A review of published case reports of inadvertent pulmonary placement of nasogastric tubes in children

Little is known about the incidence of inadvertent pulmonary placement of nasogastric tubes during blind insertions in children. Purpose: The purpose of this paper was to conduct a review of published case reports over the past two decades. Methods: An OVID Medline search was conducted of articles published from 1993 through 2012. Results: Fifteen published case reports were located; four patients died as a result of their malpositioned tubes. The auscultatory bedside method failed to detect the malpositioned tubes in all seven cases in which it was used. Conclusions: The incidence of inadvertent pulmonary placement of nasogastric tubes is relatively low but can lead to serious and even lethal results in children. The auscultatory method to predict tube location is unreliable.