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Discussion

Iatrogenic pneumothorax from misplaced insertion of an NGT down the trachea into a main bronchus is a recognized complication. 1-3 It is rarely seen clinically however, and we suspect it is even more rarely discussed with patients and their families as a potential risk of the procedure. Although our case is regarding an inpatient, the same risks apply to outpatients routinely receiving NGT insertions at home or in outpatient settings. Most publications describing this complication are found in nursing journals4 or in the adult literature. 1, 2, 5 Despite its life-threatening consequences, however, there is minimal pediatric literature about iatrogenic tension pneumothorax after incorrect placement of NGT, or about complications of other misplacements. 6, 7 Strategies to prevent this