Feeding tube safety: National guidance ignores the 'elephant in the room'.

BackgroundNational guidance attempts to prevent tubes remaining undetected and being used when misplaced in the respiratory tract. The 'elephant in the room' is that this guidance detects misplacement too late to prevent most pneumothoraces and pneumonias.ObjectiveReview risks of undetected and detected respiratory or oesophageal tube misplacements and how 'in-procedure' methods of determining tube position might reduce them.MethodsTube misplacement risk was compared for different methods of checking tube position. Data were obtained from UK NHS England (NHSE), a literature search between 1986 and 12/07/2024 using CINAHL, Embase, Medline and Emcare and from a local database.ResultsPost-procedure pH or X-ray checks on tube position have failed to prevent a rising incidence of undetected respiratory misplacements (NEVER events) (0.013%). Worse, current checks cannot prevent the 0.52% of placements that lead to in-procedure pneumothorax, constituting 97% of lung complications. In addition, pH may fail to prevent aspiration risk from oesophageal misplacement. Conversely, pneumothorax-risk would be reduced to 0.021% by using a supplementary mid-procedure CO2 check or to 0.005% with expert guided tube placement (both p < 0.0001). Guided tube placement can additionally pre-empt oesophageal-related complications, but its safety is expert-dependent, with higher rates of undetected misplacement and pneumothorax in low-use Cortrak centres (0.10%) than expert centres (0%, p < 0.009).ConclusionThe high health burden from feeding tube-related complications could be almost eliminated if regulatory authorities recommended a mid-procedure CO2 check for respiratory placement or expert guided tube placement, alongside mandates for the necessary training.