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EMS brings you a 60 year old with fever, shock and progressive respiratory failure.  The patient was seen by his primary doctor two days ago and treated for “bronchitis, possible pneumonia”. You intubate him immediately upon arrival for severe respiratory insufficiency. Breath sounds are heard bilaterally. NG tube and foley are placed.  Post-intubation vitals are P 130, BP 90/60, RR 18 on the ventilator w/ TV 550, sat 99% on 100% oxygen. He is hypothermic (rectal temp 96.2F). Resuscitation is started, ABG, & cultures are drawn, and IV antibiotics ordered.

A post-intubation CXR is done.  What does it show?
See next page for conclusion.
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This is a common complication in resuscitation, especially in a patient with a large-diameter trachea that lies very posterior in the lower pharynx.  It is also a problem that is easy to miss.  In this case, we were looking for pneumonia clinically.  The R-sided “infiltrate” or haziness would seem to suggest this diagnosis, and the busy clinician would often stop processing at that point and move forward with a diagnosis of pneumonia.  Note also that the classic “diminished breath sounds” on the appropriate side associated with ET or NG misplacement may not be appreciated in the noisy trauma room, or by busy and distracted clinicians.  In this case also, NG auscultation of the stomach was done, and the tube thought to be correctly placed.  Of course, no stomach contents were aspirated (an early clue to NG misplacement).

Placement of the NG in the R mainstem bronchus (with wall suction applied) can lead to volume loss from hypoventilation and mechanical blockage or the bronchus, as well as partial lung collapse.  This volume loss is clearly seen if you step back from the film and compare the size of the lungs left-to-right.  Clinically, the respiratory therapist helped us to identify the problem;  they noted unexpected elevated airway pressures, which led us to re-evaluate the patient by exam and to check the CXR.

Treatment is removal of the tube with repositioning in the stomach.
       
Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course.  www.emprepcourse.com
 

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