Dr Stephen Taylor highlights issues surrounding feeding tube misplacement.

While it seems intuitive and rather obvious that some form of tube tracking is required, more than 95% of tubes in most centres are placed blindly. Once a tube is placed beyond the mouth or nose, you no longer know where the tube is. Although sophisticated tracking devices are available, such devices are used in less than 5 percent of all the tubes that are placed.

Although a patient’s response such as coughing, quickly alerts a clinician that a tube may be traveling down the respiratory tract, there remains uncertainty over the precise location of the tube. In the absence of a tracking system, several ‘end-of-procedure checks’ are used to help identify tube misplacements.

These checks, designed to ensure that a feeding tube has reached its intended location, are the only checks mandated and endorsed by regulatory authorities. This focus on detection of tube misplacements ignores a more important problem; the damage that might occur with blind tube placement. While undetected misplacements occur in 0.015% of tube placements and can result in a pneumothorax, pneumonia and even death, the current end-of-procedure checks fail to recognise any direct damage from respiratory placement. 1.6% of tubes enter the respiratory tract resulting in 0.49% causing a pneumothorax. This means that 97% of tube-related major complications and/ or death, cannot be prevented by using an end-of-procedure, pH or x-ray, checks - because they have already occurred before checking. In other words, end-of- procedure checks only ensure that food, water or medications are delivered to the correct location. Such checks cannot identify any trauma caused by insertion of the tube.

Currently, pH and chest x-ray checks are the standard practice to prevent undetected misplacements. Sometimes clinicians will also use a mid-procedure x-ray check which allows the operator to identify whether the tube has become lodged in the respiratory tract rather than the alimentary canal.

Around 6% of hospital patients require invasive nutritional support, particularly with nasogastric feeding, so tube insertion has become a relatively common intervention. This means that the procedure has also become deemed to be of low risk, which is simply not the case. Most people don’t realise that placing a nasogastric tube, which is one of easiest to do, has about the same morbidity and mortality as a tracheotomy.

Unfortunately, because regulatory bodies only permit pH and X-ray as the end-of-procedure checks, despite the success of guided-tube placement, these methods are really only perceived as acceptable ‘add-ons’ that increase the overall procedural costs. This serves only to discourage clinicians from using them, despite these being the only techniques that  prevent those lung complications and oesophageal misplacements that would otherwise happen and only be detected at the very end. Evidence from studies where these more sophisticated techniques have been used by untrained hands, has led to major complications. As a result, regulatory authorities, rather than mandating high quality training, have simply suggested that these techniques cannot be relied upon.

As well as sophisticated techniques, simple measures such as tilting the head chin down or pushing the lower jaw forward, can also help reduce tube misplacements.

There is still a need to reduce the level of misplacements, but this will only occur if regulatory bodies accept that risks arise not only from undetected misplacement but also from trauma during respiratory tract misplacement and oesophageal misplacement that pH can fail to detect. Regulatory authorities need to sanction the use of guided placement by an expert. But this would require the regulator to nationally mandate evidence-based guidance and training to attain expertise in guided methods.

Though electromagnetic tracking has been available for many years but remains expensive, the technology is under-used because the focus of guidelines is on reducing undetected misplacements and not on complications. While guided techniques are expensive, the costs associated with complications such as a pneumothorax are even higher.

For too long, insertion of feeding tubes has become seen as a routine procedure. Consequently, clinical staff remain largely ignorant of the potential risks and complications associated with the procedure and that there is an urgent need to change this mindset.