Nasogastric tube syndrome:A Meta-summary of case reports

BACKGROUND Since its description in 1790 by Hunter,the nasogastric tube(NGT)is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding.However,the risks associated with its placement are often underes-timated.Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication.NGT syndrome is characterized by the presence of an NGT,throat pain and vocal cord(VC)paralysis,usually bilateral.It is poten-tially life–threatening,and early diagnosis is the key to the prevention of fatal upper airway obstruction.However,fewer cases may have been reported than might have occurred,primarily due to the clinicians'unawareness.The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging.AIM To review and collate the data from the published case reports and case series to understand the possible risk factors,early warning signs and symptoms for timely detection to prevent the manifestation of the complete syndrome with life-threatening airway obstruction.METHODS We conducted a systematic search for this meta-summary from the database of PubMed,EMBASE,Reference Citation Analysis(https://www.referencecitation-analysis.com/)and Google scholar,from all the past studies till August 2023.The search terms included major MESH terms"Nasogastric tube","Intubation,Gastrointestinal","Vocal Cord Paralysis",and“Syndrome”.All the case reports and case series were evaluated,and the data were extracted for patient demographics,clinical symptomatology,diagnostic and therapeutic interventions,clinical course and outcomes.A datasheet for evaluation was further prepared.RESULTS Twenty-seven cases,from five case series and 13 case reports,of NGT syndrome were retrieved from our search.There was male predominance(17,62.96%),and age at presentation ranged from 28 to 86 years.Ten patients had diabetes mellitus(37.04%),and nine were hypertensive(33.33%).Only three(11.11%)patients were reported to be immunocompromised.The median time for developing symptoms after NGT insertion was 14.5 d(interquartile range 6.25-33.75 d).The most commonly reported reason for NGT insertion was acute stroke(10,37.01%)and the most commonly reported symptoms were stridor or wheezing 17(62.96%).In 77.78%of cases,bilateral VC were affected.The only treatment instituted in most patients(77.78%)was removing the NG tube.Most patients(62.96%)required tracheostomy for airway protection.But 8 of the 23 survivors recovered within five weeks and could be decannulated.Three patients were reported to have died.CONCLUSION NGT syndrome is an uncommon clinical complication of a very common clinical procedure.However,an under-reporting is possible because of misdiagnosis or lack of awareness among clinicians.Patients in early stages and with mild symptoms may be missed.Further,high variability in the presentation timing after NGT insertion makes diagnosis challenging.Early diagnosis and prompt removal of NGT may suffice in most patients,but a significant proportion of patients presenting with respiratory compromise may require tracheostomy for airway protection.

Exfoliative esophageal bleeding caused by blind placement of a nasogastric tube:Two cases and a literature review

Transnasal intubation is a clinical operation usually performed blindly at the bedside.Mild adverse events,such as epistaxis and tube misplacement,are relatively common.Esophageal bleeding or perforation and other serious adverse events are rare.In the present study,two cases of severe diffuse esophageal bleeding caused by the blind placement of a nasogastric tube are described.These cases were successfully treated using a covered metal stent or Sengstaken-Blakemore tube.A review of the literature regarding the possible causes of such adverse events and the potential endoscopic treatments for severe hemorrhage are discussed.

Case Series: Nasogastric (NG) Feeding Tube Misplacement in Critically Ill Tracheostomized Patients

In this case series we present 3 cases of nasogastric tube misplacement in tracheostomy patients. Although considered safe and it being a common procedure nasogastric tube misplacement can lead to serious and life-threatening complications. We present three cases of nasogastric tube misplacement in tracheostomized patients. One of the cases presented suffered from pneumothorax. Different time intervals between procedures in these different cases resulted in similar results. We would like to emphasize the importance of due conformation of correct placement of the nasogastric tube in the tracheostomy patient as well as to suggest that over inflation of the balloon securing the tracheostomy apparatus in place during nasogastric tube placement, might prevent misplacement. Nasogastric tube placement in tracheostomized patients has potential for serious complications. As such maintaining safe practice procedure is essential. Considering over inflation of the tracheostomy apparatus balloon might be beneficial as well, by preventing entry of NGT into the trachea.

