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Misplaced nasogastric tube

Specialties > Peri-op medicine & anaesthesia

Differential Diagnosis Schema 🧠

Misplacement into Respiratory Tract

  • Tracheal Placement: Tube enters the trachea instead of the esophagus; risk of aspiration pneumonia if feeding begins.
  • Bronchial Placement: Tube extends into a bronchus, leading to risk of lung injury, pneumothorax, or pleural effusion.
  • Lung Parenchyma: Tube may penetrate lung tissue, causing pneumothorax or other serious complications.
  • Pleural Cavity: Tube may pass into the pleural space, particularly in patients with pre-existing lung disease.

Misplacement within the Gastrointestinal Tract

  • Esophageal Placement: Tube coils in the esophagus, increasing risk of ineffective feeding and esophageal injury.
  • Gastric Placement: Tube intended for duodenal feeding may end up in the stomach, potentially leading to reflux or aspiration.
  • Duodenal or Jejunal Placement: Misplacement further down the gastrointestinal tract can interfere with feeding plans, particularly if stomach access is needed.

Other Misplacements

  • Intracranial Placement: Rare but serious; occurs if tube is accidentally inserted into the brain through a skull fracture.
  • Oropharyngeal Placement: Tube may loop back into the mouth, especially in cases of difficult insertion, leading to immediate detection by the patient or healthcare provider.
  • Subcutaneous Placement: Rare, the tube can be misplaced into soft tissues, particularly in patients with difficult anatomy or altered consciousness.

Key Points in History 🥼

Symptomatology

  • Respiratory Symptoms: Coughing, choking, or respiratory distress during or after tube placement may indicate tracheal or bronchial misplacement.
  • Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting, or absence of aspirate may suggest misplacement within the GI tract.
  • Neurological Symptoms: Unusual symptoms such as headache or neurological changes could suggest intracranial misplacement, particularly in patients with skull fractures.
  • Feeding Difficulties: Difficulty in administering feeds or medications through the tube may indicate misplacement or obstruction.

Background

  • Past Medical History: History of difficult nasogastric tube placement, altered anatomy (e.g., due to surgery or congenital anomalies), or previous skull fractures.
  • Drug History: Review any anticoagulants or antiplatelet agents that could increase the risk of bleeding complications with misplacement.
  • Surgical History: Prior surgeries in the head, neck, chest, or abdomen may alter the normal anatomy, increasing the risk of tube misplacement.
  • Social History: Assess for factors such as impaired consciousness due to alcohol or drug use, which might complicate placement or detection of misplacement.

Possible Investigations 🌡️

Bedside Tests

  • pH Testing of Aspirate: A pH of 5.5 or below typically indicates correct placement in the stomach; a higher pH may indicate respiratory placement.
  • Auscultation: Listening for air insufflated into the tube over the stomach; not reliable for confirming placement.
  • Observation: Watching for signs of distress, coughing, or respiratory changes during tube placement, which might indicate misplacement.

Imaging and Specialist Tests

  • Chest X-ray: Gold standard for confirming tube placement; should be done after initial placement and before any feed or medication is administered.
  • CT Scan: May be required in complex cases where the tube’s path needs to be clearly defined, especially if there is suspicion of intracranial or other severe misplacement.
  • Endoscopy: Considered if there is difficulty placing the tube or confirming placement via non-invasive methods.

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Peri-op medicine & anaesthesia