A case report describing accidental swallowing of an intermittent oro-esophageal tube

Han Xu; Lin Yan; Yin Lei; Qin Shen; Li Ding; Lin Gu

doi:10.4103/2773-2398.356525

CASE REPORT

Year : 2022 | Volume : 1 | Issue : 3 | Page : 143-145

A case report describing accidental swallowing of an intermittent oro-esophageal tube

Han Xu, Lin Yan, Yin Lei, Qin Shen, Li Ding, Lin Gu
Department of Rehabilitation Medicine, Shanghai Ruijin Rehabilitation Hospital, Shanghai, China

Date of Submission	23-Jul-2022
Date of Decision	30-Aug-2022
Date of Acceptance	15-Sep-2022
Date of Web Publication	29-Sep-2022

Correspondence Address:
Lin Gu
Department of Rehabilitation Medicine, Shanghai Ruijin Rehabilitation Hospital, Shanghai, China
China

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2773-2398.356525

Abstract

A 74-year-old man with dementia was undergoing rehabilitation following a recent cerebrovascular accident. A nasogastric tube was inserted owing to swallowing dysfunction. However, the patient often dislodged the tube. We decided to apply intermittent feeding via an oro-esophageal tube. One day, he accidentally swallowed the tube into his stomach. The intermittent oro-esophageal tube was successfully removed by gastroscopy. This case herein highlights the need to be aware of dysphagia in patients with dementia when inserting an intermittent oro-esophageal tube.

Keywords: cognitive impairment; dementia; dysphagia; intermittent oro-esophageal tube; nasogastric tube

How to cite this article:
Xu H, Yan L, Lei Y, Shen Q, Ding L, Gu L. A case report describing accidental swallowing of an intermittent oro-esophageal tube. Brain Netw Modulation 2022;1:143-5

How to cite this URL:
Xu H, Yan L, Lei Y, Shen Q, Ding L, Gu L. A case report describing accidental swallowing of an intermittent oro-esophageal tube. Brain Netw Modulation [serial online] 2022 [cited 2023 Jun 4];1:143-5. Available from: http://www.bnmjournal.com/text.asp?2022/1/3/143/356525

Han Xu, Lin Yan
Both authors contributed equally to this work.
Funding: This study was supported by grants from Shanghai Huangpu District Health Commission, Nos. HLQ202110 and HLM202115

Introduction

Intermittent oro-esophageal (IOE) tube feeding is a common procedure that is performed by healthcare professionals to provide enteral nutrition for patients with dysphagia. Complications caused by the insertion of an IOE tube are rarely reported. Although this is a simple procedure, there is a risk of adverse events if appropriate care is not taken. In this report, we describe the case of an accidental swallowing of the IOE tube into the stomach by a patient with cognitive impairment.

Case report

A 74-year-old Han Chinese man was admitted to a local hospital with acute cerebrovascular disease on the August 11, 2021. His cranial computed tomography (CT) scan revealed a bilateral basal ganglia hemorrhage. As a result of his neurological deficits, including severe cognitive impairment (a Mini-Mental State Examination score of 8) (Wu et al., 2021), global aphasia, dysphagia and right hemiplegia, he then received rehabilitation treatment in our institution. A nasogastric tube (NGT) was inserted; this is a traditional method used to treat patients with impaired swallowing function. However, the nasogastric tube was frequently dislodged by the patient due to poor comfort. As a consequence, we planned to insert an IOE tube to facilitate feeding; this mode of treatment is more comfortable, more psychologically acceptable and has fewer complications, such as aspiration-related pneumonia, when compared with NGT. We demonstrated that the pharyngeal reflex could be elicited voluntarily. The patient then underwent a video-fluoroscopic swallowing study (VFSS). The VFSS reported delayed swallow initiation in the oral phase, penetration, and residuals in the epiglottis when swallowing a 10-mL nectar bolus and pudding bolus in the pharyngeal phase. The first IOE tube was inserted by an experienced rehabilitation physician on day 20 after admission. To insert the IOE, the patient was placed in a sitting position. Then, a conventional enteral tube (18 Fr, 6 mm) was inserted orally. The patient was then encouraged to swallow when the tip touched the lateral wall of the pharynx. The tube was placed on the edge of his lips after reaching the lower esophagus. A water pouch was then created by injecting 5 mL of water to fix the tube. The depth of insertion was marked. Then, a bolus of food was injected via the tube. Finally, the tube was withdrawn after a full injection. According to the patient’s specific meal volume, the patient received 300-400 mL per injection. The injection speed was slow (50 mL/min). After feeding and extubation, the patient remained seated for at least 30 minutes.

Consent was obtained from the patient’s family, and he cooperated well. Despite his cognitive impairment, the intubation procedure was uneventful in the first 2 weeks. At dinner time on the 21^st of January 2022, a physician placed the IOE tube to the previously marked point and fixed it in position; she then turned around to prepare the food. However, the physician was unable to find the newly inserted IOE tube when preparing to feed.

We suspected the patient mistook the tube for noodles and swallowed it because had he expressed the desire to eat noodles that afternoon. However, nothing was found in his mouth. He did not present with shortness of breath, desaturation, abdominal pain, nausea or vomiting. While confirming the position of the tube by gastroscopy, we found the connector of the tube had been swallowed down into the middle of the esophagus [Figure 1]A. We failed to grip the tube by the ferrule because the “Y”-shaped connector had stuck in the wall of the esophagus. Furthermore, when the patient swallowed, the tube had reached the stomach; the tip of the tube was close to the pylorus. As we had used a “Y”-shaped connector, there was a high risk of the connector becoming stuck and the ferrule falling off. We changed the target to the tube tip so that the tube could be grasped tightly. Fortunately, although the tube tip was close to the entrance to the pylorus, it had not fallen off [Figure 1]B. Subsequently, the tube was removed uneventfully; the patient had no discomfort during the procedure. He continued to undergo a period of rehabilitation treatment before being discharged upon clinical improvement.