Nasogastric tube syndrome induced by an indwelling long intestinal tube

The nasogastric tube(NGT) has become a frequently used device to alleviate gastrointestinal symptoms. Nasogastric tube syndrome(NTS) is an uncommon but potentially life-threatening complication of an indwelling NGT. NTS is characterized by acute upper airway obstruction due to bilateral vocal cord paralysis. We report a case of a 76-year-old man with NTS, induced by an indwelling long intestinal tube. He was admitted to our hospital for treatment of sigmoid colon cancer. He underwent sigmoidectomy to release a bowel obstruction, and had a long intestinal tube inserted to decompress the intestinal tract. He presented acute dyspnea following prolonged intestinal intubation, and bronchoscopy showed bilateral vocal cord paralysis. The NGT was removed immediately, and tracheotomy was performed. The patient was finally discharged in a fully recovered state. NTS be considered in patients complaining of acute upper airway obstruction, not only with a NGT inserted but also with a long intestinal tube.

Nasogastric or nasointestinal feeding in severe acute pancreatitis

AIM:To assess the rate of spontaneous tube migration and to compare the effects of naso-gastric and nasointestinal(NI)(beyond the ligament of Treitz) feeding in severe acute pancreatitis(SAP).METHODS:After bedside intragastric insertion,tube position was assessed,and enteral nutrition(EN) started at day 4,irrespective of tube localization.Patients were monitored daily and clinical and laboratory parameters evaluated to compare the outcome of patients with nasogastric(NG) or NI tube.RESULTS:Spontaneous tube migration to a NI site occurred in 10/25(40%) prospectively enrolled SAP patients,while in 15(60%) nutrition was started with a NG tube.Groups were similar for demographics and pancreatitis aetiology but computed tomography(CT) severity index was higher in NG tube patients than in NI(mean 6.2 vs 4.7,P=0.04).The CT index seemed a risk factor for failed obtainment of spontaneous distal migration.EN trough NG or NI tube were similar in terms of tolerability,safety,clinical goals,complications and hospital stay.CONCLUSION:Spontaneous distal tube migration is successful in 40% of SAP patients,with higher CT severity index predicting intragastric retention;in such cases EN by NG tubes seems to provide a pragmatic alternative opportunity with similar outcomes.

Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care

Purpose of review: This article reviews the thoracic complications from malpositioned blindly inserted nasogastric feeding tubes in mechanically ventilated patients in intensive care and the methods to check the position and promote safe placement of the feeding tubes. Recent findings: Malpositioned feeding tubes are not included in risk management databases. The reported incidence is 1-3% and more than half occur in mechanically ventilated patients. Eighty three mechanically ventilated patients were reported with malpositioned nasogastric tubes and 66% of them developed serious thoracic complications. Pneumothoraces accounted for 80% of thoracic complications that were evenly distributed between tubes with and without stylet. Repeated misplacements appear to increase the risk. Non-radiological confirmation of the position of the tube has suboptimal performance. Protocols to place feeding tubes and new technology are promising candidates. Summary: Malpositioned nasogastric feeding tubes are underreported and associated with serious thoracic complications in mechanically ventilated patients. We need more data to answer whether we can afford to prevent them.

Comparison of a novel bedside portable endoscopy device with nasogastric aspiration for identifying upper gastrointestinal bleeding

AIM: To compare outcomes using the novel portable endoscopy with that of nasogastric(NG) aspiration in patients with gastrointestinal bleeding.METHODS: Patients who underwent NG aspiration for the evaluation of upper gastrointestinal(UGI) bleeding were eligible for the study. After NG aspiration, we performed the portable endoscopy to identify bleeding evidence in the UGI tract. Then, all patients underwent conventional esophagogastroduodenoscopy as the gold-standard test. The sensitivity, specificity, and accuracy of the portable endoscopy for confirming UGI bleeding were compared with those of NG aspiration.RESULTS: In total, 129 patients who had GI bleedingsigns or symptoms were included in the study(age 64.46 ± 13.79, 91 males). The UGI tract(esophagus, stomach, and duodenum) was the most common site of bleeding(81, 62.8%) and the cause of bleeding was not identified in 12 patients(9.3%). Specificity for identifying UGI bleeding was higher with the portable endoscopy than NG aspiration(85.4% vs 68.8%, P = 0.008) while accuracy was comparable. The accuracy of the portable endoscopy was significantly higher than that of NG in the subgroup analysis of patients with esophageal bleeding(88.2% vs 75%, P = 0.004). Food material could be detected more readily by the portable endoscopy than NG tube aspiration(20.9% vs 9.3%, P = 0.014). No serious adverse effect was observed during the portable endoscopy.CONCLUSION: The portable endoscopy was not superior to NG aspiration for confirming UGI bleeding site. However, this novel portable endoscopy device might provide a benefit over NG aspiration in patients with esophageal bleeding.

