Two-day-old infant with respiratory distress after nasogastric tube placement

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Doctor's Information

Name : Mehrzad
Family : Mehdizadeh
Affiliation :Radiology departement of Children's Medical Center
Academic Degree : Associate professor
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Reza Hanifehpour

Case Section

Pediatric Radiology

Patient's Information

Gender : Female
Age : 2 Day

Clinical Summary

A Two-day-old infant with respiratory distress after nasogastric tube placement

Imaging Findings

In a two-day-old infant who had respiratory distress after NG tube placement and mild pneumothorax was evident on CXR. With suspected rupture of the esophagus contrast examination (Visipaque) was performed. In this examination entry of contrast material to the right pleural space confirmed the diagnosis of esophageal perforation in thoracic segment.

Differential Diagnosis

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Final Diagnosis

Iatrogenic oesophageal perforation

Discussion (Related Text)

Nasogastric tube (NGT) is inserted for providing nutrition, drugs or for gastric drainage. Although a simple procedure, the blind placement of nasogastric feeding tubes is not without risks. Iatrogenic oesophageal perforation occurs mainly in preterm and low birth weight babies, secondary to difficult intubation and forceful attempts to pass NG tubes and suction catheters. It is usually seen in the cervical region of the oesophagus, most commonly involving the pyriform sinus. Babies may present with respiratory distress, blood stained secretions, cyanosis, feeding difficulties or vomiting which may result in delay in establishing full feeds. Most babies can be treated conservatively although surgical intervention may be required in severe cases. Preventive measures such as adequate training in intubation, use of more experienced staff for intubating extremely preterm infants, extra care during suctioning, placement of naso/orogastric tubes and high index of suspicion are required. The various routine methods for confirming the position of the NGT includes auscultation of air insufflated through the feeding tube (whoosh test), testing acidity/alkalinity of the aspirate, interpreting absence of respiratory distress as an indicator of correct positioning, monitoring bubbling at the end of NGT and observing the appearance of the feeding tube aspirate. But these methods are not reliable. The reliable methods include measuring the pH of the aspirate and use of radiography which is considered to be most confirmatory . A nasogastric feeding tube is considered malpositioned if it does not stay within the esophageal lumen or if the distal end of the tube is not below the gastroesophageal junction. A high index of suspicion in infants with sudden deterioration of respiratory status following procedures involving pharyngeal region is essential for a timely diagnosis, which can be confirmed by radiological investigations.

References

-http://www.ispub.com/journal/the-internet-journal-of-pediatrics-and-neonatology/volume-8-number-2/iatrogenic-oesophageal-perforation-in-a-newborn -P. Khanna, et al., “ The Nasogastric Tube in the Thorax after Gastric Pull Up!," Open Journal of Anesthesiology, 2012, 2, 36-37