Portal de Periódicos da CAPES

“Isocal Pneumonia” with Respiratory Failure

1982; Elsevier BV; Volume: 81; Issue: 3 Linguagem: Inglês

10.1378/chest.81.3.390a

1931-3543

Petham P. Muthuswamy, Kirit Patel, Rosula Rajendran,

Dysphagia Assessment and Management

Nasogastric tube feeding is commonly utilized in critically ill patients without any frequent major life threatening pulmonary complications. We report massive aspiration pneumonia which occurred in a patient who received liquid dietary supplement (Isocal) tube feeding through a misplaced nasogastric tube into his right lower lobe bronchus. A 51-year-old man with advanced COPD with respiratory failure was intubated with a No 8 mm innerdiameter endotracheal tube and was on mechanical ventilatory support. The patient was receiving enteral hyperalimentation with 2,000 ml of full strength polymeric enteral alimentation feeding mixture (Isocal) per 24 hours. On the day of the patient's demise, the nasogastric tube was found not functioning, so it was removed and a 16 Fr Salem sump tube was inserted by the nurses and feeding continued. The tube placement was verified to be in the stomach by injecting air and listening over the upper stomach and also by aspirating Isocal-like stomach contents. After receiving about 500 ml of Isocal in the following six hours, the patient's general condition, oxygenation and ventilatory status deteriorated. A stat chest x-ray film showed dense alveolar infiltrates in his right lower lung field and also the tip of the nasogastric tube was noted to be in one of the right lower lobe segmental bronchi. The Salem sump tube was removed from the wedged position during which time Isocal spillover into the airways occurred; the patient had sudden cardiac arrest and resuscitative measures were unsuccessful. Wide bore nasogastric tubes have a higher incidence of producing pharyngitis, gastroesophageal reflex and pulmonary aspiration. The fine bore Silastic tubes with mercury weighted tips (eg, Dobbhoff enteric feeding tube) are better tolerated with fewer complications.1Bryan Brown CR Adler CD. Aspiration pneumonia in the intensive care unit..International Anesthesiology Clinic. 1977; 15: 71-84Crossref Scopus (2) Google Scholar,2Heymsfield SB et al.Enteral hyperalimentation: An alternative to central venous hyperalimentation..Ann Intern Med. 1979; 90: 63-71Crossref PubMed Scopus (215) Google Scholar Placement of the tube into the stomach is usually confirmed by injecting air and listening over the upper stomach. Radiologic confirmation of placement is not done routinely. Vigorous peristaltic sounds could be mistaken for injected air; to avoid misplacement of the feeding tube into lungs, the performer should be experienced in the procedure. If there is any doubt, radiologic confirmation should be obtained before initiating feeding. The presence of a cuffed endotracheal tube should not give a false sense of security that a nasogastric tube will not pass into the tracheobronchial airways. Isocal is made of soy oil and medium chain triglycerides fractionated from coconut oil. Even though vegetable oil aspiration produces less intense inflammation when compared to aspirations of animal oils, (eg, cod liver oil) the sudden spillover of Isocal might have produced severe oxygenation problems in this patient.