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LETTER TO EDITOR
Year : 2021  |  Volume : 10  |  Issue : 8  |  Page : 3167-3168  

Endotracheal tube as a conduit for difficult gastric feeding tube insertion in a tracheostomized patient


1 Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
2 Department of Anaesthesiology and Critical Care, AIIMS, Bhubaneswar, Odisha, India
3 Department of College of Nursing, AIIMS, Bhubaneswar, Odisha, India

Date of Submission04-Feb-2021
Date of Acceptance20-May-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Dr. Upendra Hansda
Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_255_21

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How to cite this article:
Hansda U, Tripathy S, Paniyadi NK, Varghese JJ. Endotracheal tube as a conduit for difficult gastric feeding tube insertion in a tracheostomized patient. J Family Med Prim Care 2021;10:3167-8

How to cite this URL:
Hansda U, Tripathy S, Paniyadi NK, Varghese JJ. Endotracheal tube as a conduit for difficult gastric feeding tube insertion in a tracheostomized patient. J Family Med Prim Care [serial online] 2021 [cited 2021 Sep 24];10:3167-8. Available from: https://www.jfmpc.com/text.asp?2021/10/8/3167/324714



A 60-year-old male was admitted to our hospital with a history of stroke, fever, and weakness and was diagnosed with COVID-19. He was on ventilator support for 20 days in the ICU. He recovered from COVID-19 and was discharged home with a tracheostomy and nasogastric (NG) tube for home-based care. Before discharge, he had a difficult NG tube insertion requiring critical care consultant intervention, use of an ice-cold tube, and direct laryngoscopy with Magills forceps. At home, it got dislodged, and local paramedical personnel could not insert it even with multiple attempts.

He was invited back for critical care follow-up visit the next day. On examination, the swallowing reflex was not strong, but the airway was maintained. As the patient expressed a strong desire for speaking, it was decided to decannulate the tracheostomy and insert a Freka nasogastric tube for a long stay. The Freka tube is a silicone feeding tube with a guidewire. There was resistance after some depth of insertion of the Freka tube. Direct laryngoscopy disclosed a blind false passage in the submucosa of the posterior pharyngeal wall.

Trying different methods, such as different scopes and upward pulling of the trachea,[1],[2],[3] did not work. So, we decided to insert the feeding tube orally. However, we were not able to advance from the proximal esophagus even after manipulating with Magill forceps. We first inserted the NG tube through one nare and pulled out the tip through the mouth with Magills forceps. Then, we inserted an endotracheal tube (ETT) into the esophagus under direct vision, and through this inserted the NG tube down the esophagus [Figure 1]. The ETT was split with a pair of scissors while slowly withdrawing it inch by inch. The position of the feeding tube was checked with a gastric insufflation test and imaging. The patient had no respiratory distress and feeds given through the feeding tube.
Figure 1: (a) Gastric tube passing through an endotracheal tube inserted into the esophagus. (b) Splitting of the endotracheal tube with a pair of scissors while withdrawing it

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Kumar et al. have described in detail, causes and methods of dealing with difficult NG insertion. In our case, ETT was not in situ, and the tracheostomy tube was removed. Still, we faced difficulty in inserting the Ryle's tube even with the maneuver described above. We inserted the feeding tube with the aid of an ETT. Although our technique is closest to Kumar et al.,[4] we feel it is simpler and more feasible in resource-limited settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dharmalingam TK, Gunasekaran V. Overcoming a difficult nasogastric tube insertion procedure with a video laryngoscope (C-Mac®). Indian J Crit Care Med 2016;20:751-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68-70.  Back to cited text no. 2
    
3.
Sahu S, Kishore K, Sachan V, Chatterjee A. A novel and innovative way of nasogastric tube insertion in anesthetized intubated patient. Anesth Essays Res 2017;11:248-50.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kumar P, Ray S, Shastri P, Rao BK. Gastric tube placement in difficult cases: An extensive review of the alternative methods. Indian Anaesthetists' Forum 2008. Available from: http://www.theiaforum.org. [Last accessed on 2021 Feb 4].  Back to cited text no. 4
    


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