Rare complication of nasogastric tube insertion

Sir,

We report a rare complication of nasogastric (NG) tube insertion. A 66-year-old woman, a known case of carcinoma hypopharynx on long-term radiotherapy and chemotherapy, diabetic, hypertensive and hypothyroid, was scheduled for tracheostomy under monitored anesthesia care. Following tracheostomy NG tube insertion was performed for further enteral feeding. Postoperative chest radiography revealed the NG tube lying in the right pleural space [Figure 1]. Patient was asymptomatic during the waiting period. The NG tube was removed immediately and she was scheduled for a feeding jejunostomy at later date. There was no radiographic evidence of pneumothorax or respiratory distress. Though insertion of a NG tube is a common clinical procedure, it can produce unexpected complications. Esophageal perforation and pleural cavity penetration are rare and serious complication. It causes severe pneumothorax commonly.[1] This case patient instead developed left-sided pleural effusion and pneumonia [Figure 2]. She developed life-threatening recurrent stable ventricular tachycardia and cardiorespiratory compromise, subsequently. She was managed conservatively and improved not requiring intercostal tube drain. Pneumonia was managed with broad spectrum antibiotics. Rassias et al.,[2] reported a 2% incidence of tracheopulmonary complications among 740 tube insertions and 0.3% mortality from the complications. Esophageal perforation, inadvertent intracranial placement, pneumothorax, and trachea bronchopleural placement are rare complications of NG tube placement. Unrecognized insertion of tube into lungs or pleural space occurs in less than 1% of cases causing pneumonitis, pneumonia, pleural effusion, and occasionally empyema.[3] Wang et al.,[4] described a case of inadvertent NG tube insertion into the right lower lobe bronchus of a 79-year-old patient despite the patient having a cuffed tracheostomy tube in situ, resulting in pneumonia and septic shock. Thus, pleural effusion and pneumonia is also possible sequel to pleural perforation following nasogastric tube insertion. Roubenoff and Ravich[5] proposed a two-step protocol for NG tube insertion, wherein tube is initially advanced blindly to 30 cm and the position is verified by chest radiograph. Then, the tube is further inserted to its adequate length and a second radiograph is taken to confirm the final position. However, this is time-consuming and would not prevent complications like esophageal perforation. Common technique of insertion is still blind and still X-ray remains the gold standard to verify the correct placement. Pneumothorax is not a definite sequale always, though a high index of suspicion is necessary. Additional caution is necessary in patients with high-risk factors like elderly, tracheotomized patients, and those with upper airway malignancy.

Figure 1.

Antero Posterior view thorax showing nasogastric tube extending into the right lower pleural space

Figure 2.

Antero Posterior view thorax showing left sided pleural effusion and pneumonia