Correspondence

Accidental Pneumothorax from a Nasogastric Tube

N Engl J Med 1996; 335:1325-1326October 24, 1996

Article

To the Editor:

We report an instance of the intrapleural administration of charcoal due to penetration of the pleura by a transbronchial nasogastric tube.

A 37-year-old woman jailed for public intoxication was transferred to our center. Before her transport, a nasogastric tube was inserted through which 180 ml of activated charcoal slurry was lavaged to treat a suspected ingestion of drug. On her arrival, the patient was awake but lethargic, with a Glasgow coma score of 15. Her voice was minimally hoarse, and her vital signs normal.

Portable chest radiography revealed a pneumothorax and nasogastric intubation of the right mainstem bronchus, with the tip of the tube situated along the right costophrenic sulcus (Figure 1Figure 1Chest Radiograph Showing Misplacement of a Nasogastric Tube.). The tube was removed, and a closed-tube thoracostomy was performed. The thoracostomy tube returned approximately 500 ml of charcoal slurry and was lavaged with sterile saline until the fluid was clear. The patient's recovery was uneventful.

The rate of inadvertent insertion of nasogastric and nasoenteric tubes into the trachea and distal airways ranges from 0.3 percent to 15 percent.1,2 Both penetration of the airways and the introduction of various chemicals into the lung and pleural spaces may occur before it is recognized that the tube has been misplaced. Such misadventures can be fatal.3

The physical examination is often a poor predictor of tube malposition, especially in a patient with an obtunded mental state. The placement of a nasogastric tube is often first evaluated by aspirating fluid from the proximal port2 or insufflating air and auscultating the abdomen to induce a “pseudoconfirmatory gurgle.”4 Both maneuvers may yield false positive results.

Radiographic imaging is commonly used to confirm the position of the tube and is strongly recommended before the tube is used for enteral feeding or the instillation of drugs or other material. However, the radiograph can be misinterpreted. Hendry et al.3 reported that among 11 patients with malpositioned nasogastric tubes who all had radiography to determine the tube placement, the malpositions were not identified in 3 (27 percent).

Despite its occasional fallibility, radiographic confirmation of tube placement should be mandatory before material is lavaged through a nasogastric tube. This, along with a keen awareness of the potential morbidity and mortality associated with the tubes, will help minimize such events.

Bruce Thomas, D.O.
David Cummin, M.D.
Robert E. Falcone, M.D.
Grant Medical Center, Columbus, OH 43215

4 References

1. 1

   Boyes RJ, Kruse JA. Nasogastric and nasoenteric intubation. Crit Care Clin 1992;8:865-878
   Web of Science | Medline

2. 2

   Nakao MA, Killam D, Wilson R. Pneumothorax secondary to inadvertent nasotracheal placement of a nasoenteric tube past a cuffed endotracheal tube. Crit Care Med 1983;11:210-211
   CrossRef | Web of Science | Medline

3. 3

   Hendry PJ, Akyurekli Y, McIntyre R, Quarrington A, Keon J. Bronchopleural complications of nasogastric feeding tubes. Crit Care Med 1986;14:892-894
   CrossRef | Web of Science | Medline

4. 4

   Torrington KG, Bowman MA. Fatal hydrothorax and empyema complicating a malpositioned nasogastric tube. Chest 1981;79:240-242
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   Amgad S. Hanna, Christopher R. Grindle, Alpesh A. Patel, Marc R. Rosen, James J. Evans. (2011) Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. American Journal of Otolaryngology
   CrossRef

2. 2

   J. Braun, T. Bein, C.H.R. Wiese, B.M. Graf, Y.A. Zausig. (2011) Ernährungssonden bei kritisch kranken Patienten. Der Anaesthesist 60:4, 352-365
   CrossRef

3. 3

   Z. Yang, Q. Zheng, Z. Wang. (2008) Meta-analysis of the need for nasogastric or nasojejunal decompression after gastrectomy for gastric cancer. British Journal of Surgery 95:7, 809-816
   CrossRef

4. 4

   Thomsen, Todd W., Shaffer, Robert W., Setnik, Gary S., . (2006) Nasogastric Intubation. New England Journal of Medicine 354:17,
   Full Text

5. 5

   Sandip A. Godambe, Jennifer W. Mack, David S. Chung, Robert Lindeman, Craig W. Lillehei, Andrew A. Colin. (2003) Iatrogenic pleuropulmonary charcoal instillation in a teenager. Pediatric Pulmonology 35:6, 490-493
   CrossRef

6. 6

   Maurizio Buscarini, John P Stein, Michael A Lawrence, Gary Lieskovsky, Donald G Skinner. (2000) Tube gastrostomy after radical cystectomy and urinary diversion: surgical technique and experience in 709 patients. Urology 56:1, 150-152
   CrossRef

7. 7

   S. Kannan, B. Morrow, G. Furness. (1999) Tension pneumothorax and pneumomediastinum after nasogastric tube insertion. Anaesthesia 54:10, 1012-1013
   CrossRef

8. 8

   Russell Gruen, Richard Cade, Dominic Vellar. (1998) PERFORATION DURING NASOGASTRIC AND OROGASTRIC TUBE INSERTION. ANZ Journal of Surgery 68:11, 809-811
   CrossRef

9. 9

   (1997) Mandatory Radiographs after Tube Placement. New England Journal of Medicine 336:15, 1108-1109
   Full Text

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