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients: A meta-analysis

BACKGROUND Several techniques of nasogastric tube(NGT)insertion have been described in the literature with different success rates.AIM To systematically search the literature and conduct a meta-analysis comparing the success rates,insertion time and complications associated with different techniques of NGT insertion in anesthetized and intubated patients.METHODS An electronic search of the PubMed,Scopus,CENTRAL(Cochrane Central Register of Controlled Trials),and Google Scholar databases were performed up to October 31,2019.We included 17 randomized controlled trials with 2500 participants in the meta-analysis.RESULTS As compared to the conventional method,successful insertion of the NGT on first attempt was higher with modified techniques such as the reverse Sellick’s maneuver[relative risk(RR)1.94;95%confidence interval(CI):1.62-2.31],use of a frozen NGT(RR 1.55;95%CI:1.13-2.13),inserting the NGT with neck flexion and lateral neck pressure(RR 1.64;95%CI:1.10-2.45),endotracheal tube-assisted(RR 1.88;95%CI:1.52-2.32)and video-assisted placements(RR 1.60;95%CI:1.31-1.95).All the modified techniques also led to comparatively higher insertion success rates than the conventional technique.CONCLUSION The use of modified techniques of NGT insertion such as the reverse Sellick’s maneuver,neck flexion with lateral neck pressure,frozen NGT,endotracheal tube-guided or video-assisted methods result in a significantly better chance of successful tube insertion at first attempt as compared to the conventional technique.All modified techniques also significantly improve the overall chance of successful NGT placement as compared to the conventional method.

Passage of nasogastric tube through tracheo-esophageal fistula into stomach: A rare event

Esophageal atresia with tracheo-oesophageal fistula(TEF) occurs in 1 in 3500 live births. Anorectal malformation is found to be associated with 14% of TEF. Esophageal atresia with TEF is a congenital anomaly which classically presents as excessive frothing from the mouth and respiratory distress. Rarely gastric position of the feeding tube in a case of TEF can be obtained delaying the diagnosis of TEF. We had an uncommon situation where a nasogastric tube reached the stomach through the trachea and tracheo-esophageal fistula, leading to misdiagnosis in a case of esophageal atresia with tracheoesophageal fistula. By using a stiff rubber catheter instead of a soft feeding tube for the diagnosis of esophageal atresia and TEF, such situation can be avoided.

Bedside ultrasonic localization of the nasogastric tube in a patient with severe COVID-19:A case report

BACKGROUND The indwelling nasogastric tube is commonly used for supplying enteral nutrition to patients who are unable to feed themselves,and accurate positioning is essential in the indwelling nasogastric tube in the body of the aforementioned patients.In clinical practice,abdominal radiography,auscultation,and clinical determination of the pH of the gastric juice are routinely used by medical personnel to determine the position of the tube;however,those treatments have proved limitations in specific cases.There are few case reports on the precise positioning of the nasogastric tube in patients with coronavirus disease 2019(COVID-19),for whom a supply of necessary nutrition support is significant throughout the process of treatment.CASE SUMMARY A 79-year-old patient,diagnosed with COVID-19 at the stage of combined syndromes with severe bacterial lung infection,respiratory failure,multiple comorbidities,and a poor nutritional status,was presented to us and required an indwelling nasogastric tube for enteral nutrition support.After pre-treatment assessments including observation of the patient’s nasal feeding status and examination of the nasal septal deviation,inflammation,obstruction,nasal leakage of cerebrospinal fluid,and other disorders that might render intubation inappropriate,we measured and marked the length of the nasogastric tube to be placed and delivered the tube to the intended length in the standard manner.Then further scrutiny was conducted to ensure that the tube was not coiled in the mouth,and gentle movements were made to avoid damage to the esophageal mucosa.However,back draw of the gastric juice using an empty needle failed,and the stethoscope could not be used for auscultation due to the specific condition presented by the internal organs of the patient,and the end of the tube was placed in saline with no bubbles spilling out.Therefore,it was not possible to determine whether the nasogastric tube was placed exactly in the stomach and no nutrient infusion was performed for the time being.Subsequently,the ultrasound probe was utilized to view the condition of the patient’s stomach,where the nasogastric tube was found to be translucent and running parallel to the esophagus shaped as“=”.The pre-conditions were achieved and 100 mL nutritional fluid was fed to the patient,who did not experience any discomfort throughout the procedure.His vital signs were stable with no adverse effects.CONCLUSION We achieved successfully used ultrasound to position the nasogastric tube in a 79-year-old patient with COVID-19.The repeatable ultrasound application does not involve radiation and causes less disturbance in the neck,making it advantageous for rapid positioning of the nasogastric tube and worthy of clinical promotion and application.

