Abstract
BACKGROUND: Nasogastric tube (NGT) misinsertion into the airway can sometimes cause penetrating trauma, resulting in pneumothorax or empyema which can lead to critical respiratory failure if not promptly recognized. Elderly patients with a diminished cough reflex and impaired communication are particularly vulnerable to NGT misinsertion. We report a case of fistulous empyema caused by tube feeding through an NGT that was misinserted into the airway and penetrated into the pleural cavity. CASE PRESENTATION: An 82-year-old bedridden woman with severe disability and a medical history of intracerebral hemorrhage was transferred to our department because of acute respiratory failure a day after her NGT was replaced at the referring hospital. During the 19 h between NGT replacement and the first observation of respiratory failure, tube feedings were administered twice via the new NGT. Computed tomography revealed NGT misinsertion into the left lower lobe bronchus and massive liquid accumulation with pneumothorax in the left pleural cavity, suggesting a penetrating bronchopulmonary trauma. After the patient was transferred to our hospital, a chest tube was inserted immediately to drain the contents of the tube feeding that had accumulated in the pleural space. Several days later, surgery was performed to irrigate the empyema cavity and repair the laceration. The postoperative course was uneventful, and the patient returned to the referring hospital. CONCLUSIONS: Our case highlights the importance of careful NGT insertion and recognizing misinsertion by radiological findings to avoid severe airway complications, particularly in elderly and neurologically impaired patients.