Nasogastric tube feeding-induced iatrogenic empyema: a report of two cases and literature review
Case Report

Nasogastric tube feeding-induced iatrogenic empyema: a report of two cases and literature review

Nobutaka Kawamoto ORCID logo, Shunsuke Morita, Masanobu Watari, Keizo Misumi ORCID logo

Department of Thoracic Surgery, JA Hiroshima General Hospital, Hatsukaichi, Japan

Contributions: (I) Conception and design: N Kawamoto, K Misumi; (II) Administrative support: K Misumi; (III) Provision of study materials or patients: N Kawamoto, M Watari, K Misumi; (IV) Collection and assembly of data: N Kawamoto, S Morita; (V) Data analysis and interpretation: N Kawamoto; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Nobutaka Kawamoto, MD, PhD. Department of Thoracic Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima 738-8503, Japan. Email: kawamotonobutaka@gmail.com.

Background: The incidence of incorrect nasogastric tube (NGT) insertion into the trachea or distal airways is approximately 2%. When an NGT penetrates the visceral pleura and enteral feeding products are inadvertently administered into the lungs or thoracic cavity, severe chemical pneumonia and empyema can develop. Thus, confirming the NGT placement site before initiating feeding is crucial. Chest radiography (CXR) remains the gold standard for confirming NGT placement. However, enteral feeding products are often administered without prior CXR, leading to complications. This report describes two cases of iatrogenic empyema caused by incorrect placement of NGT in the thoracic cavity.

Case Description: Case 1 was a 70-year-old man with a history of cerebral hemorrhage sequelae who was receiving NGT feeding. Routine NGT replacement was performed without CXR. Dyspnea developed following the administration of an enteral feeding product. Emergency CXR revealed incorrect NGT placement in the right thoracic cavity. The patient’s circulation was stable, and he was managed with chest drainage. Case 2 involved a 95-year-old woman who was debilitated due to advanced age and was receiving NGT feeding. Routine NGT replacement was performed without CXR. Subsequently, she developed dyspnea and hypotension after the administration of an enteral feeding product. Emergency CXR and computed tomography revealed NGT placement in the right thoracic cavity, accompanied by a right pneumothorax and pleural effusion. As the patient was in shock, emergency surgery was performed following chest drainage. Both patients recovered successfully.

Conclusions: Iatrogenic empyema induced by NGT feeding is a severe complication often resulting in respiratory failure. Prompt management with chest drainage is critical, and emergency surgery should be considered in cases of circulatory failure. To prevent such events, accurate evaluation of NGT placement via CXR before commencing feeding is imperative. Additionally, the indications for NGT insertion should be carefully assessed on a case-by-case basis.

Keywords: Case report; empyema; enteral nutrition; medical malpractice; nasogastric tube (NGT)

Received: 30 December 2024; Accepted: 21 May 2025; Published online: 10 September 2025.

doi: 10.21037/acr-24-294

Highlight box

Key findings

• Nasogastric tube (NGT) feeding-induced empyema is a serious medical malpractice.

• Chest drainage plays a crucial role in treatment, and emergency surgery should be considered, particularly in cases of circulatory failure.

What is known and what is new?

• NGTs can be incorrectly inserted into the thoracic cavity. Although chest radiography (CXR) is the gold standard for confirming the placement of an NGT, enteral feeding products are often administered immediately after insertion without performing a CXR.

• This is the first review of cases of NGT feeding-induced iatrogenic empyema caused by incorrect insertion of the NGT into the thoracic cavity via the distal airway. NGT feeding-induced empyema frequently leads to respiratory failure; therefore, respiratory status should be closely monitored following the initiation of NGT feeding.

What is the implication, and what should change now?

• To prevent similar incidents, it is critical to confirm the placement of the NGT using a CXR before commencing feeding.

• Given the potential for severe complications, the indication for NGT insertion must be carefully evaluated on a case-by-case basis.

