Punctured lung via OG tube with intubated patient?

usalsfyre · Apr 20, 2011

Very, very unlikely without someone using a hugely inappropriate amount of force. Most pneumothoraces in the intubated patient are iatrageniocally caused by mechanical ventilation.

ckh23, BSN, RN · Apr 20, 2011

Not very. You would need a lot of force. You would also have to puncture and go through the cuff of the ETT. The minute you did that the vent alarm would start going off.

sunnycalifRN · Apr 20, 2011

How likely is it to puncture a lung by inserting an OG tube in an intubated patient?

I agree with the other posters. Not likely. If you're inserting the OG and the pt has an intact cough/gag reflex, once you slid past the ETT cuff, when you touched the carina, the coughing would tell you that you're in the wrong place; time to withdraw. I suppose, if the patient was paralyzed, you could get past the carina with no coughing and then keep on shoving until you popped a pneumo?? But, that would mean, you inserted WAY deep and used a lot of force, which you shouldn't do.

Did it happen?

Reno1978, BSN, RN · Apr 20, 2011

You would think there'd be a lot of coughing, but I once inserted a small bore feeding NGT on an awake, alert patient. The patient coughed once or twice, nothing dramatic, and I hit resistance before I hit the mark I expected I'd be able to advance it. XR showed it in the right lung, no question.

With that being said there was no pneumothorax, and I think you'd have to hit resistance and be quite forceful to cause one in this manner.

usalsfyre · Apr 20, 2011

Yes, but it sounds like that was in an unintubated patient. There's no doubt you can put an NG in the lung, but getting past the inflated cuff an an ETT would be, uh, IMPRESSIVE....

To amend my earlier statement, I don't think its impossible, but I'd say the odds are only slightly better than the odds that the 16 YOF who is crowning really WASN'T having sex.

Alford · Apr 20, 2011

I didn't think it was likely, just trying to think of every possibility as to why the patient who arrested and subsequently intubated was only able to have a PO2 of 49, despite being on a PEEP of 12.

JulieCVICURN, BSN, RN · Apr 20, 2011

There's lots of reasons why that could happen, not the least of which is pulmonary emboli. If a patient has those, you can conceivably blow all the oxygen in the world into those lungs and it may not get out of the lungs and into circulation.

Off the top of my head I can't think of more reasons, but I know there are.

MomRN0913 · Apr 21, 2011

I didn't think it was likely, just trying to think of every possibility as to why the patient who arrested and subsequently intubated was only able to have a PO2 of 49, despite being on a PEEP of 12.

PE as one said, ARDS, pulmonary fibrosis.....

JulieCVICURN, BSN, RN · Apr 21, 2011

Thanks, MomRN. I'm a former CVICU RN, but I was having brain freeze today and didn't feel like making more of an effort.

MomRN0913 · Apr 21, 2011

Thanks, MomRN. I'm a former CVICU RN, but I was having brain freeze today and didn't feel like making more of an effort.

LOL. I think I am brain freezing too, because there are more....

Now that I am thinking about it, was there a feeding going? Because i know of a patient who kept bucking the vent and desating because it turned out the feeding was on but the tube was not in the stomach.....

GreyGull · Apr 21, 2011

Not very. You would need a lot of force. You would also have to puncture and go through the cuff of the ETT. The minute you did that the vent alarm would start going off.

Don't count on the ventilator alarming. An OG can slip past with the cuff forming around it. No cuff should be inflated to where nothing can slip by it especially with all the slimy secretions that quickly accumulate on top of the cuff with or without a subglottic sx port. The slippery slime will make a tube slide past rather easily.

Occasionally an NG/OG tube will slip past a cuff and enter the lungs. You hope someone is confirming placement adequately. Usually this will happen in an emergent situation with lots of confusion going on. We now require a CXR confirmation before something like charcoal (rare) is given emergently.

The weighted and stylet tubes can definitely present with some complications including esophageal or tracheal perforation if that is the path it has chose. Pneumothorax or even passage through a bronchus can occur which then you hope there is a thoracic surgeon in house.

Even without the stylet, small bore tubes can present with the most problems.

If you google this you will probably come up with several CXR photos.

Since we have been placing mostly OGs in ventilator patients (VAP recommendation) we have has less inadverent lung placements than when NGs were being done. Either way it takes a good assessment sense and feeling for placement. Some of the newer gadgets that guide placement are worth the cost also.

However, I doubt if this is the situation here. With a PEEP of 12 your would more than likely get subq air. If a bronchus is torn, this can have a massive accumulation quickly.