Abstract
Nasogastric tube insertion is a common bedside procedure. In an awake patient, unexpected passage into airway is easily noticeable due to the gag reflex; however, in the case of ventilated patients false cannulation is liable to be missed, unless insertion is carried out under direct visualization. We present a case of passage of nasogastric tube into peripheral bronchiole of the right lung, which was initially missed on chest radiography. This case report highlights the fallacy of relying on a chest radiograph.
Introduction
A 71-year-old man presented to our trauma centre following fall from a height of 10 feet. On arrival, he was noted to be quadriplegic with sensory deficit below T12 level. Endotracheal intubation was performed in view of his laboured breathing. The rest of the primary survey was unremarkable. Nasogastric and per-urethral catheterization were performed and chest and pelvic radiographs were taken, following standard procedure as adjuncts of the primary survey. The supine Chest X-ray (CXR) showed a radio opaque shadow in the right subdiaphragmatic region (Figure 1). Contrast-enhanced computed tomography was undertaken in view of his major trauma, which incidentally revealed the presence of the nasogastric tube in the trachea adjacent to endotracheal tube, traversing the right bronchus and reaching the peripheral bronchiole, with its tip lodged almost at the right costophrenic angle. The patient could be adequately ventilated during this period. The nasogastric tube was removed after deflating the cuff of the endotracheal tube.
Supine chest X-ray showing a radio-opaque shadow in right sub-diaphragmatic region.
Discussion
A portable supine antero-posterior chest radiograph is part of the ATLS trauma protocol. Our patient was nursed on a spine board in view of suspected (and later confirmed) spinal injury. The radiological image represents a serious shortcoming of relying on this modality. Owing to its two-dimensional view, it is difficult to distinguish a subdiaphragmatic lesion from a lesion in the costo-phrenic recess of the lung. On first appearance, it appears to represent an abdominal pathology. The problem was further compounded by the fact that a single view does not adequately visualize superimposed soft tissues. 1 In addition, our patient was on a partially radio-opaque spine board when the image was taken. Spine board has been reported to reduce transmission of radiation by 9–23% in a chest x-ray.2,3
A chest radiograph after endotracheal intubation is a standard procedure to confirm the position of the tube, and may likewise be used to confirm the position of a nasogastric tube.
Several cases of nasogastric tube being accidently pushed down the trachea have been reported, with subsequent complications. Where the nasogastric tube lies in the trachea, a significant air leak leading to inadequate ventilation may occur. Other complications such as lung contusion, pneumothorax, and post-procedural pneumonia have been reported. 4 Nasogastric tube placement should be confirmed by auscultation of air insufflation over the stomach. However, normal bowel sounds may be mistaken as a bubbling tube. Confirmatory acid testing of gastric aspirate with Litmus paper is indeed the truly reliable test, as its name implies!4,5
Footnote
Follow-up chest radiograph showed normal lung fields. A central cord syndrome due to C3/C4 prolapsed intervertebral disc was demonstrated, and an anterior cervical discectomy with vertebral fixation was performed. Our patient was discharged with a tracheostomy in situ, and advised home-based physiotherapy. Prophylaxis (warfarin) against venous thrombosis was also advised. though his neurological status remained unchanged.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