Introduction

Background

The blind placement of a nasogastric tube (NGT) is a common bedside procedure, with an estimated 2% incidence of incorrect insertion into the trachea or distal airways (1). Complications such as pneumothorax or hemothorax can occur if the NGT penetrates the visceral pleura (1). Additionally, administering enteral feeding products into the lungs or thoracic cavity can lead to severe chemical pneumonia and empyema (2). Therefore, it is crucial to evaluate the placement of the NGT before initiating feeding.

Rationale and knowledge gap

Although the auscultation of gas insufflation is widely used to confirm that an NGT is located in the stomach, its sensitivity and specificity have been reported to be 79% and 61%, respectively (3). Another method involves measuring the potential of hydrogen (pH) of NGT aspirate samples. It has been reported that in 98.9% of the cases in which an NGT was located in the stomach, the pH of the aspirate samples was ≤5.5 (3). However, obtaining gastric aspirate samples immediately after NGT insertion is possible in only about half of the cases, and the intragastric pH can change easily due to proton pump inhibitors, prolonged fasting, or enteral nutrition (3). Consequently, these methods are not reliable for confirming the NGT placement site, and chest radiography (CXR) is the gold standard method (1). Despite this, enteral feeding products are often administered after NGT insertion without performing a CXR, depending on the patient’s medical situation. There have been several case reports of NGT feeding-induced iatrogenic empyema caused by incorrect NGT insertion into the thoracic cavity (1,2,4-11).

Objective

Herein, we report two cases of iatrogenic empyema induced by NGT feeding, resulting from incorrect NGT insertion into the thoracic cavity via the distal airway. Additionally, we review previously reported similar cases to clarify the patient’s backgrounds and the circumstances of occurrence, and to identify preventive measures for this medical malpractice. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-294/rc).

Case presentation

Case 1

A 70-year-old man with disorders of consciousness and dysphagia due to sequelae of cerebral hemorrhage was receiving NGT feeding. Routine NGT replacement was performed and an enteral feeding product was administered through the NGT without confirming placement via CXR. Subsequently, the patient developed dyspnea. Emergency CXR revealed that the NGT had been incorrectly inserted into the airway through the right bronchus and had entered the right thoracic cavity (Figure 1A). The NGT was removed, and the patient was transferred to our hospital. Upon arrival, his vital signs were as follows: body temperature of 38.5 ℃, heart rate of 101 beats per minute, blood pressure of 154/103 mmHg; regarding the respiratory status, the saturation in peripheral oxygen (SpO2) was 100% (oxygen 6 L/min via non-rebreather mask) and respiratory rate was 36 breaths per minute. A CXR revealed collapse of the right lung and decreased permeability of the right lung field (Figure 1B). Computed tomography (CT) showed a right pneumothorax, right pleural effusion, and pulmonary infiltrating shadow in the right lower lobe (Figure 1C,1D). A chest drainage tube was inserted, and the enteral feeding product in the thoracic cavity was drained. A bacterial culture of pleural effusion detected Klebsiella pneumoniae. Antibiotics were administered to treat the chemical pneumonia and empyema. The following day, the air leakage was resolved. Subsequently, the chest drainage tube was removed on hospitalization day 11, and the patient was transferred back to the previous hospital on hospitalization day 32.

Figure 1 Imaging findings of Case 1. (A) A CXR image showing a NGT passing through the right bronchus and entering the right thoracic cavity. (B) A CXR image taken after NGT removal, demonstrating a right pneumothorax (yellow arrows delineate the pneumothorax) and reduced permeability of the right lung field. (C,D) Computed tomography images demonstrate a right pneumothorax, right pleural effusion, and pulmonary infiltrate in the right lower lobe. CXR, chest radiography; NGT, nasogastric tube.

