Tension Pneumothorax Following Nasogastric Tube Placement -A Case Report

ABSTRACT

Introduction: Naso-(NGT) and oro-gastric tubes play an integral role in the nutritional support of patients who are not able to meet dietary needs through independent oral consumption. Although uncommon, serious pulmonary complications may arise from this mostly blindly performed procedure (0.2-2%). We report a case of an elderly female who developed a right-sided tension pneumothorax (PTX). necessitating tube thoracostomy following NGT misplacement. Case Our patient is a 79-year-old elderly female woman with no known past medical history who was admitted for altered mentation and hypoxemia due to COVID-19. Although her initial course was complicated by progressive respiratory failure requiring ICU admission and initiation of high-flow nasal cannula, she was quickly weaned to nasal cannula and transferred to a regular floor. Due to poor mentation and inconsistent food intake, enteral access was attempted using a weighted-tip 10 FR NGT. The patient had mild cough and discomfort during the procedure. There was no resistance during insertion. After advancement to 55 CM the patient ceased coughing and the procedure was completed. Chest X-ray (CXR) obtained as part of routine post-procedural evaluation revealed an intra-pleural NGT abutting the R hemi-diaphragm (Figure) and small PTX. Follow-up CXR revealed enlarging PTX with mediastinal shift to the left for which emergent thoracostomy utilizing a 14FR pig-tail catheter was performed. There was complete resolution of the pneumothorax with removal of the chest tube three days later. The patient was discharged home shortly after. Discussion: NGT placement is commonly performed by healthcare providers of varying degrees of expertise and experience. Risk factors associated with complications include multiple attempts, insertion at night, presence of artificial airway and altered mentation, among others. In case of trans-pulmonary placement, withdrawal of intra-pleural NGTs is associated with high risk of pneumothorax and requires close observation. To decrease the likelihood of malposition, a two-step radiograph, gradual progression technique can be deployed if fluoroscopic placement is not available. This should be strongly considered in patients at high risk for adverse events. Conclusions: Blind insertion of NGT using traditional techniques may be of limited safety and put patients at risk of complications. This is particularly true in those who are critically ill, frail or experiencing altered mentation. Institutional protocols to identify patients at high risk on whom blind placement should not be attempted are warranted. Post-withdrawal CXR to rule-out the presence of tension physiology is highly recommended.