Vol.2, No.10, 1135-1141 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Blindly inserted nasogastric feeding tubes and thoracic
complications in intensive care
Elpis Giantsou*, Kevin J. Gunning
John V. Farman Intensive Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, England, UK;
*Corresponding Author: elpisgiantsou@yahoo.com
Received 4 July 2010; revised 13 July 2010; accepted 20 July 2010.
Purpose of review: This article reviews the tho-
racic complications from malpositioned blindly
inserted nasogastric feeding tubes in mechani-
cally ventilated patients in intensive care and the
methods to check the position and promote safe
placement of the feeding tubes. Recent findings:
Malpositioned feeding tubes are not included in
risk management databases. The reported incid-
ence is 1-3% and more than half occur in mech-
anically ventilated patients. Eighty three mech-
anically ventilated patients were reported with
malpositioned nasogastric tubes and 66% of
them developed serious thoracic complications.
Pneumothoraces accounted for 80% of thoracic
complications that were evenly distributed be-
tween tubes with and without stylet. Repeated
misplacements appear to increase the risk. Non-
radiological confirmation of the position of the
tube has suboptimal performance. Protocols to
place feeding tubes and new technology are
promising candidates. Summary: Malpositioned
nasogastric feeding tubes are underreported and
associated with serious thoracic complications
in mechanically ventilated patients. We need
more data to answer whether we can afford to
prevent them.
Keywords: Malpositioned Nasogastric Feeding
Tube; Thoracic Complications and Mechanical
Critically ill patients, who cannot meet their daily nutria-
nt requirements by oral intake but have a functional gas-
trointestinal tract should be considered for enteral feed-
ing [1]. Although usually considered a simple procedure
the blind placement of nasogastric feeding tubes is not
without risks. This is the reason why the National Patient
Safety Agency in the United Kingdom has recently issu-
ed a safety alert regarding the placement of nasogastric
feeding tubes in neonatal intensive care units [2]. More
than 50% of malpositioned blindly inserted nasogastric
feeding tubes occur in patients with endotracheal tube or
tracheostomy [3]. The malpositioned nasogastric feeding
tubes are not included in risk management databases,
therefore they may well be underreported. This may ex-
-plain, at least in part why the data on malpositioned
nasogastric tubes in mechanically ventilated patients are
limited. Recent data suggest that malpositioned blindly
inserted feeding tubes may cause serious thoracic com-
plications in mechanically ventilated patients. Rassias
et al. reported that of 13 mechanically ventilated patients
with malpositioned blindly inserted feeding tubes 36%
had serious complications [4]. Similarly, Mardestein
et al. reported that of 57 mechanically ventilated with
malpositioned nasogastric feeding tubes 38% had serious
thoracic complications [5]. However, these reports may
be difficult to interpret as they investigated interventions
to reduce malpositions of nasogastric and promote a
safer placement of nasogastric tubes in mechanically
ventilated patients.
This review outline the thoracic complications associ-
ated with the blind placement of the nasogastric feeding
tube for mechanically ventilated patients in intensive ca-
re, and the methods used to verify the position and pro-
mote safer gastric placement of the nasogastric tubes.
2.1. Definitions and Incidence
The development of nasogastric feeding tube is attribu-
ted to John Hunter in the late 1700s but it was not until
1976 that Dobbie and Hoffmeister developed the na-
rrow-bore soft polyvinylchloride enteral feeding tube [1].
E. Giantsou et al. / Health 2 (2010) 1135-1141
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These tubes reduced problems associated with the earlier
large-bore tubes related to the patient’s comfort and mu-
cosal ischaemia due to compression by the tube. They
usually have stylets which give stiffness and strength to
the tubing and allow easier advancement of the device.
However, not long after the introduction of narrow-bore
feeding tubes into the clinical practice complications be-
gan to be reported. In 1978 James et al. described perfo-
ration of the oesophagus and mediastinum by a narrow-
bore non-proprietary nasogastric tube in a mechanically
ventilated patient. He concluded that cardiomegaly had
resulted in significant oesophageal distortion leading to
perforation by the nasogastric tube [6].
