Mistaken Endobronchial Placement of a Nasogastric Tube During Mandibular Fracture Surgery

A 64-year-old male had an awake right nasal fiber-optic intubation with an endotracheal tube for open reduction and internal fixation of bilateral displaced mandibular fractures. After induction of anesthesia, an 18 Fr nasogastric tube (NGT) was inserted through the left nostril and was secured. The patient required high flow rates to deliver adequate tidal volumes with the ventilator. A chest x-ray done in the postanesthesia care unit revealed a malpositioned NGT in the left lower lobe bronchus, which was immediately removed. The patient was extubated on postoperative day 2. Various traditional methods, such as aspiration of gastric contents, auscultation of gastric insufflations, and chest x-ray are in use to detect or prevent the misplacement of an NGT. These methods can be unreliable or impractical. Use of capnography to detect an improperly placed NGT should be considered in the operating room as a simple, cost-effective method with high sensitivity to prevent possibly serious sequelae of an NGT placed within the bronchial tree.Key words: Nasogastric tube, Misplacement, Oral surgeryPlacement of a nasogastric tube (NGT) preoperatively for decompression of the stomach is common practice to allow drainage of gastrointestinal contents in the case of bowel obstruction, or in other cases when the patient is at risk of aspiration for some other reason. This case report involves a patient who required aspiration precautions via NGT placement for mandibular surgery due to facial trauma; the NGT was later found to be misplaced in the left main stem bronchus as the misplacement was unrecognized intraoperatively. We discuss the necessity of preventing the possible intraoperative and postoperative complications of a misplaced NGT and simple measures to recognize misplacement in patients presenting for similar surgeries.