[Nasogastric tube: intratracheal malposition and entrapment in a bronchial suture]

We report the unrecognized accidental intratracheal insertion of a nasogastric tube, following endotracheal intubation in a patient scheduled to undergo right lower lobectomy for carcinoma. After surgery, which had an unremarkable course, the trachea was extubated. However, the gastric tube was entrapped and attempts to withdraw it elicited fits of coughing. A chest X-ray showed the tube malpositioned in the right bronchus. A fibreoptic bronchoscopy did not permit removal of the tube extremity which was embedded in the bronchial suture. Finally an additional thoracotomy was required to withdraw the tube securely. The manifestations of the intratracheal position of a nasogastric tube as well as the preventive and diagnostic measures of such a complication are considered.