Case 2

A 95-year-old woman, debilitated due to aging, was receiving NGT feeding. During routine NGT replacement, insertion was found to be difficult; therefore, an NGT with a wire stylet was inserted. The NGT placement site was confirmed by auscultation over the epigastrium. An enteral feeding product was administered through the NGT, and the patient subsequently developed dyspnea and decreased blood pressure. Emergency CXR revealed that the NGT was incorrectly inserted into the right bronchus, decreasing the permeability of the right lung field (Figure 2A). The patient was transferred to our hospital. On arrival, her vital signs were as follows: body temperature of 37.5 ℃, heart rate of 107 beats per minute, blood pressure of 89/63 mmHg; regarding the respiratory status, the SpO2 was 100% (oxygen 10 L/min via non-rebreather mask) and respiratory rate was 27 breaths per minute. CT revealed that the NGT had been placed in the right thoracic cavity through the right lower-lobe bronchus and right lower-lobe lung parenchyma (Figure 2B-2G). In addition, right pneumothorax, right pleural effusion, complete atelectasis of the right lower lobe, and a pulmonary infiltrating shadow in the left lower lobe were observed. The patient was in shock, and emergency thoracoscopic surgery was performed following right-sided chest drainage. Surgical findings showed that the enteral feeding product was pooled in the right thoracic cavity (Figure 3A). The NGT had penetrated the visceral pleura of the right lower lobe, and a tube was observed in the thoracic cavity (Figure 3B). The NGT was removed under bronchoscopic guidance (Figure 3C), and the penetrating wound involving both the visceral pleura and lung parenchyma was resected using a surgical stapler (Figure 3D). The operative time was 88 minutes, with minimal blood loss. The bacterial culture of the pleural effusion was negative. Postoperatively, antibiotics and respiratory care with a ventilator were administered to treat the chemical pneumonia. The patient was weaned from the ventilator on postoperative day (POD) 6 and norepinephrine was discontinued on POD 7. The chest drainage tube was removed on POD 8, and the patient was transferred back to the previous hospital on POD 14.

Figure 2 Imaging findings of Case 2. (A) A chest radiography image showing incorrect placement of a NGT in the right bronchus and reduced permeability in the right lung field. (B-G) Computed tomography images show the NGT (yellow arrows) entering the right thoracic cavity via the right lower-lobe bronchus and parenchyma, causing a right pneumothorax, right pleural effusion, complete atelectasis of the right lower lobe, and pulmonary infiltration in the left lower lobe. NGT, nasogastric tube.
Figure 3 Surgical findings of Case 2. (A) Pooling of an enteral feeding product in the right thoracic cavity. (B) Visualization of the NGT penetrating the visceral pleura of the right lower lobe and entering the thoracic cavity. (C) Blockage of the right B7–10 bronchi by enteral feeding products, with NGT removed using bronchoscopic guidance. (D) Resection of the penetrating wound involving both the visceral pleura (yellow arrow) and lung parenchyma was performed using a surgical stapler. NGT, nasogastric tube; RLL, right lower lobe; RML, right middle lobe.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and the Declaration of Helsinki (and its subsequent amendments). Written informed consent was obtained from the patients for the publication of this case report and the accompanying images. A copy of the written consent form is available for review by the journal’s editorial office.

Discussion

Key findings

We have described two cases of NGT feeding-induced iatrogenic empyema caused by incorrect insertion of the NGT into the thoracic cavity. In both cases, enteral feeding products were administered through the NGT without confirming the placement via CXR. Treatment included chest drainage, with emergency surgery performed in Case 2 due to circulatory failure. Both patients were successfully treated.

Strengths and limitations

A key strength of this report is that it is the first review of previously reported cases of NGT feeding-induced iatrogenic empyema caused by incorrect NGT insertion into the thoracic cavity via the distal airway. Understanding the patient characteristics and circumstances could help in identifying high-risk individuals and stimulate discussions on preventive strategies for this form of medical error. Additionally, this report encourages a reevaluation of the indications and necessity for NGT feeding. A limitation is the scarcity of similar case reports, which restricts the generalizability of our findings. Accumulating further case reports may help in identifying life-saving measures.

