Ventilatory failure due to an improperly placed nasogastric tube

A case is described of a 35-yr-old patient who was transferred to the operating room for the repair of a right ventricular laceration. Prior to transfer a nasogastric tube was placed unknowingly beyond the tracheal tube cuff into the trachea. During the surgery, the patient's head was turned to insert a central venous line at which time the ventilator low pressure alarm sounded and effective ventilation ceased. The problem was corrected by turning off the nasogastric tube suction. It is postulated that the nasogastric tube became unkinked when the head was turned and this led to the evacuation of gas from the lungs and breathing circuit through the nasogastric tube suction. Identification of the problem was complicated by the lack of a temporal relationship between the insertion and connection to suction of the nasogastric tube, and the episode of ventilatory failure.