A nasogastric feeding tube is considered malposition-
ed if it does not stay within the oesophageal lumen or if
the distal end of the tube is not below the gastrooesopha-
geal junction. To place a nasogastric tube we assume the
median distance from the anterior nasal spine to the tra-
cheooesophageal junction to be about 20 cm, the oesop-
hagus to be 25 cm long and aim for the tip of the nasog-
astric tube to lie 10cm below the gastro-oesophageal jun-
ction. Therefore, ideally the nasogatsric tube should be
secured at the 50 to 60 cm mark at the nasal vestibule [7].
Alternatively, adding the distance from the nose to the
pinna and the distance from the pinna to the xiphoid pro-
cess and adding another 5 cm, will place the tip of the
nasogatsric tube in the fundus of the stomach.
Mc Wey et al. reported an incidence of malpositioned
tubes of 1.3% of which 61% occurred in mechanically
ventilated patients [8]. Sorokin et al. reported an inci-
dence of malpositioned tubes of 1.3% of which > 50%
occurred in mechanically ventilated patients, with a pro-
cedure related rate of serious thoracic complications of
28% [3]. Mardestein et al. reported malpositioned feed-
ing tubes in 2%, of which 67.8% occured in mechani-
cally ventilated patients, with serious thoracic complica-
tions in 38% [5]. Rassias et al. found malpositioned na-
sogastric feeding tubes in 2%, of which 92% occurred in
mechanically ventilated with serious complications in
35% [4]. Nascimento et al. reported an incidence of mal-
positioned tubes in a tertiary care referral hospital of 3%
[1]. Although the figure of three malpositioned tubes in
every 100 patients that had this procedure may not seem
particularly high at first glance, the fact that 40% of the
malpositioned tubes led to pneumothorax and 4 patients
died raised the authors concern. They translated this fig-
ure into one death every three months in a tertiary care
hospital from a “simple” procedure.
2.2. Thoracic Complications in
Mechanically Ventilated Patients
Malpositioned blindly inserted nasogastric feeding tubes
were divided by Pillai et al. [7] into tubes which were
malpositioned and remained intrathoracic and tubes
which were malpositioned but did not remain intratho-
racic, the majority of which were misplaced intracrani-
ally. Eighty three patients who were mechanically venti-
lated in intensive care were reported in the literature to
have an intrathoracic malpositioned blindly inserted na-
sogastric feeding tube. Of them 55 (66%) mechanically
ventilated patients had thoracic complications from the
malpositioned nasogastric tubes that required treatment
other than observation as it is now presented in Table 1
[4,6-32]. Some patients had more than one thoracic com-
plications since 59 complications were described in 55 me-
chanically ventilated patients in intensive care (Table 1).
Table 1. Summary of thoracic complications from malpositioned nasogastric feeding tubes in mechanically ventilated patients in
intensive care.
N Reference
Patients with thoracic complications that required treatment 55 4,6-32
Complications that required treatment 59 4, 6-32
Pneumothoraces that required ICD
Side not stated
4, 6, 8-11, 13, 16,17, 21, 23-31
8-11, 13-16, 21, 23-25, 28, 29
8, 10, 14,
4, 17, 27, 30, 31
Pneumonias treated with antibiotics 9 8, 9, 14, 17, 18, 20
Knotting of NGT that needed sedation to remove it and steroids 3 19, 22, 23, 32,
Oesophageal perforation-mediastinitis treated with antibiotics 2 6, 8
Loss of tidal volume that required manual ventilation 1 12
Abbreviations: NGT, nasogastric tube; ICD, Intercostal drain.