Safety of gastric lavage using nasogastric ryle’s tube in pesticide poisoning

Objective: Gastric lavage is mandatory irrespective of nature in all patients with acute poisoning in India. Present study was undertaken with aim whether lavage done using nasogastric Ryle’s tube and small aliquots of water or normal saline is safe. Patients and Methods: All the patients above 12 years of age admitted consecutively with pesticide ingestion or exposure between July 2004 to June 2005 were studied with respect to complications associated with lavage using Ryle’s tube. Forty five patients were admitted directly to our hospital and lavage was undertaken using Ryle’s tube (16F ) with 100 - 200 mL of aliquots till 1 - 1.5 liters of fluid was lavaged, with prophylactic endotracheal intubation in patients with Glasgow coma scale ( GCS) < 10 (group I). The incidence of complications related to lavage in group I was compared to that in 53 patients admitted during same period with pesticide poisoning but lavaged outside using nasogastric Ryle’s tube and referred to our institute (group II). Results: The significant complications observed in group I were significant drop in SaO2 (6 patients) laryngospasm, tachycardia, electrolyte imbalance and tube getting struck in throat (one each). In one patient in group I (had no prophylactic intubation though GCS 3) In group II, 7 had aspiration pneumonia (no prophylactic intubation). Other significant complication was drop in SaO2 during lavage. None of them had any serious life threatening complication. Conclusion: Gastric lavage carried out using nasogastric Ryle’s tube and small aliquots of water or normal saline is relatively safe in patients with pesticide poisoning when combined with prophylactic endotracheal intubation in patients with GCS < 10. In absence of prophylactic intubation, risk of aspiration is there. However aspiration pneumonia is generally mild and not life threatening.

The Nasogastric Tube in the Thorax after Gastric Pull Up!

Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding tubes is not without risks. Chest radiogram is done to confirm the correct position of the NGT. We report a case where radiography could not be confirmatory for the correct position of the tube in a specific group of patients.

A Review of Location Methods of Nasogastric Tube in Critically Ill Patients

Nasogastric tube is widely used in intensive care units. The complications of misplacement are rare but very dangerous for critically ill patients. Accurate localization of the position of the tip of nasogastric tube can effectively decrease complications and ensure the safety of critically ill patients. There are various methods that can be used to verify the location of the nasogastric tube such as radiography, PH measurement, electromagnetic navigator and ultrasound. However, there is a lack of general consensus regarding a standard method. In this review, we found that the accuracy of nasogastric tube placement can be greatly improved by visual technology such as X-ray, sonography and electromagnetic navigator. However, visual technology has not been widely used to locate the tip of nasogastric tube in critically ill patients. Best practice guidelines based on the available knowledge and evidence of current methods are necessary to increase the accuracy placement of nasogastric tube. It is envisioned that development of visual technologies will determine a new standard of care for verification of placement of nasogastric tube.

