Deadly pressure pneumothorax after withdrawal of misplaced feeding tube: a case report

Journal of Medical Case Reports

Lotte Usinger¹  Martin Frydland²  Erik Nygaard Andresen¹ 

[1] Department of Internal Medicine, University Hospital Glostrup, Nordre Ringvej 57, Glostrup, 2600, Denmark;The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark

关键词: Deadly;    Tension;    Pneumothorax;    Tube;    Nasogastric;   

Others  :  1235809
DOI  :  10.1186/s13256-016-0813-y

 received in 2015-05-25, accepted in 2016-01-14,  发布年份 2016

【 摘 要 】

Background

Many patients have a nasogastric feeding tube inserted during admission; however, misplacement is not uncommon. In this case report we present, to the best of our knowledge, the first documented fatality from pressure pneumothorax following nasogastric tube withdrawal.

Case presentation

An 84-year-old Caucasian woman with dysphagia and at risk of aspiration underwent routine insertion of a nasogastric feeding tube; however, shortly after insertion she developed respiratory distress. A chest X-ray showed the tube had been misplaced into our patient’s right lung. The tube was removed, but our patient died less than an hour after withdrawal. The autopsy report stated that cause of death was tension pneumothorax, which developed following withdrawal of the misplaced feeding tube.

Conclusions

The indications for insertion of nasogastric feeding tubes are many and the procedure is considered harmless; however, if the tube is misplaced there is good reason to be cautious on removal as this can unmask puncture of the pleura eliciting pneumothorax and, as this case report shows, result in an ultimately deadly tension pneumothorax.

【 授权许可】

   
2016 Andresen et al.

【 图 表 】

Fig. 1.

【 参考文献 】

• [1]National Patient Safety Agency. Quarterly Data Summary Issue 9, England 2008. http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60199&type=full&servicetype=Attachment. Accessed 24 Jan 2016.
• [2]Ellett ML: What is known about methods of correctly placing gastric tubes in adults and children. Gastroenteral Nurs. 2004, 27:253-9.
• [3]de Aguilar-Nascimento JE, Kudsk KA: Clinical costs of feeding tube placement. JPEN J Parenter Enteral Nutr. 2007, 31:269-73.
• [4]Amirlak B, Amirlak I, Awad Z, Zahmatkesh M, Pipinos I, Forse A: Pneumothorax following feeding tube placement: precaution and treatment. Acta Med Iran. 2012, 50:355-8.
• [5]Freeberg SY, Carrigan TP, Culver DA, Guzman JA: Case series: tension pneumothorax complicating narrow-bore enteral feeding tube placement. J Intensive Care Med. 2010, 25:281-5.
• [6]Paul V, Shenoy A, Kupfer Y, Tessler S. Pneumothorax occurring after nasogastric tube removal. BMJ Case Rep. 2013 Dec 2;2013. doi:. 10.1136/bcr-2013-010419 webcite
• [7]Patient Safety Alert NPSA/2011/PSA002. Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. www.nrls.npsa.nhs.uk/alerts/?entryid45=129640. Accessed 24 Jan 2016.