E. Giantsou et al. / Health 2 (2010) 1135-1141
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Ninety one percent of the reported thoracic complica-
tions were tracheobronchopleural (Table 1). The comm-
onest tracheobronchial complication was pneumothorax,
which occurred more commonly on the right side and
accounted for 80% of complications. It was treated with
intercostal drains which were kept in place from a few
days up to 2 weeks. Pneumonia occurred in 16%. Others
have reported higher rates of pneumonia following a ma-
lpositioned tube. Bankier et al. reported that 40% of 10
patients developed pneumonia at the former site of the
tip of the malpositioned tube [9]. None of them had evi-
dence of pleural perforation or alimentary feeding over
the malpositioned tube. This difference between the rate
of pneumonia from malpositioned nasogastric tubes be-
tween the data of Bankier et al. and those of Malderstein
et al. may be explained at least in part by the differrent
methods used to diagnose pneumonia in mechanically
ventilated patients [5,9]. Knotting of nasogastric feeding
tube around the epiglottis or around the endotracheal tube
has been reported to cause vocal cords oedema that was
treated with removal of the nasogastric tube under direct
laryngoscopy and hydrocortisone [19]. Loss of tidal vo-
lume was described when an intrabrochially misplaced
nasogastric feeding tube produced, through its connec-
tion with negative pressure suction, constant flow of gas
out of the airways and rapid ventilator triggering [12].
The reported incidence of oesophageal perforation from
malpositioned nasogastric feeding tubes appear to be
low in mechanically ventilated patients [6,8]. The intro-
duction of soft narrow bore feeding tubes may have some
contribution to the low incidence of oesophageal perfora-
tion [10]. This complication may be more common when
intubated patients with mediastinitis have surgical ma-
nipulation or repetitive advancement of the nasogastric
tube under general anaesthesia [33].
Large volume low pressure cuffs are now in use in in-
tensive care since they cause less mucosal compression
and necrosis and reduce some of the complications asso-
ciated with long term intubation. However, because the
large volume low pressure cuffs are softer than the low
volume high pressure cuffs and remain wrinkled even
when inflated and occluding the tracheal lumen, a wire-
guided narrow-bore nasogastric feeding tube may be in-
troduced into the trachea. Moreover, endotracheal mis-
placement of a narrow-bore nasogastric feeding tube can
be facilitated by endotracheal tubes that are large com-
pared to the tracheal lumen or have a small cuff diameter
to tracheal diameter ratio. Misplacement of large bore
feeding tubes without stylet into the trachea of mechani-
cally ventilated non-sedated patients with tracheostomy
tubes of inner diameter 8.5 mm has also been reported
[18,19]. Under these circumstances the endotracheal tu-
be did not appear to act as a barrier to the passage of a
large or narrow bore feeding tube with or without stylet
down the trachea. However, sedation and obtundation
very often accompany ventilator support. Thus, the end-
otracheal or tracheostomy tube may simply be a marker
for altered or unstable mental status which in turn may
be the true risk factor that depresses the airway reflexes.
Of the 55 mechanically ventilated patients with malposi-
tioned nasogastric tubes 42 (76.36%) were sedated or
not alert.
The episodes of endotracheal misplacement of a nar-
row bore nasogastric tube were evenly distributed betw-
een tubes with and without stylet (Table 2). While stylet
migration may be a concern in cases of pulmonary per-
foration, we know no case of a bronchial perforation by
a metal stylet that slipped out of the nasogastric tube in
mechanically ventilated patient. While metal stylets may
be regarded as facilitating pneumothoraces by stiffening
the tube, insertion of a nasogastric tube may be much
easier with the stylet in place.
Woodall et al. initially suggested that narrow tipped
tubes perforated the lungs more easily than bulbous tip-
ped tubes, in their series of 17 patients insertion into the
distal bronchial tree led to pneumothorax regardless of
the tube type whereas insertion into the proximal bron-
chial tree did not [34]. The blind element of insertion
and the distance at which the tube is advanced appear to
have more significant contribution to misplacement and
the relevant complications than the type of the nasogas-
tric tube.