Routine nasogastric tube placement in patients with small esophageal perforation after endoscopic foreign body removal may be unnecessary:a propensity score matching analysis

Background:Nasogastric tube(NGT)placement is part of the post-operative management of upper gastrointestinal perforation,but its routine use in esophageal perforation(EP)caused by foreign bodies remains unclear.The purpose of this research was to investigate the necessity for routine NGT placement in patients with EP after endoscopic foreign body removal.Methods:A total of 323 patients diagnosed with EP caused by foreign bodies at the First Affiliated Hospital of Nanchang University between January 2012 and December 2021 were included in this retrospective study.Patients were divided into the NGT group and the non-NGT group according to whether or not NGT placement was performed.The perforation healing rate,post-operative adverse events,hospital stay,and death rate were analysed using a 1:1 propensity score matching model.Results:Before matching,there were 263 patients in the NGT group and 60 patients in the non-NGT group.There were significant differences in the time to treatment,infection,albumin,and types of endoscopy between the two groups,while the length of hospital stay in the NGT group was significantly longer than that in the non-NGT group.After 1:1 propensity score matching,48 pairs of patients were matched between the two groups.The perforation healing rate,post-operative adverse events,length of hospital stay,and death rate did not show significant differences between the two groups.Conclusions:For patients with small EP caused by foreign bodies,routine NGT placement after endoscopic foreign body removal may be unnecessary.

Advantages of nasogastric tube feeding during neoadjuvant concurrent chemoradiotherapy for esophageal cancer:A retrospective study

ObjectiveTo compare the effects of oral intake and nasogastric tube(NG)feeding on nutritional status,complications and survival during neoadjuvant chemoradiotherapy for esophageal squamous-cell carcinoma(ESCC)patients.MethodsA total of 61 ESCC cases treated with neoadjuvant chemoradiotherapy from December 2018 to March 2020 were enrolled,including(38 in oral intake group,and 22 in NG feeding group.Disease characteristics and baseline nutritional markers were collected in both groups.Nutritional status,complication and completion rate of chemoradiotherapy in both groups were evaluated.ResultsCompared with the oral intake group,patients in the NG feeding group had a later T stage(P=0.027)and clinical stage(P=0.014).The levels of energy intake(P=0.033),serum prealbumin(P<0.001),albumin(P=0.017)and hemoglobin(P=0.015)before treatment in NG group were significantly lower than those in oral intake group.Furthermore,patient-generated subjective global assessment(PG-SGA)score(P=0.016)and the levels of serum C-reactive protein(P=0.014)of NG feeding group were significantly higher than those of oral intake group.However,at the end of treatment,PG-SGA scores were increased in oral intake group and decreased in NG feeding group.In addition,the NG feeding group had a lower incidence of grade≥2 esophagitis(P=0.037),and higher completion rate of chemotherapy compared with oral intake group(P=0.034).Meanwhile,the proportion of parenteral nutrition(P=0.008)and anti-inflammatory(P=0.022)treatment in NG feeding group was significantly lower than that in oral intake group.Although patients in the NG feeding group had a worse prognosis,there were no statistically significant differences in overall survival(OS)and progression-free survival(PFS)between the two groups(P>0.05).ConclusionsAs a safe and effective enteral nutrition approach to improving nutrition,nasogastric tube feeding could increase treatment completion rate and reduce the incidence of≥grade 2 esophagitis reaction during neoadjuvant chemoradiotherapy.

Self‐knotting of distal end of nasogastric tube—Not an uncommon possibility

Importance A nasogastric tube is used commonly to decompress the stomach and provide enteral feeding in surgical and medical practice.Sometimes this safe and innocent‐looking tube may lead to unexpected complications.We focus here on the possibility of spontaneous‘lariat loop’knotting of the nasogastric tube when some resistance is felt on tube retrieval and describe a method of safe tube removal.Case presentation We present a case of self‐knotting of a nasogastric tube that was placed to decompress the stomach during the postoperative period after surgical repair of anorectal malformation in a 4‐month‐old boy.Conclusion Self‐knotting of the distal end of nasogastric tube is an unusual complication with catastrophic sequelae if not addressed properly.If any resistance is felt during nasogastric tube retrieval,self‐knotting of the tube must be suspected.

