Complications associated with a narrow bore nasogastric tube

The use of a new narrow bore nasogastric feeding tube with stylet has resulted in two cases of misplacement with traumatic laceration of the visceral pleura. Diagnoses were made by chest x-ray film, one case immediately and the other 24 hours later. In both cases, the narrow bore tube was inserted asymptomatically by a graduate physician. Detailed case reports of both patients are presented, those patients at risk for abnormal placement of this nasogastric tube are discussed, and new guidelines for safer use are proposed.