-step protocol in which the NGT is initially advanced only to the level of the fourth or fifth intercostal space, followed by cervical thoracic or lateral oropharyngeal radiography to confirm proper intraesophageal placement before final positioning. This would decrease the likelihood of advancing a misdirected tube deep enough to cause lung injury.

Commentary

This case series described a potential complication that was associated with NGT placement in 2 dogs that had not previously been reported. The article reviewed more common complications associated with NGT, including oropharyngeal trauma, epistaxis, and inadvertent tracheal intubation. The article also emphasized the use of thoracic radiography, including imaging of the cervical region, to correctly identify tube placement.—Lisa L. Powell, DVM, DACVECC

Source

Iatrogenic pneumothorax associated with inadvertent intrapleural NGT misplacement in two dogs. Gladden J. JAAHA 49:e1-e6, 2013.

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