Intrapleural feeding tube placement—an uncommon complication!! Free

Narrow bore enteral feeding tubes were originally introduced to avoidthe complications associated with large bore feeding tubes e.g. erosive complications and ulcerations (1,2,3). They are made from silastic tubes, softer and thus lead to higher patient comfort. However their use is not without risk and complications. Tracheopulmonary injuries are associated with their usage and can be attributable to their small size and stiffnessof the inner stylet ( 1,5-8)We wish to draw attention to our experience of insertion of a feeding tubein the pleural cavity.A 48 year old extremely cachectic and malnourished lady, with a six months history of weight loss and a background of anorexia nervosa presented with severe lower body oedema, dyspnoea and albumin of 15 gm/l.She was initially treated for a presumed pulmonary oedema but needed tracheal intubation and mechanical ventilation later on.A narrow bore feeding tube, CORFLO 8 FR. (2.8 mm) with stylet was introduced using a laryngoscope and McGill Forceps. No cough, hiccups or unusual haemodynamic parameters were observed. CT scans of abdomen and chest were then performed. The CT chest showed massive bilateral pleural effusions, and the feeding tube was found to have gone through the trachea, bronchi and exit in the left pleural cavity sitting very close to the left ventricle. The feeding tube was used to aspirate nearly 100 ml of pleural fluid and then pulled out. Subsequently the patient had bilateral chest drains inserted and nearly 1.5 litres of pleural fluid were aspirated. Chest X ray showed no signs of pneumothorax.24 hours later, patient developed left sided pneumothorax; presumably because of a broncho-pleural fistula, a known sequel of such a complication (10,11) The pnuemothorax resolved within the next 24 hours with no untoward incident. The lady had another feeding tube placed and was managed for a chest infection and anorexia nervosa. She made a successful recovery from ICU after nearly 6 weeks.Misplacement of feeding tubes in the tracheobroncial or pleural cavity is not unknown. The largest study suggested the malposition rate at 1.3% based on radiographic detection(2,9) Intubated and paralyzed patients are at higher risk of misplacement because of the alteration of the normal anatomical alignment of the oesophagus (1, 2) Experience of the person placing the tube did not reducethe risk (1,)

Easy placement, absence of cough and most importantly auscultation ofair insufflations do not necessarily mean the feeding tube is in the rightplace (1, 2)

To our knowledge this is the first case report of such a complicationin a severely malnourished patient with Anorexia Nervosa.

References:(1)Athos J Rassias1 , Perry A Ball and Howard L Corwin.A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Critical Care 1998, 2:25-28

2. R. Kawati, S. Rubertsson (2005) Malpositioning of fine bore feeding tube: A serious complication. Acta Anaesthesiologica Scandinavica 49 (1), 58-61.

(3)Jackson RH, Payne DK, Bacon BR: Esophageal perforation due to nasogastric intubation. Am J Gastroenterol 1990, 85:439-442

(4)Sofferman RA, Hubbel RN: Laryngeal complications of nasogastric tubes. Ann Otol Rhinol Laryngol 1981, 90:465-468. [PubMed Abstract] (5)Hendry PJ, Akyurekli Y, Mclntyre R, et al.: Bronchopleural complications of nasogastric feeding tubes. Crit Care Med 1986, 14:892-894

(6)Olbrantz KR, Gelfand D, Choplin R, et al.: Pneumothorax complicating enteral feeding tube placement. JPEN 1985, 9:210-211.

(7)Bohnker BK, Artman LE, Hoskins WJ: Narrow bore nasogastric feedingtube complications. Nutr Clin Pract 1987, 2:203-209.

(8)Odocha O, Lowery RC, Mezghebe HM, et al.: Tracheopleuropulmonary injuries following enteral tube insertion. J Natl Med Assoc 1989, 81:275-281

(9) McWeyRE, Curry NS, Schabel SI, Reines HD.Complications of nasoenteric feeding tubes. Am J Surg 1988; 253-7(10)Ross O'Neil, Ruben Krishnananthan (2004) Intrapleural nasogastric tubeinsertion.Australasian Radiology 48 (2), 139-141(11)C. Kolbitsch, A. Pomaroli, I. Lorenz, M. Gassner, T. J. Luger , Pneumothorax following nasogastric feeding tube insertion in a tracheostomized patient after bilateral lung transplantation, Intensive Care Medicine Volume 23, Number 4 / April, 1997(12)Jain Bhaskara Pillai, Annette Vegas and Stephanie Brister Thoracic complications of nasogastric tube: review of safe practice, Interact CardioVasc Thorac Surg 2005;4:429-433

(13)Dr. Divatia J. V. Dr. Bhowmick K. Complications of endotracheal intubation and other airway management procedures/complications of endotracheal intubation Indian J. Anaesth. 2005; 49 (4) : 308 -318

Conflict of Interest:

None declared