Use a Two-Step Technique with Radiographic Confirmation when Placing a Feeding Tube
Julius Cuong Pham MD
Placement of a feeding tube is not without peril to the patient and requires a high level of concern on the part of the practitioner, as illustrated in the following scenario.
Mr. JCP was a 68-year-old male who was postoperative day four from an aortic-valve replacement complicated by a stroke. Despite having no previous history of pulmonary disease, his airway pressures on the ventilator were persistently high, as noted on morning rounds. The nurse from the night shift noted a significant amount of residual from his feeding tube. She was instructed to continue the feeds because the stomach “makes a lot of secretions.” On radiology rounds, a significant left-sided pneumothorax was noted with the feeding tube positioned in the left pleural space.
Feeding tubes are commonly placed in the intensive care unit (ICU) for enteral feeding in the patient who is not able to orally take nutrition. Many types of tubes are available to accomplish this. One type of tube that is commonly used is the flexible small bore/stylet-guided tube (e.g., Dobhoff). These tubes have the advantage of being small and comfortable. They are more suitable for medium-term feeding. Because these tubes are small and flexible, they require a metal stylet to give them enough rigidity for placement. Unfortunately, this rigidity and small size make them ideal for inadvertent bronchial placement. This occurs in about 4.4% of feeding-tube placements. A correctly positioned endotracheal tube with the cuff inflated does not preclude placement into the main-stem bronchus. It has been postulated that the endotracheal tube may act as a guide for the feeding tube to follow. Both recognized and unrecognized, the results can be devastating and complications include pneumothorax, “isocalothorax,” pneumonia, empyema, sepsis, and death.