Feeding tube placement in adults: safe verification method for blindly inserted tubes.

E nteral feeding is a common and necessary practice in critical care. Clinical practice for verification of smalland large-bore feeding tubes is variable. Although radiographic confirmation is the reference standard for blindly inserted small-bore tubes, it is not consistently performed to verify large-bore tubes before administration of formula or medication. These practices raise concerns; both smalland large-bore tube placement in the tracheobronchial tree have been reported. Malpositioning has also involved the intracranial cavity. In a review of more than 2000 insertions of small-bore tubes, 50 pulmonary placements (3%) were detected. In another study, the incidence of inadvertent pulmonary placement did not differ between smalland large-bore tubes. Of note, endotracheal or tracheostomy tube cuffs do not prevent pulmonary malposition. Unfortunately, pulmonary malplacement may occur silently, without coughing, dyspnea, or oxygen desaturation. Adding confusion, aspirated fluids that resemble gastric fluids have been obtained from tubes placed in the lungs. Malpositioned tubes may cause pneumonia, pneumothorax, perforations, empyema, and bronchopleural fistula—events that can lead to death in rare cases. The Joint Commission identified pulmonary malposition of nasogastric tubes as one of the most frequent procedural complications that result in postoperative sentinel events. Expert recommendation included checking tube placement with an abdominal radiograph. Also, failure to report malpositioned tubes and complications due to insertion continues to be a problem. In addition to pulmonary malposition, aspiration risk is high when tubes are placed in the esophagus A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.