Comparison with similar research

Incorrect NGT placement in the thoracic cavity has been reported not only via the distal airway (i.e., bronchus and lungs) but also via the pharynx or esophagus (12-14). This review focuses on cases of NGT feeding-induced iatrogenic empyema arising from incorrect NGT insertion into the thoracic cavity via the distal airway (Table 1) (1,2,4-11). Of the ten cases with known prognosis, five resulted in death, underscoring the severity of this medical error. Most patients were in acute care or were debilitated older individuals. While enteral nutrition is critical for acute care patients (15), it has not been recommended for terminal-stage older patients in Western countries since 2000 (16). Conversely, long-term enteral nutrition is commonly administered to older individuals in East Asia (17,18). The practical guidelines of the European Society for Clinical Nutrition and Metabolism recommend less than 6 weeks of nutritional support with NGTs, and percutaneous endoscopic gastrostomy (PEG) is appropriate for patients who require long-term nutritional support (19). In East Asia, since family members are reluctant for patients to undergo further surgical procedures in addition to the current disabilities and diseases due to cultural and religious factors, an NGT tends to be used for long-term enteral nutrition rather than PEG (20). CXR remains the gold standard for confirming correct NGT placement in the stomach and is routinely performed in the intensive care unit (1). However, bedside availability of CXR varies based on the medical context (21). Accordingly, recent cases of NGT feeding-induced iatrogenic empyema have primarily involved debilitated older patients in East Asia (8,9).

Table 1

Reported cases of NGT feeding-induced iatrogenic empyema

Author Year Country Age (years) Sex Underlying medical conditions Reason for NGT insertion CXR Laterality Symptom Pleural fluid culture test Treatment Outcome
Torrington et al. (4) 1981 USA 43 Male Multiple sclerosis, debility Routine replacement No Left Fever, chills N/A Chest drainage Dead
Miller et al. (5) 1985 USA 68 Female Pulmonary embolism, UMV Routine replacement No Right None N/A Chest drainage Unknown
Odocha et al. (6) 1989 USA 54 Female Post CABG, UMV Initial insertion No Right Respiratory failure N/A Chest drainage, antibiotics Alive
Rassias et al. (1) 1998 USA Unknown Male Sepsis, UMV Initial insertion Yes Left Unknown N/A Chest drainage Dead
Haas et al. (2) 2006 Netherlands 65 Female Debility Unknown Yes Right Fever, respiratory failure, cough N/A Chest drainage Unknown
Felipe-Silva et al. (7) 2012 Brazil 61 Female Lymphoma, debility Initial insertion No Right Respiratory failure, shock N/A Conservative treatment Dead
Kao et al. (8) 2012 China 67 Male Ulcerative colitis Unknown No Right Respiratory failure, chest pain, cough N/A Chest drainage, antibiotics, lung lavage, ECMO Alive
Cao et al. (9) 2020 China 79 Female Cerebrovascular disease Routine replacement No Right Dysphoria N/A Chest drainage Dead
Hussain et al. (10) 2021 USA 66 Male Septic shock, encephalopathy Initial insertion Yes Left Respiratory failure N/A Chest drainage, antibiotics Dead
Chan et al. (11) 2022 Australia 80 Female Cerebrovascular disease Self-removal Yes Left Respiratory failure MRSA, Enterococcus faecalis Chest drainage, antibiotics Alive
Present Case 1 2024 Japan 70 Male Cerebrovascular disease Routine replacement No Right Respiratory failure Klebsiella pneumoniae Chest drainage, antibiotics Alive
Present Case 2 2024 Japan 95 Female Debility Routine replacement No Right Respiratory failure, shock Negative Chest drainage, antibiotics, operation Alive

CABG, coronary artery bypass grafting; CXR, chest radiography; ECMO, extracorporeal membrane oxygenation; MRSA, methicillin-resistant Staphylococcus aureus; N/A, not applicable; NGT, nasogastric tube; UMV, under mechanical ventilation.

