C48-12 Delayed Recognition of Nasogastric Tube Displacement: A Case of Aspiration Leading to Respiratory Failure After Extubation

Introduction Nasogastric (NG) tube misplacement is a recognized yet preventable cause of pulmonary complications in critically ill patients. Although malposition is typically detected during or shortly after insertion, delayed recognition following initially confirmed placement is uncommon and can result in significant morbidity. Case Presentation A 42-year-old male with history of hypertension, and hyperlipidemia was admitted after a high-speed motor-vehicle collision, presenting as a level 1 trauma. Injuries included a grade 3 liver laceration, grade 2 splenic injury, mesenteric contusions with active bleeding, small- and large-bowel injuries, and multiple extremity fractures. He underwent emergent laparotomy with bowel resection and temporary abdominal closure, followed by re-exploration and ileocolonic anastomosis with definitive closure. During his ICU course, he developed acute hypoxic respiratory failure requiring intubation and vasopressor support. An NG tube was placed intraoperatively and its position confirmed. On hospital day five, he was extubated but developed emesis and progressive hypoxia about 12 hours later. Repeat imaging revealed migration of the NG tube into the right mainstem bronchus with evidence of aspiration. He was promptly re-intubated, and bronchoscopy performed after re-intubation showed minimal right-sided secretions without significant airway inflammation. Broad-spectrum antibiotics were started but discontinued once no radiologic or clinical evidence of aspiration pneumonia was observed. He remained hemodynamically stable and recovered with supportive care, with plans for orthopedic fixation once medically optimized. Discussion This case highlights a rare instance of delayed NG-tube migration after initially confirmed placement, leading to aspiration and respiratory failure. Migration can occur silently because of patient movement, coughing, or inadvertent advancement during care. Even when placement is confirmed, subsequent displacement may develop without warning, underscoring the importance of re-evaluation whenever respiratory status changes. Conclusion Routine reassessment of NG-tube position should be incorporated into ICU safety protocols particularly following extubation, airway manipulation, or the onset of new hypoxia. Clinicians should recognize that silent migration can cause bronchial misplacement and aspiration without overt signs. Early detection and structured post-placement verification protocols can substantially reduce preventable respiratory complications and improve patient safety in the critical-care environment.