2.3. Diagnosis of Malpositioned Feeding
The diagnosis of malpositioned nasogastric tube inser-
tion in most of the cases reported was made by the post
procedural radiograph, which in several cases did not
occur immediately. However, there are reports where the
diagnosis occurred during the procedure, immediately
afterwards or even post hospital discharge. A 67 year old
patient was complaining of epigastric pain of 3 months
duration two years after being discharged from intensive
care following a triple vessel coronary artery bypass
graft. Endoscopy reported a gastric ulcer associated with
a tubular foreign body which was proved to be the en-
dotracheal tube that was used to facilitate the insertion of
the nasogastric tube [35].
The majority of malpositioned nasogastric feeding tu-
bes have uneventful insertion without feeling of resista-
nce or malposition. Only in 9% of the 55 cases with mal-
positioned nasogastric feeding tubes it was reported that
the operator felt sensation of resistance that alerted him
or her of the possibility of misplacement.
Radiographic and non-radiographic methods to confirm
the placement of nasogastric tubes are in use. The non-
radiographic indicators of tube placement are aspiration
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Table 2. Characteristics of the malpositioned nasogastric feeding tubes that were used in 55 mechanically ventilated patients with
thoracic complications.
N References
Malpositioned nasogastric tubes associated with thoracic complications 55 4, 6-32
Time from tube insertion to diagnosis
1. < 12 h
2. 12-24 h
3. Not stated
4,11, 14, 10, 12, 21-25, 32
4, 18, 28
6, 8, 9, 13-17, 26, 27, 29-31
Nasogastric tubes
1. with stylet
2. without stylet
3. Not stated
8, 10, 11, 13, 14, 16, 17, 21, 25
4, 9, 18,22, 26
6, 11, 12, 15, 19, 20, 23, 24, 27-32
Tube position verified by
1. X-ray only
2. Auscultation or aspiration
3. X-ray post auscultation or aspiration
4. Laryngoscopy
4, 8, 9, 12, 15-17, 20, 21-24, 27, 30
17, 18, 26, 28, 29, 31
6, 10, 11, 13, 14, 25
19,22, 23, 32
Tube insertion
1. Easy without resistance
2. Difficult
3. Not stated
4, 6, 8, 10-12, 14-16, 18, 19, 21-25
4, 23, 28, 32
9, 13, 17, 20, 26, 27, 29-31
Pneumothoraces on removal of a malpositioned NGT 5 21, 23, 24, 29
Recurrent pneumothoraces 5 9, 10, 17, 26, 27
Patient outcome
1. Discharge
2. Death
3. Not stated
4, 8, 11, 15-18, 23, 27-29
4, 6, 10, 14,17, 19, 21, 27
9, 12, 13, 17, 20, 22, 24- 26, 30-32
of gastric fluid, measurement of the gastric fluid ph and
auscultation over the epigastrium of air injected through
the nasogastric tube. The reported sensitivity of aspira-
tion and measurement of gastric fluid ph was respecti-
vely 77% and 49% whereas the reported specificity was
38% and 74% [36]. The authors suggested that the com-
bination of the three non-radiographic indicators did not
improve the sensitivity and specificity. Aspiration of
fluid should not be interpreted as appropriate placement
in the stomach because fluid aspirated may come from
the pleural space, bronchial secretions, stomach or even
brain [37]. There are several reasons why insufflation of
air with sounds heard over the left upper quadrant should
not be accepted as evidence of gastric tube placement: 1)
small bore tubes do not always allow sufficient passage
of air; 2) vigorous peristalsis may be mistaken for insu-
fflated air; 3) air bubbling in the pleura, lung, pharynx or
oesophagus may be transmitted below the diaphragm
X-ray remains the most accurate although not infalli-
ble method to verify proper nasogastric feeding tube pla-
cement [39]. Hendry et al. reported that of 11 patients
with malpositioned nasogastric tubes, all of which had
radiography for tube placement confirmation, the malpo-
sition was not identified in 27% [40]. The non-identified
malpositioned tubes in that report had been placed in the
left costophrenic sulcus which is difficult to distinguish
from intragastric placement. The practice alert issued in
2005 by the American Association of Critical Care
Nurses recommends radiographic confirmation of cor-
rect tube placement prior to initial use in all critically ill
patients receiving feedings or medications via blindly
inserted tubes. Although not explicitly stated this rec-
ommendation refers to all blindly inserted tubes regard-
less of size [41]. Within this context many institutions
now require X-ray confirmation not only of the position
of the tube in the gastrointestinal tract but also that the
ports of a nasogastric tube are in the stomach and there-
fore it is properly positioned in the gastrointestinal tract.
