[Displacement of endobronchial tube in a neonate in spite of using recommended methods]

Placement of nasogastric tubes are common procedures in neonatal departments, but there is a risk of severe complications although it is considered an innocuous procedure. This case report describes accidental endobronchial tube displacement in a mature neonate despite using clinically recommended methods of verification. It illustrates how symptoms of tube displacement can be disregarded, especially in critically ill neonates. Radiologic examination is the recommended method to ensure tube position but it cannot be used as daily practice. Commonly used methods of bedside verification are discussed.