The importance of chest X-ray during nasogastric tube insertion

Dear Editor,

We read the paper by Stawicki and Deb on the bronchial nasoenteric tube misplacement with great interest, for what we would like to extend our thanks.[1] Nasogastric tube (NGT) or nasoenteric tube misplacement and complications related to them are almost always preventable issues. Despite the presence of various radiologic and endoscopic facilities, NGT–related complications are still present. The question is to recognize when, in which case, and for what signs and symptoms to use them. We would like to share another case of bronchial NGT misplacement.

A 49-year-old female patient with chronic renal failure corrected by dialysis was admitted with a 3-day history of abdominal pain. After physical and instrumental examinations, the patient was diagnosed with complicated acute appendicitis, for which open appendectomy was performed. Since the approach was gridiron incision, intraoperative manual control was impossible. The patient was transferred to the Intensive Care Unit postoperatively because of severe chronic disease and sepsis. On the 1^st postoperative day, after extubation, the patient developed postoperative ileus, for what it was decided to insert a double lumen NGT. During NGT insertion at 30–35 cm, resistance was encountered. Chest X–ray was performed which revealed the tip of the NGT to be in the right superior lobar bronchus [Figure 1]. The tube was withdrawn and readvanced without any resistance. On control chest X–rays, no delayed complications were revealed. The postoperative course was uneventful and the patient was discharged on the 7^th postoperative day. On the follow–up after a month, the patient was well.

Figure 1.

Chest X-ray. Nasogastric tube misplacement to the right superior lobar bronchus

In the treatment of postoperative ileus, NGT is one of the most effective measures. However, NGT placement in rare cases, especially in nonexperienced hands, can lead to specific serious complications, such as bronchial misplacement, lung perforation, esophageal perforation, pneumonia, and pneumothorax.[2] Several techniques and diagnostic measures have been reported, such as the SORT maneuver which is the mnemonic for the four main steps constituting the technique: sniffing position, NGT orientation, contralateral rotation, and twisting movement.[3] In the systematic review, Bennetzen et al. found Level 2B evidence for colorimetric capnography as an accurate method for verifying NGT placement with the sensitivity and specificity reaching 100%, nevertheless, with a concern that capnographs are not manufactured specifically to fit NGT and they have to be connected to the NGT by an adaptor system.[4] Despite the diversity of methods facilitating NGT placement, chest X–ray remains the gold standard. It is worth emphasizing that for experienced physicians, the most reliable way is clinical signs and symptoms and physical examination (auscultation) with the main rule “Do not proceed if you encountered resistance.” And this is probably the point when instrumental methods could be involved. In surgical practice, the best and the most accurate method is intraoperative NGT insertion with manual control.

To conclude, NGT tube placement can lead in rare cases to serious complications. In case if resistance is faced during the first attempt, chest X–ray should be performed. If during subsequent attempts resistance is encountered, other navigating or guiding diagnostic methods should be utilized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.