Down the wrong road - a case report of inadvertent nasogastric tube insertion leading to lung laceration and important pearls to avoid complications

Abstract

Nasogastric tube (NGT) insertion is a common procedure performed by residents and nursing staff to access the stomach. Although an apparently simple procedure, it is associated with technical difficulties and complications if proper care is not taken during insertion. We present a case of a 79-year-old female with multiple comorbidities who had a percutaneous enteral gastrostomy tube removed due to infection of an insertion site wound and a NGT was inserted for feeding. A few minutes post-insertion the patient developed shortness of breath and a drop in oxygen saturation. An immediate chest X-ray showed the NG tube traversing along the course of the trachea and the right main bronchus into the right upper abdomen with right-sided pneumothorax. The NG tube was immediately removed and a right chest drain inserted. Subsequent imaging showed right-sided pneumothorax with evidence of lung laceration and underlying lung collapse and diaphragmatic injury. The patient underwent a prolonged course of hospitalisation due to hospital-acquired pneumonia before being discharged upon clinical improvement. We highlight the fact that a simple and routine procedure such as NGT insertion can have devastating complications if due care is not taken. Along with a literature review, we provide and compare different methods to confirm correct placement of a NGT. The article also discusses important pearls for practising physicians and nursing staff to avoid such complications. Owing to the frequency of the procedure in hospitals and long-term care units, appropriate awareness among medical staff is necessary.

Keywords: complications; inadvertent nasogastric tube insertion tracking; nasogastric tube; percutaneous enteral gastrostomy tube; pneumothorax.

Figure 1.

(A) Frontal portable chest X-ray 1 shows an abnormal location of the nasogastric tube (black arrows). The NGT is observed as traversing along the course of the trachea and right main bronchus and is further seen to overlap the right upper abdomen. (B) Frontal portable chest X-ray 2. Imaging performed after removal of the NGT shows the appearance of mild right-sided pneumothorax (black arrow). Note the displaced pleural line (white arrow) and the appearance of a patch of right basal consolidation (star).

Figure 2.

(A) CT scan image of a chest coronal reformation lung window. It shows mild pneumothorax (black arrows). Note a linear dark line traversing the lung parenchyma (short white arrows) likely representing the site of iatrogenic lung laceration. This is a sagittal reformatted image. (B) CT scan image of a mediastinal window. It shows a thin continuous diaphragmatic slip anteriorly (black dashed arrows) which is discontinuous in the centre (white arrow), representing the site of diaphragmatic injury. The presence of pneumothorax is shown (black arrows).