CASE REPORT zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Lung Perforation by zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA CLINICAL NUTRITION zyxwvutsrqponmlkjihg (1984) 2: 197-199 Nasogastric Feeding Tubes zyxwvutsrqponmlkj W . Druml, G. Kleinberger, W . Base, J. Huller, A. Laggner and K. Lenz 1st Department of Medicine (Head: Prof. Dr Dr. E. Deutsch), University of Vienna, Vienna, Austria Reprint requests to: Dr. W. Drum], I. Med. Univ. Klinik, Lazarettg. 14 A-l 090 Wien, Austria zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQ ABSTRACT Endotracheal misdirection of narrow bore nasogastric feeding tubes resulted in perforation of the lung, pneumothorax and hydrothorax in two intensive care patients. Both were intubated with cuffed endotracheal low pressure tubes, one patient was on respirator therapy with neuromuscular relaxation. Feeding tubes were inserted by experienced personnel with the assistance of a steel stylet without difficulties. Aspiration of fluid was misinterpreted as proof of correct positioning, the liquid being however pleural elision and not gastric juice. Similarly auscultation of gurgling sounds in the upper epigastrium was not a reliable sign of intragastric position. Insertion of nasoenteric feeding tubes may be complicated by perforation of the upper gastrointestinal tract and lung in poorly responsive patients with cuffed endotracheal devices during neuromuscular blockage. In these patients a laryngoscope and forceps should be used to ensure free passage of the tube into the oesophagus. RGntgenographic confirmation of correct positioning of the tube immediately after insertion is mandatory. INTRODUCTION Enteral nutrition via nasoenteric feeding tubes is increasingly used in nutritional support of intensive care patients. Among the advantages of this technique are the prevention of stress induced gastric erosions [l], the normalisation of intestinal motility [2], a better metabolic control [3] and the low risk of serious side effects [4]. There is however an increasing number of reports that tube feeding can be associated with complications. Diarrhoea, electrolyte derangements, hyperosmolar coma and sepsis [5,6] have been observed. Because of their low rigidity fine bore tubes often require a guide wire for insertion and placement itself can result in perforation of the pharynx [7], oesophagus [8], stomach [9] and duodenum [lo]. Moreover, endotracheal misdirection [11,12] with intrapulmonary infusion of nutrients and acute respiratory distress syndrome [ 131 and perforation of the lung in chronically debilitated patients [14,15] have been observed. We report two patients who were intubated with cuffed nasotracheal low pressure tubes and in whom insertion of nasogastric feeding tubes caused lung perforation and intrapleural displacement of the tubes. The usual methods for confirmation of correct positioning (propulsion of air and auscultation above the stomach, aspiration of fluid) were falsely positive and hence not reliable. CASE REPORTS &se I: A 65-year-old patient was transferred to the Intensive Care Unit (ICU) following a cardiac arrest. The patient had suffered from chronic glomerulonephritis and had received regular haemodialysis treatment for 5 years. He had suffered a myocardial infarction on two occasions. Cardiopulmonary resuscitation was successful but the patient required ventilatory support for more than 24 h and remained intubated with a cuffed nasotracheal low pressure tube for a tirther 2 days. On the second day of admission a nasogastric feeding tube (Entriflexa feeding tube) was inserted with the assistance of a guide wire. The tube was advanced without difficulty. A yellowish fluid could be aspirated and insufFlation of air caused bubbling sounds in the upper epigastrium and both signs were taken as proof of intragastric position. An X-ray of the thorax was misinterpreted as having been performed before insertion with the tube lying on the outside of the thorax. Ion exchange resins, antacids and a nutritional solutjon were administered through the feeding tube. On the next day the X-ray showed a right sided pleural elision and the mercury filled tip of the tube positioned in the right phrenocostal sinus. A thoracostomy tube was inserted and the pleural cavity was irrigated. The pleural effision grew Klebsiella pneumoniae and antibiotic treatment was started. On the following day ventricular fibrillation occurred and the patient died in cardiac arrest. At autopsy a massive left ventricular myocardial infarction was seen. There was only a mild fibrinous pleuritis. zyxwvutsrqponmlkjihgfedcbaZYXWVUTS Case 2: A 32-year-old man with a long history of alcohol abuse was transferred to the ICU from a regional hospital because of 197