Four cases of misinterpreted NGT placement on CXR have been reported (1,2,10,11). Accurate evaluation requires review of both frontal and lateral CXR images by multiple physicians. If CXR results are inconclusive, CT should be considered. As respiratory failure is common in NGT feeding-induced empyema, the patients’ respiratory status should be closely monitored post-feeding initiation. Additionally, in patients who already have an NGT in place and have received enteral feeding several times, the insertion length should be checked each time before administering enteral feeding products to ensure that the NGT is not misaligned.

In all but one of the reported cases, chest drainage was performed, indicating that it plays a crucial role in treatment. In Case 1, the NGT was removed without chest drainage at another hospital. Removal of an NGT incorrectly placed in the thoracic cavity may result in tension pneumothorax, which can be fatal (22). Although tension pneumothorax did not occur in Case 1, chest drainage is recommended before removing such NGTs. In Case 2, emergency surgery was performed to address shock. Prompt closure of bronchopleural fistula is important in the treatment of empyema with fistula (23). However, surgical intervention in a critical situation with altered vital parameters can be over-invasive; therefore, the necessity and timing of surgery should be carefully determined in each case. As a surgical procedure, closure of the penetrating wound of the visceral pleura could be sufficient. However, a lung abscess because of foreign bodies may form at the penetrating wound of the lung parenchyma (24). In Case 2, the penetrating wound involving both the lung parenchyma and visceral pleura was resected for more reliable infection control. Management strategies for incorrect NGT insertion into the distal airway or thoracic cavity are outlined in Figure 4.

Figure 4 Treatment strategy following incorrect NGT insertion into the distal airway or thoracic cavity. Yellow arrow, tip of the NGT. CXR, chest radiography; NGT, nasogastric tube.

Explanations of findings

Preventing incorrect NGT insertion is crucial to avoid NGT feeding-induced iatrogenic empyema. Encouraging patients to swallow during NGT insertion reduces the risk of airway entry. Major risk factors for incorrect placement include endotracheal intubation, tracheostomy, altered mental status, and diminished cough or gag reflexes (1,25). Therefore, high-risk patients for incorrect NGT insertion are often asymptomatic at the time of NGT misplacement (1). Techniques such as fluoroscopy, laryngoscopy, or endoscopy-guided NGT insertion, and confirmation with ultrasonography or capnography, have been proposed to ensure safe placement (1,21,26). Although these techniques increase the cost and time required for insertion and necessitate specialist assistance, they are preferable for patients at high risk of incorrect NGT placement. In routine clinical practice, however, it is impractical to apply these methods during all NGT insertions, and the procedure often involves a degree of blind placement. If incorrect NGT placement into the thoracic cavity is identified before initiating feeding, the situation is less likely to become critical. Therefore, confirming the placement of the NGT using CXR following insertion is crucial.

Implications and actions needed

Accumulative reports on complications associated with NGT feeding highlight the serious risks involved, promoting increased awareness of these issues. Consequently, the indications and necessity for NGT placement should be carefully reconsidered.

Conclusions

Iatrogenic empyema caused by NGT feeding is a significant medical complication. Prompt chest drainage is critical for management, and emergency surgical intervention should be considered, especially in cases of circulatory instability. Moreover, it is important to recognize the potential for NGT misplacement in the thoracic cavity. To prevent such occurrences, an accurate evaluation of NGT placement using CXR is essential before starting feeding.

Acknowledgments

We thank Editage (http://www.editage.jp) for their assistance with English language editing.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-294/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-294/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-294/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (and its subsequent amendments). Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/acr-24-294
Cite this article as: Kawamoto N, Morita S, Watari M, Misumi K. Nasogastric tube feeding-induced iatrogenic empyema: a report of two cases and literature review. AME Case Rep 2025;9:148.

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