Accidental tracheal intubation of feeding tube

Feeding tube insertion is a basic routine procedure. Little has been written on how to check for placement of small bore nasointestinal feeding tubes. A major risk is accidental placement of the tube into the respiratory system. We report a case of accidental tracheal intubation of feeding tube in an intubated, polytrauma patient. The patient was shifted to intensive care unit (ICU) for ventilatory support in the post-operative period. He was weaned off the ventilator and enteral feeding was planned by the third post-operative day. Immediately after feeding tube insertion the patient developed respiratory distress. Mechanical ventilation was resumed. On re examination, the feeding tube was found to be in the trachea. It was immediately removed. The condition of the patient improved thereafter.