Misplacement of a nasogastric feeding tube: a case report.

Nasogastric tube (NGT) insertion is widely used for enteral feeding. After blind insertion of a NGT, confirmation of correct placement prior to feeding using reliable methods is mandatory. NGT misplacement in the respiratory tract can lead to serious complications. We report a case of a patient with dysphagia and malnutrition that needed enteral feeding as nutritional support. A NGT was blindly inserted, and its gastric position was confirmed through air insufflation and epigastric auscultation. Enteral feeding was initiated. Few hours later, the patient presented with respiratory distress. An urgent thoracic computed tomography was requested due to suspiction of pulmonary embolism, which revealed the NGT in the respiratory tree and a pneumonia in the lower lobe of the right lung. The NGT was removed, a new insertion was attempted and its gastric position was confirmed by radiography. Enteral feeding was initiated uneventfully. This case highlights the need for use of reliable methods of confirming tube location in order to avoid complications of misplacement.