There are reports of patients who aspirated through na-
sogastric tubes that ended in the distal oesophagus.
Many experts and professional bodies agree that the cost
of an X-ray to confirm correct placement of a blindly
inserted tube of any size prior to its use to administer
formula or medications should be regarded as a justified
expense [42].
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X-ray may correctly identify the majority of mispla-
ced nasogastric feeding tubes and prevent intrapleural or
intrabronchial alimentation. However, it does not appear
to prevent pneumothoraces and consequently does not
spare the patients from subsequent intercostal drains and
prolonged stay in health care facilities.
2.4. Methods to Increase the Safety of Blind
Insertion of Feeding Tubes
Different methods to increase the safety of blind inser-
tion of nasogastric tubes have been developed. Direct
visualization of the larynx with laryngoscopy and poste-
rior passage of the tube has been used with positive re-
sults [43,44]. Fluoroscopy has been another option as the
tubes are radioopaque. Roubennof et al. calculated that
fluoroscopy involve 0.01 Gy/min which for a procedure
of 5 mins involves 50 mGy per fluoroscopic insertion
[45]. Ultrathin transnasal endoscopy has also been tested
in patients with oesophageal cancer and was successful
in 99% of cases [46]. However, fluoroscopy and endo-
scopy may require equipment that is not always avail-
able or transfer of a critically ill to the radiology or en-
doscopy department.
Thomas et al. used a colorimetric end-tidal CO2 indi-
cator device, that has been attached to the proximal end
of a small bore feeding tube to test, in 11 mechanically
ventilated patients, whether it would reliably discriminate
between those tubes passed into the airways and those
passed into the alimentary tract [47]. The device uses a
sulphapthalein impregnated ph-sensitive filter paper
which changes from purple to yellow in the presence of
CO2. The authors suggested that it was 100% sensitive
and specific and that the cost compared favourably to
radiographic evaluation (14.50 USD for the capnograph
detector and 60.45 for a single portable chest radiograph,
exclusive of nursing and physician’s time). This device
has also been tested by another group in a two-phase
study in mechanically ventilated patients [48]. First, the
authors reported 100% accuracy in 10 intubated patients
in whom the feeding tube was deliberately placed into
the endotracheal tube. Then they retested the method in
93 intubated patients in whom the tube was inserted in a
two-step radiological technique. After advancing the tu-
be approximately 25 cm from the lips, insertion was sto-
pped and the colorimetric determination of placement
was made before a radiograph was taken. The method
correctly identified seven of eight tracheal placements
with a sensitivity of 88% and specificity of 99%. How-
ever, with insertion of gastric tubes, especially in recum-
bent critically ill patients, gastric contents may flow back
up the tube and moisten the colorimetric indicator. In
these instances, clinicians should proceed with other
verification methods rather than rely on the colorimetric
indicator. Although promising, this technology is not
widely available. Therefore it may not be a replacement
for radiography but a method of improving safety by
preventing potential airway or lung intubation during
placement of a gastric tube.
