Malpositioned Nasogastric Tube

A 67-year-old woman, who had hypertension and chronic obstructive pulmonary disease, presented to the emergency department with mild abdominal discomfort and shortness of breath. A chest film revealed free air under the diaphragm. A right hemicolectomy for a perforated colon was performed during an emergent exploratory laparotomy. Dr Luis Taylor of Watsonville Community Hospital, Watsonville, Calif, reported that postoperative broad-spectrum antibiotics, a dopamine drip, fentanyl, and propofol were administered. The patient was sedated and intubated, and mechanical ventilation was started. Blood pressure was 90/50 mm Hg; heart rate, 110 beats per minute; and respiration rate, 18 breaths per minute. The lungs were clear; the heart rate was regular, without murmurs; and no edema or cyanosis of the extremities was detected. Arterial blood gas levels included a pH of 7.48; PaCO₂, 36 mm Hg; and PaO₂, 161 mm Hg on a fraction of inspired oxygen of 50%. The hemoglobin level was 12.3 g/dL, and white blood cell count was 22,000/μL. Other laboratory values were sodium, 137 mEq/L; potassium, 5.1 mEq/L; chloride, 103 mEq/L; bicarbonate 21 mEq/L; blood urea nitrogen, 49 mg/dL; and creatinine, 1.5 mg/dL. No drainage was obtained from a nasogastric tube that was inserted postoperatively and connected to low suction. A chest film (A) demonstrated that the tube was incorrectly positioned through the sides of the endotracheal tube and into the tracheobronchial tree in the posterior lateral segment of the left lower lobe. Lead wires also were present in the chest; possibly, these wires confused the clinician during tube insertion. A second chest film (B) obtained 2 hours later showed a left-sided pneumothorax without mediastinal shift. The patient subsequently died of complications related to the pneumothorax. Always obtain a chest film to check the placement of a nasogastric tube. Even in an intubated patient, a nasogastric tube may be inadvertently inserted into the trachea and distal airway without creating an air leak, triggering the ventilator alarm, or causing significant hypoventilatory blood gas abnormalities. In this patient, the malpositioned nasogastric tube likely caused the pneumothorax.