“Fast Track”nasogastric decompression of rectal cancer surgery

This study evaluates the application of fast track(FT)nasogastric decompression in patients who underwent anterior resection of rectal cancer.A randomized control trial was performed comparing the group with the fast track treatment(n=57)and the group with traditional nasogastric decompression(n=84).Preoperative characteristics and postoperative recovery indices were recorded and analyzed.The results indicate no significant differences in gender(P=0.614),age(P=0.653),tumor location(P=0.113),and TNM stages(P=0.054)were observed between the 2 groups.The differences in the type of resection,anastomosis,and adoption of protective colostomy were all not significant between the FT and the traditional group.During the first 24 hours after surgery,the volume of nasogastric drainage averaged 197 ml in the FT group and 155 ml in the traditional group(P=0.197).The initiation of test-meal(P=0.000),semiliquid diet(P=0.002),and ordinary diet(P=0.008)were all significantly shorter in the FT group.Furthermore,compared with the other group,the patients in the FT group enjoyed earlier removal of the abdominal drainage,urinary catheter,and shorter hospital stays(P=0.000).Based on a correlation test,the duration of nasogastric decompression is related to the time of test-meal and semiliquid diet.The routine usage of nasogastric decompression in rectal surgery is unnecessary.The fast track procedure might help in facilitating postoperative functional and diet recovery,reducing the time of catheterization,and shortening hospital stay.

留置鼻胃管对扁桃体术后创面缝合伤口的影响

扁桃体切除术最常见的并发症是术后出血,术中缝合腭舌弓、腭咽弓封闭术腔,可减少术后出血。然而缝合的腭舌弓、腭咽弓经常自行裂开,如何尽量减少扁桃体术后创面缝合伤口裂开是值得关注的问题。本研究通过回顾分析我院156例全麻下行传统扁桃体切除术或低温等离子扁桃体切除术并且行术中缝合腭舌弓、腭咽弓封闭术腔的病例,探讨术中留置鼻胃管对扁桃体术后创面缝合伤口的影响以及患者术后疼痛程度。

A pilot study of single-use endoscopy in screening acute gastrointestinal bleeding

AIM:To investigate the feasibility of a single-use endoscopy as an alternative procedure to nasogastric lavage in patients with acute gastrointestinal(GI) bleeding.METHODS:Patients who presented with hematemesis,melena or hematochezia were enrolled in this study.EG scan and conventional esophagogastroduodenoscopy(EGD) were subsequently performed.Active bleeding was defined as blood in the stomach,and inactive bleeding was defined as coffee ground clots and clear fluid in the stomach.The findings were recorded and compared.RESULTS:Between January and March,2011,13 patients that presented with hematemesis(n = 4),melena(n = 6),or bleeding from a previous nasogastric feeding tube(n = 3),were enrolled in this study.In 12 patients with upper GI bleeding,the EG scan device revealed that 7 patients had active bleeding and 5 patients had inactive bleeding,whereas conventional EGD revealed that 8 patients had active bleeding and 4 patients had inactive bleeding.The sensitivity and specificity of the EG scan device was 87.5% and 100% for active bleeding,with conventional EGD serving as a reference.No complication were reported during the EG scan procedures.CONCLUSION:The EG scan is a feasible device for screening acute upper GI bleeding.It may replace nasogastric lavage for the evaluation of acute upper GI bleeding.

Esophageal obstruction due to enteral feed bezoar:A case report and literature review

This paper describes a rare complication of enteral feeding,esophageal obstruction due to feeding formula bezoar,and reviews the published cases. An attempt to re-insert the nasogastric tube in a chronically ventilated 80-year-old female fed via a nasogastric tube with Jevity failed. An esophagogastroduodenoscopy revealed an 18 cm-long concretion of the feeding formula,fi-lling most of the esophageal lumen,which was removed endo scopically. Forty-two cases of feeding formula esophageal bezoars have been reported in the literature. The formation of feeding formula bezoars is triggered by acidic gastroesophageal reflux. The acidic pH in the esophagus causes clotting of the casein in the formula. Predisposing factors for bezoar formation are:mechanical ventilation,supine position,neurological diseases,diabetes mellitus,hypothyroidism,obesity and history of partial gastrectomy. Diagnosis and removal of the bezoar is done endoscopically. Feeding in a semi-recumbent position,administration of prokinetic agents and proton pump inhibitors may prevent this complication.