A two-step insertion of a nasogastric feeding tube has
been tested by Mardestein et al. [5]. These authors app-
lied a protocol which required a pause when the nasog-
astric tube has reached 35cm, so that a radiograph could
confirm that the tube had not been placed in a bronchus.
If the tube was determined to be in the oesophagus, it
could be safely advanced without danger of passing into
the distal tracheobronchial tree. A second chest X-ray
was performed when the nasogastric tube was put in
place to verify the position of the tube in the stomach.
Although, this approach has been initially proposed by
Roubenof f et al., it has not been tested until Mardestein
et al. reported that with the two step approach no tube
placed in the oesophagus has caused pulmonary damage
[5,45]. The post-intervention incidence of pneumothorax
among patients having an intrabronchial feeding tube
has been reduced to 3.3% from the pre-intervention rate
of 26.9%. The contrary view was that the extra cost of
an additional X-ray for each patient with a nasogastric
tube may not be affordable on a wider scale [49]. The
argument was that we don’t have the data that would
justify system wide interventions.
Sorokin et al. applied a policy to reduce pneumotho-
races from nasogastric feeding tubes in intubated or se-
dated patients [3]. They applied three changes: 1) They
initially limited who inserted nasogastric tubes to intu-
bated or sedated patients and then evaluated the benefit
of using a safer tube and a safer two-step method of inse-
rtion. The tubes were either not advanced beyond 35 cm
until a radiograph was obtained or were advanced under
direct laryngoscopic, fluoroscopic or capnometric guida-
nce. 2) The feeding tubes malpositions and related com-
plications were monitored and reported regularly to the
clinical staff and 3) resident education program on feed-
ing tube insertion was started. The contrary view was
that smaller institutions may not afford a specialized
team devoted to feeding tube placement.
Haddad et al. used an external transmitter with an ele-
ctromagnetic pulse sensor system at the bedside to ob-
serve the location of the tip of the tube as it is manually
inserted [50]. Although not thoroughly studied prelimi-
nary reports suggest high success rates and decreased
insertion time. Bercik et al. studied a magnet – tipped
computer tracking system and compared it with simul-
taneous fluoroscopic and manometric monitoring [51].
The authors reported excellent correlation between the
three techniques.
Our review has limitations. At first it is subject to the
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problems inherent to retrospective data collection. Second
we may underestimate the rate of malpositions and com-
plications. This is so because clinicians or nursing staff
may not report all the malpositioned tubes that may
occur in the same patient, since this procedure does not
require informed consent and in several countries in-
cluding USA does not have a billing record. Additionally
patients experiencing a pneumothorax after a difficult
tube placement may have been missed if the tube had
been removed before obtaining the X-ray. Third we in-
cluded specialized and general intensive care units.
The insertion of a malpositioned nasogastric feeding tu-
be is not included in risk management databases, does
not require informed consent and may well be underre-
ported. However, it may cause serious complications in
mechanically ventilated patients that may extend the pa-
tients stay in expensive intensive care facilities. More
than 50% of mechanically ventilated patients with repo-
rted malpositioned nasogastric feeding tubes had serious
thoracic complications. Several approaches to reduce the
rate of complications have been proposed. Although a
zero complication rate is desirable the data available
does not suggest that it is affordable by smaller institu-
tions that are unable to devote the resources, either per-
sonnel or money of a specialized team or a second X-ray
for every nasogastric feeding tube or up to date technol-
ogy. Data on the complications from blindly inserted na-
sogastric feeding tubes in mechanically ventilated patie-
nts are urgently needed, to measure the accurate burden
of thoracic complications from malpositioned nasogas-
tric feeding tubes. Then we would be able to answer the
question of whether we can afford to prevent them. Until
then direct laryngoscopy to verify that the tube is in the
oesophagus, followed by X-ray as soon as possible to
confirm that all ports are in the stomach and certainly
before any use of the tube seems to be a reasonable and
affordable approach, that many clinicians apply for seda-
ted mechanically ventilated patients in intensive care.
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