Case Report: PDF OnlyInadvertent Tracheobronchial Placement of Feeding Tube in a Mechanically Ventilated PatientWang, Po-Chiena; Tseng, Guan-Yinga; Yang, Hsiao-Baib; Chou, Kuo-Chiha; Chen, Chung-Huaa, *Author Information aDepartment of Internal Medicine, Ton-Yen General Hospital, Hsinchu, Taiwan, R.O.C. bDepartment of Pathology, Ton-Yen General Hospital, Hsinchu, Taiwan, R.O.C. *Correspondence to: Dr Chung-Hua Chen, Department of Internal Medicine, Ton-Yen General Hospital, Jhubei City, Hsinchu County 302, Taiwan, R.O.C E-mail: [email protected] Received: October 4, 2007; • Accepted: March 3, 2008. Journal of the Chinese Medical Association: July 2008 - Volume 71 - Issue 7 - p 365-367 doi: 10.1016/S1726-4901(08)70141-2 Metrics Abstract Nasogastric (NG) tube misplacement into the airways is a rare complication. The presence of a cuffed endotracheal or tracheostomic tube often gives primary care providers a false sense of security. This report presents a case of inadvertent NG tube insertion into the right lower lobe bronchus of a 79-year-old patient with advanced chronic obstructive pulmonary disease, resulting in pneumonia and septic shock. In this report, the literature is reviewed, the influence of tube size on complications is compared, and the reliability of different methods to verify correct tube position is discussed. We conclude that a cuffed tracheostomic tube does not prevent advancement of a large-bore feeding tube into the tracheobronchial system. If any doubt exists regarding proper tube position, a chest radiograph should be obtained prior to initiation of feeding. © 2008 by Lippincott Williams & Wilkins, Inc.