Tracheobronchial malposition of fine bore feeding tube in patients with mechanical ventilation

e increasing prevalence of the use of enteral feeding tubes during critical illness leads to the increased potential for malposition of the tube [1], which may result in severe complications. We report tracheo-bronchial malposition of feeding tubes in six mechanically ventilated patients. six multiple trauma patients with mechanical ventilation in the emergency ICU were included in this study. Th ey were male, aged 20 to 84 years, with an injury severity score (ISS) of 29 to 41. Five patients were intubated and one underwent tracheo-tomy. Insertion of a fi ne bore feeding tube (CH10 CM145 Bengmark naso-intestimal tube, Nutricia Medical Devices BV, Switzerland) was tried 1 to 3 days after ICU admission. Th e fi rst patient had intermittent cough accompanied by slight irritability and tachycardia during insertion. Immediate bronchoscopy confi rmed malposition of the feeding tube in the trachea. Th e feeding tube was inserted without obvious diffi culty in the following four patients. However, auscultation detected inconclusive bubbling sounds from the epigastrium after insuffl ation of air. Later, bronchoscopy for treatment of pneumonia in one patient and chest radiography in three patients revealed trachebronchial malposition of the tube before initiation of enteral nutrition. Th e sixth patient had no cough during insertion but auscultation detected slight bubbling sounds from the epigastrium after insuffl ation of air. However, chest computed tomography (CT) confi rmed tracheobronchial malposition of the feeding tube (Figure 1). Th e patient died of septic shock due to blood stream infection 12 days later. Endotracheal intubation and tracheotomy have been thought to be potential risk factors for trachebronchial malposition of the feeding tube [2]. Mechanically ventilated patients have poor response due to sedation. Th e metal stylet and weighted tip contribute to the rigidity of the feeding tube, which may be easy to pass through the space between the tracheal wall and infl ated cuff. It has been advised to monitor the pressure of the endotracheal tube's cuff during insertion [3]. Neither auscultation of bubbling sounds from the epigastrium after insuffl ation of air nor aspiration of 'gastric content' is thought to be reliable. Measuring the level of carbon dioxide in the feeding tube is a simple way to confi rm trachebronchial malposition [4]. Th e UK National Patient Safety Agency has requested pH testing of gastric aspirate be used as the fi rst line method for testing trachebronchial malposition, with pH between 1 and 5.5 …