1173

CLINICAL NOTE

Accidental Pneumothorax From a Nasogastric Tube in a
Patient With Severe Hemineglect: A Case Report
Martin Winterholler, MD, PhD, Frank J. Erbguth, MD, PhD
ABSTRACT. Winterholler M, Erbguth FJ. Accidental
pneumothorax from a nasogastric tube in a patient with severe
hemineglect: a case report. Arch Phys Med Rehabil 2002;83:
1173-4.
Nasogastric tubes are frequently used for nutrition of patients with neurologic diseases. We report an instance of inadvertant placement of a standard nasogastric tube into the left
pleural space in a patient with right parietotemporal intracerebral hemorrhage and severe hemineglect on the left side. The 2
confirmatory maneuvers—aspiration of fluid and auscultating
the abdomen on insufflating air—were false-positive. We conclude that only radiologic confirmation of the position of nasogastric tubes and the awareness of the associated dangers will
help minimize the occurence of such events in patients with
disorders of perception or altered consciousness.
Key Words: Case report; Intubation, nasogastric; Neurologic disorders; Rehabilitation.
© 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
ASOGASTRIC TUBES are frequently used in hospitals,
rehabilitation units, and nursing homes for nutrition of
N
patients with neurologic diseases who have difficulties swallowing or impaired consiousness. The placement of such tubes
may have potential serious side effects.1 The risks in comatose
patients are well defined, but little is known about the risk of
such a procedure in patients with disorders of perception. We
report an instance of inadvertent placement of a nasogastric
tube into the left pleural space in a patient with right parietotemporal intracerebral hemorrhage and severe hemineglect on
the left side.
CASE DESCRIPTION
A 68-year-old woman with a history of arterial hypertension
was hospitalized for an acute stroke. A computed tomography
scan showed a right hemispheric temporo-occipital intracranial
hemorrhage (3⫻5⫻3cm). She was somnolent and had incomplete left hemiparesis but was able to communicate (Glasgow
Coma Scale [GSC] score, 14). She had severe hemineglect,
complete hemianopsia, hemianalgesia, and hemihypesthesia on
her whole left side. Because she was unable to swallow, a
standard nasogastric tube was inserted for fluid, medication,
and food. She was alert during the procedure (GCS score, 14)

From the Neurologische Klinik, Martin-Luther-Universität Halle, Halle, Germany
(Winterholler); and the Neurologische Klinik, Klinikum Nürnberg, Germany (Erbguth).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Martin Winterholler, MD, PhD, Neurologische Klinik, MartinLuther-Universität Halle, Ernst-Grube-Str 40, D-06097 Halle, Germany, e-mail:
martin.winterholler@medizin.uni-halle.de.
0003-9993/02/8308-6785$35.00/0
doi:10.1053/apmr.2002.33643