Figure 1: Detection of an IOE tube in the esophagus under gastroscopy.
Note: (A) The tube was swallowed down into the middle esophagus. (B) The tip of the IOE tube was close to the pylorus. IOE: Intermittent oro-esophageal.

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This case report was approved by the Institutional Review Board of Shanghai Ruijin Rehabilitation Hospital (approval No. RKIRB2022-01) in 2022. The patient also provided signed and informed written consent.

Discussion

Full oral feeding can only be achieved in 27.3–64.7% of patients with dysphagia after stroke (Kim et al., 2015; Kang et al., 2019). In 2006, researchers proved that IOE tube feeding can be used as an efficient feeding method for acute stroke patients with serious dysphagia (Nakajima et al., 2006). The IOE tube is inserted into the esophagus or stomach through the mouth whenever patients need to eat and is then removed immediately after feeding. This feeding method is considered more consistent with the physiological needs of the human body, thus reducing the risks of aspiration and aspiration-associated pneumonia (Wu et al., 2021). Insertion of an IOE tube can be therapeutic for dysphagia since it can stimulate oropharyngeal sensation through repeated intubation, induce the pharyngeal reflex, and encourage oropharyngeal muscle activity when swallowing to improve swallowing function (Woodhouse et al., 2018). Nowadays, IOE tube insertion is a common feeding procedure for nutritional support that is often-performed bedside. Side effects related to IOE tube insertion are rarely reported. In contrast, there are a number of well-documented adverse events associated with the continuous use of a NGT, including careless removal of the tube with an essential risk of pulmonary aspiration and the discontinuation of nutritional intake caused by frequent misplacement of the nasogastric tube (Norton et al., 1996).

Only minor complications were reported by Nakajima et al. in their study of IOEs. One patient showed an exacerbation of bronchitis due to increased pharyngeal secretions. The oral cavity of one patient experienced supplemental reflux, but no pneumonia. There were no complications in any of the other 11 patients. This research suggested that IOE tubes should not be applied to patients who are unable to comprehend the IOE procedure (Nakajima et al., 2006). Almost all previous studies associated with IOE tubes excluded patients with cognitive dysfunction. However, in clinical practice, rehabilitation physicians need to be able to place IOE tubes for patients with dementia. There is a risk of some of these patients dislodging their nasogastric tubes on a frequent basis due to comfort, as in our present case. Despite his cognitive impairment, we attempted to insert an IOE tube for feeding after VFSS. Unfortunately, the tube was swallowed down into the stomach. This is a very rare event.

Nutritional support for dysphagia with cognitive impairment remains a challenging problem. Several authors have discussed the application of enteral nutrition for the management of dysphagia (Gomes et al., 2015; Ojo and Brooke, 2016; Flynn et al., 2018; Juan et al., 2020). A typical management technique is to alter the consistency of food or fluids or both, although the efficacy of such treatment may be influenced by the specific type of dementia (Flynn et al., 2018). Long-term nutritional support includes inserting a percutaneous endoscopic gastrostomy (PEG) tube. However, this method is an invasive procedure that is not the first choice for most patients. In addition, according to previous research, patients with a PEG were associated with a worse quality of life and lived in institutions more frequently (Ojo and Brooke, 2016). NGT is also a classic and widely used technique but has many limitations. First, NGT may result in aspiration pneumonia due to increased levels of gastric secretion. Second, some patients often refuse the NGT feeding method due to discomfort and its unsightly appearance. Third, a large proportion of patients with dysphagia also require rehabilitation treatment. The NGT device may impact the efficacy of training. In conclusion, compared with other feeding methods, feeding with an IOE tube may reduce the occurrence of pneumonia and enhance a patient’s swallowing abilities, quality-of-life and psychological status (Juan et al., 2020). Therefore, IOE tube feeding could be promoted and applied in clinical practice. In our hospital, we always select IOE tube feeding for patients with dementia and swallowing difficulties if they understand the procedure. Nevertheless, we would also like to consider this method for patients with severe cognitive impairment after VFSS. Since there is no need for an NGT, the IOE tube can promote swallowing function and has a more acceptable appearance. This may give patients more faith in their ability to recover and help them adhere to their treatment plan in a more energetic and effective manner. Hence, the exploratory use of IOE tube feeding in patients with severe cognitive impairment meets our current clinical needs. In future, we will develop a safer technique for high-risk patients, as in the case described herein, to avoid serious complications caused by the insertion of an IOE tube.

There are certain limitations in this case that need to be considered. First, the IOE tube that we used was slightly too short. Second, fixation was only applied on a single end of the tube. Furthermore, injecting a water pouch should not be considered the only way to fix the tube after insertion, especially for patients with dementia. For this patient, we adjusted and fixed the interface end at the same time; subsequently, the tube was never swallowed again. Nutritional support for patients with dysphagia and cognitive impairment is a major challenge but also an urgent problem. In our institution, IOE tube feeding is usually selected after VFSS. In future, it is important to be aware of the expectant complications of cognitive impairment. This case highlights the need for special attention when inserting tubes and reminds us that each step during insertion should be handled with extreme caution. However, appropriate criteria for the insertion of IOEs in patients with varying degrees of cognitive impairment have yet to be established and needs to be investigated in future research.

Author contributions: Study conception: HX, LY; manuscript draft and resion: HX, LY, YL, QS, LD; supervision: LG. All authors contributed to the article and approved the submitted version of the manuscript.

Conflicts of interest:

All authors have no conflict of interest to declare.

Open access statement:

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