American Journal of Emergency Medicine xxx (2015) xxx–xxx

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Correspondence

Endotracheal tube–assisted orogastric tube insertion in intubated patients in an ED: some pragmatical concerns☆ To the Editor, We read with interest the article of Kwon et al [1] about the insertion of orogastric tube using an endotracheal tube as a guide to ease the procedure. We have some major concerns about this study. The first of all is related to the indications. The authors wanted to compare the insertion of a nasogastric tube with an orogastric tube in intubated patients maintaining a neutral position of the patients’ head [1]. However, we cannot understand the clear implications for clinical practice because the main reasons for orogastric intubation are usually maxillofacial injuries involving the skull base structures or anatomical or surgical hindrances to the passage of nasogastric tube through the nostrils [2,3]. Currently, in scientific literature, there are no absolute or relative contraindications to the insertion of nasogastric tubes in patients with cervical spine injury [2,3]. Therefore, we would like to ask the authors why they decided to perform orogastric and nasogastric intubation with the patients’ heads in neutral position, how they achieved and maintained it, and if they administered paralytic agents to ease the tube insertions. Moreover, as previously underlined by Liu et al [4], we think that Kwon et al should have compared the trial intervention with other known orogastric intubation methods [5]. Comparing only orogastric intubation procedures could have been useful to identify the best method for this kind of exception to the conventional procedure of insertion. Furthermore, even if the authors stated it in the discussion, the auscultation method used to confirm the correctness of tube’s position remains a huge limitation in this study. The main reason is because of the widely diffuse guidelines from literature advising against the risk of falsepositive result of the woosh test (injection of air through the gastric tube and contemporary auscultation of goorgling sound) [6]. It should have been sufficient to perform a chest x-ray in parallel to whoosh test, to confirm the nasogatric tube position. The lack of a chest x-ray response calls the 100% success rate of orogastric intubation in question. Lastly, we do not agree with the statement of the authors about the justification to resort to the orogastric way only because a high number of failed attempts of nasogastric tube introduction was reported in literature [1]. We would recall that orogastric tube is only a second choice in respect to the nasogastric way and that, as soon as possible, it must be changed. The feeding tube in the oropharyngeal cavity can easily be

dislodged and stimulate vomit receptors on the tongue, needing a good sedation level to tolerate it. Therefore, these conditions require a prompt replacement of the tube passing through the nostrils, allowing patients to begin programs of early awakening trial in intensive care unit, while being fed by the administration of enteral nutrition. Stefano Bambi RN, MSN University of Florence, Trauma and Extracorporeal Life Support Intensive Care Unit, DAI-DEA, Azienda Ospedaliero Universitaria Careggi 50134, Florence, Italy Corresponding author at: University of Florence; Trauma and Extracorporeal Life Support Intensive Care Unit, DAI-DEA, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3 50134, Florence, Italy E-mail addresses: [email protected], stefano.bambi@unifi.it Alberto Lucchini RN General Intensive Care Unit, Ospedale San Gerardo Monza 20052, Monza, Italy E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.03.043

References [1] Kwon OS, Cho GC, Jo CH, Cho YS. Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED. Am J Emerg Med 2015;33:177–80. [2] Shlamovitz GZ, Nirav RS, Chang AK, Windle ML, Lovato LM, Kate V. Nasogastric intubation. Medscape Reference. Updated: Oct 13, 2014 http://emedicine.medscape.com/ article/80925overview#a03. [Accessed 03-02-2015]. [3] Thomsen TW, Shaffer RW, Setnik GS. Videos in clinical medicine. Nasogastric intubation. N Engl J Med 2006;27(354(17)):e16. [4] Liu GP, Xue FS, Li RP, Sun C, Yang GZ. Measures to facilitate endotracheal tube-assisted orogastric tube insertion. Am J Emerg Med 2015;33:304. [5] Appukutty J, Shroff PP. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study. Anesth Analg 2009;109:832–5. [6] NHS – National Patients Safety Agency. Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=129697&; 2011. [Accessed 02-07-2015].

☆ The authors state that they have no conflicts of interest and no source of funding. 0735-6757/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Bambi S, et al, Endotracheal tube–assisted orogastric tube insertion in intubated patients in an ED: some pragmatical concerns, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.043

Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED: some pragmatical concerns.

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