A 33-year-old immuno-compromised patient was admitted to the Intensive Care Unit with respiratory failure necessitat- ing mechanical ventilation. Two days earlier a small-bore nasogastric tube had been positioned and enteral feeding started. Not until the following day did the patient, who was fully conscious, complain about chest pain, dyspnoea and cough. A chest X-ray showed consolidations in the right lung. The nasogastric tube was visible but had initially remained unrecognized. Bronchoscopy showed the displacement of the nasogastric tube between the vocal cords and it was immediately removed. No artificial food was seen in the bronchial tree. Pleural drainage revealed purulent fluid, containing artificial food. Despite maximal support the patient died as a consequence of multi-organ failure. In conclusion, displacement of a nasogastric tube can be potentially dangerous. The routine procedures for checking the correct position are not fully reliable.
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