and was not observed to cough severely during tube placement.
A small amount of fluid was aspirated, and, on insufflating air,
auscultation of the abdomen revealed a confirmatory gurgle.
Tea and 100mL of nutrition were administered. One hour
later, she began to suffer from severe dyspnea. A chest radiograph (fig 1) was immediately performed. It revealed misplaced insertion of the nasogastric tube into the left mainstem
bronchus, pneumothorax, and pleural effusion. The tube was
immediately removed, she was intubated, and a closed tube
thoracostomy and bronchoscopy were performed. The patient’s
recovery was complicated by severe pneumonia and pleuritis
caused by Staphylococcus aureus, which was treated with
imipenem. Two weeks later she was transferred to a rehabilitation unit.
DISCUSSION
This patient had an atypical right hemispheric intracranial
hemorrhage resulting in hemianopsia, hemineglect, and hemianalgesia. She was awake when the nasogastric tube was
inserted. The typical symptoms of tube misplacement into the
lower respiratory tract— coughing and discomfort—were not
present. Reduced perception and severe hemineglect including
the left bronchial system and the left pleura may have contributed to the lack of symptoms related to the nasogastric tube
misplacement.
For the general patient population, there are a number of
commonly accepted clinical signs that suggest proper placement of a nasogastric tube including (1) insufflation of air with
sounds heard over the region of the stomach; (2) aspiration of
fluid, suggesting placement of the tube in the stomach; (3)
passage of the full distance of the tube with easy removal of a
guide wire; and (4) absence of coughing, suggesting esophageal passage of the tube.2,3 These traditional criteria for proper
tube placement, however, have been shown to be suboptimal in
critically ill patients.4 Major underlying factors favoring tube
malpositioning include depressed sensorium, impaired gag reflex, recent endotracheal intubation, decreased laryngeal sensitivity, and neuromuscular blocking drugs.5-9
Cases of complications caused by misplaced nasogastric
feeding tubes have been reported from at least 10 different
teaching hospitals.2,5,10 All pleuropulmonal complications were
the result of the inadvertent passage of tubes into the transbronchial tree with eventual perforation into the lung and
pleural space. Although perforation of the esophagus or the
skull base by a nasogastric tube has been reported sporadically,
malpositioning of nasogastric tubes in the tracheobronchial tree
appears to be more common.11
The rate of inadvertent insertion of nasogastric and nasoenteric tubes into the trachea and distal airways ranges from 0.3%
to 15%.10,12,13 Both penetration of the airways and the introduction of several chemicals into the lung and the pleural
spaces may occur before it is recognized that the tube has been
incorrectly placed. Bankier et al10 found a pneumothorax in 4
of 14 cases with tracheobronchial intubation of nasogastric
tubes. Such complications may be fatal.14
Physical examination is often a poor predictor of tube misplacement.10,13,15 In our case, the 2 confirmatory maneuvers—
Arch Phys Med Rehabil Vol 83, August 2002

1174

ACCIDENTAL PNEUMOTHORAX, Winterholler

CONCLUSION
Only radiologic confirmation of the position of nasogastric
tubes and the awareness of the associated dangers will help
minimize the occurence of such events in patients with disorders of perception or altered consciousness. Furthermore,
newly developed guide wire Dobhoff feeding tubes, which are
softer than conventional nasogastric tubes, can be positioned in
the proximal small bowel with radiologic confirmation. This
procedure reduces the risk of reflux and aspiration.19

Fig 1. Chest radiograph showing misplacement of a nasogastric
tube. The tube was inserted down the left mainstem bronchus into
the left lung penetrating the pleura, resulting in left-side pneumothorax and iatrogenic hydrothorax.

aspiration of fluid and auscultating the abdomen on insufflating
air—were false-positive.
Therefore, the traditional criteria for appropriate tube positioning are not applicable for critically ill patients or the mentally ill and patients with disorders of perception for the following reasons. Insufflation of air with sounds heard over the
region of the stomach should not be accepted as evidence of
gastric placement because small bore tubes do not always allow
sufficient passage of air. Moreover, air bubbling in the pleura,
lung, or esophagus may be transmitted below the diaphragm.4
Aspiration of fluid should not be interpreted as appropriate
placement in the stomach because fluid aspirated may come
from the pleural space, from bronchial secretions, or even from
the brain.11 If the tube passes the full length and an eventual
guide wire is removed easily, the tubing is thought to be
straight and unlikely to be kinked or coiled up in the lung.
However, several reports6,16 refute this claim.
Radiographic imaging is commonly used to confirm the
position of the tube; it is strongly recommended in all cases
with neurologic or mental deficits, as well as in cases with
diminished consciousness, especially before the tube is used
for enteral feeding or the instillation of drugs and other substances.12,13 However, the radiograph may be misinterpreted17,18; in a series of 11 patients with misplaced nasogastric
tubes, the fault position was not identified in 3 cases (27%).14
The majority of the reported patients with intrapulmonary or
pleural misplacement of the nasogastric tube were comatose or
intubated.2,4,6-14 But patients with disorders of perception or
other acute neurologic diseases may also be at high risk.

Arch Phys Med Rehabil Vol 83, August 2002

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