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Lung Collapse and Other Complications from Feeding Tube Insertion
When nutrition fails or is not delivered to the body because of illness, pathology, or incapacitation, nutrition must continue. The solution may be a feeding tube for nutrition delivery, but this can result in accidental lung collapse (pneumothorax).
A feeding tube is necessary for a patient unable to feed, swallow, or consume the appropriate diet. Inserting feeding tubes into the gastrointestinal tract simplifies nutrition while maintaining the aspects of the body's natural process.
For proper placement in the gastrointestinal tract, a feeding tube must bypass the entrance to the trachea. Only recently, safeguards have been established to ensure proper placement, such as verification with an X-ray after insertion. However, even this gold standard takes time, and pneumothorax is a time-sensitive emergency. Certain safeguards may not be sufficient, considering blind insertion raises the risk of misplacement by 2-5% or higher.
Reducing the Risk of Lung Collapse Following Feeding Tube Insertion
All medical procedures, protocols, diagnostics, and therapeutics are based on the "first, do no harm" caveat (primum, non nocere). This simple mandate determines the whole concept of risk vs. benefit that is imbued in every medical decision on a patient's care flowsheet.
Feeding tube insertion has pitfalls that create life-threatening complications, so an appropriate placement methodology for nutrition delivery is required. Any deviation is unacceptably dangerous. In 2020, there were over 27 million feeding tube placements conducted worldwide, of which a million entered the lungs instead of the proper gastrointestinal target. This has resulted in considerable medicolegal expenses.
Modern feeding tube navigation technology, such as the ENvue system, guarantees this proper insertion and placement. It precludes the most feared complications of feeding tube insertion, i.e., pneumothorax (lung collapse from feeding tube insertion errors) or iatrogenic aspiration/pneumonitis. Such technology reduces risk and saves lives.
Conditions Requiring Feeding Tube Placement
Conditions in which normal eating is compromised:
- Inability to swallow, including medication delivery
- Malnourishment
- Overactive gag reflex
- Neurological conditions of swallowing dysfunction and aspiration risk
- Intubated patients
- Anorexia nervosa, bulimia, and other psychiatric disorders
- Inflammatory bowel disease, i.e., Crohn's, ulcerative colitis
- Trauma or surgery involving the face or throat
- Gastrointestinal cancer
- Colitis
- Stricture
- Short bowel syndrome
- Low level of consciousness, e.g., coma, persistent vegetative state
- Dementia
- Weakness and debilitation from disease, e.g., cancer, sepsis, electrolyte imbalance
- Prolonged incapacitation or postoperative convalescence
Monitoring the Placement of a Feeding Tube
All feeding tube placement risks initiate from improper insertion.
Placement requires correct navigation into the targeted area (stomach or beyond, into the small intestines). Proper placement also calls for patient cooperation, often absent when dealing with children or incapacitated adults (e.g., dementia or in cases of obtunding sedation). It also requires correct measurement of feeding tube lengths, although this may be unnecessary with newer navigational advances.
- Blind placement carries the most risk. Insertions taking a substantial amount of time or involving more than three attempts increase the risk of laryngopharyngeal injury.
- X-ray or ultrasound can be cumbersome; also, this method identifies any misplacement only after it has occurred.
- Suctioning to confirm the retrieval of gastric contents can be misleading if a patient has been fasting and, again, identifies misplacement after the fact. pH readings can be falsely reassuring in the case of those taking acid-reducing medication or being given formula supplements.
- Capnography, i.e., monitoring the concentration of CO2 that would indicate tracheal placement, is not a sensible first-choice verification method.
- Camera technology can verify entrance into the stomach, but this is still being evaluated for efficacy for small bowel insertion.
Risks Associated with Misplaced Feeding Tubes
The ideal navigation system for feeding tubes should avoid misplacement on the front end of procedures. It should include real-time confirmation as the insertion progresses.
Feeding tubes are designed to be in the gastrointestinal tract. Misdirecting one into a main stem bronchus can result in:
- Perforation of lung parenchyma, leading to pneumothorax;
- Infusion of nutritional liquids into the lung itself, resulting in fluid collection and alveoli inaccessible for respiration;
- Infection;
- Delayed diagnosis of pneumothorax: Lung puncture may not be obvious until the tube is removed, thereby allowing air to exit toward a condition of pneumothorax. Initially, the presentation might be falsely reassuring. Any escape of air is blocked by the tube itself, with removal allowing the pneumothorax process to occur. This may result in a deadly tension pneumothorax; and
- Damage to the vocal cords, lungs, or trachea, all of which can lead to serious injury or death.
Avoiding Complications From Feeding Tube Insertion
The medical knowledge of safe feeding tube insertion is well established. First, the prudent decision to abandon inserting a feeding tube can be based on contraindications.
Absolute contraindications:
- Midface trauma
- Recent nasal surgery
- Mechanical obstruction, e.g., tumors, scar tissue from surgery, etc.
Relative contraindications:
- Coagulopathy
- Esophageal rupture
- Esophageal varices
- Esophageal strictures or obstructions
Second, insertion must include proper preparation, technique, and verification as per institutional protocol:
- Backup using X-ray-considered the "gold standard" of verification-or ultrasound if gastric pH is inaccessible.
- Aspirate from the feeding tube to verify gastric pH (0-5).
Again, although these steps are valid and based on evidence-based medicine, misplacement can only be identified after the procedure. By then, trauma to the pulmonary system may have already occurred. To obviate this complication and the sequelae that follow, new technology is available to assist navigation of feeding tube insertion in real time.
The Newest Technology to Avoid Lung Collapse
Guided feeding tube placement via electromagnetic placement devices (EMPD) to prevent lung collapse (pneumothorax) are available to hospitals.
ENvizion Medical's solution uses this technology in its feeding tube placement system in tandem with integrated navigation sensors and body mapping to provide safe, progressive placement and immediate feedback in three dimensions. It displays real-time feeding tube insertion progress along the patient's anatomical landmarks, including the gastrointestinal tract and pulmonary tree. The system employs both graphical and textual alerts to instantaneously highlight critical deviations in the tube route.
The Bottom Line on Lung Collapse from Feeding Tube Insertion
Done correctly, feeding tube insertion allows for natural nutrition to those unable to feed normally. Misplacing a feeding tube risks lung collapse, tension pneumothorax, iatrogenic aspiration, serious infection, and possibly death.
Total medical knowledge is doubling every 73 days. From this expansion, devices using electromagnetic technology have arisen to avoid feeding tube complications. The time to assess correct navigation is always during the insertion, not after.
