ACD 08.14Sandra P. Susanibar Adaniya Chief Resident IM - UAMS

What is the diagnosis?

Thoracic complications of nasogastric tube: review of safe practice

0Traditionally, nasogastric tubes have been inserted blindly.0The X-ray remains the gold standard to verify the correct

placement.0Bedside ‘confirmatory’ signs of gastric placement may not be

reliable and should not be used as a substitute to the X-ray.0The check X-ray, detects a complication, but does not prevent

it.0Tracheobronchial complications are not uncommon with blind

nasogastric tube insertions.0Pneumothorax is the commonest pulmonary complication.

Pillai. Thoracic complications of nasogastric tube: review of safe practice. Interact CardioVasc Thorac Surg (2005) 4 (5): 429-433. doi: 10.1510/icvts.2005.109488

2-step NGT insertion

0The 2-step insertion is the best way to prevent complications.

0 Initial 30 cm is the crucial damage limiting distance, as it is at the tracheoesophageal transition zone.

0The final nasogastric-position is ideally at 50–60 cm from the incisor teeth.

0 Insertion of excess tubing is to be avoided.0High risk patients include:

0 Intubated and sedated0 Elderly0 Mentally obtunded0 Repeated attempt after earlier pulmonary misadventure

Pillai. Thoracic complications of nasogastric tube: review of safe practice. Interact CardioVasc Thorac Surg (2005) 4 (5): 429-433. doi: 10.1510/icvts.2005.109488

Learning pointsRadiation induced Lung Disease

Radiation-induced lung disease (RILD)

0Common. Though incidence varies depending upon the particular regimen used and upon the radiation field. 0 In patients with breast cancer, clinical pneumonitis occurred in

0 to 10 percent, while radiographic abnormalities were present in 27 to 40 percent.

0 In patients with lung cancer, clinical pneumonitis occurred in 5 to 15 percent of patients, while radiographic abnormalities were present in 66 percent. It is unclear to what extent the latter were due to irradiation versus tumor.

CLINICAL MANIFESTATIONS

Acute radiation

pneumonitis

• Timing: four to twelve weeks

late or fibrotic

radiation pneumonitis

• Timing: after six to twelve months.

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Symptoms

• Nonproductive cough• Dyspnea may only occur with

exertion• Inability to take a deep breath.• Fever is usually low grade, in the

acute phase• Chest pain (pleuritic or substernal)

- can represent pleuritis, esophageal pathology, or rib fracture.

• Malaise and weight loss.

Signs

• Crackles or a pleural rub may be heard; in some cases auscultation is normal.

• Dullness to percussion = a small pleural effusion; 10 % of patients.

• Effusions often cause no symptoms and may spontaneously remit.

• In contrast to malignant effusions, radiation-induced effusions do not increase in size after a period of observed stability. 

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Radiologic manifestations

Acute radiation

pneumonitis

• Ground-glass attenuation within the area of irradiated lung

late or fibrotic

radiation pneumonitis

• Opacities may evolve into a fibrotic phase, characterized on CT by linear opacities (scarring) or an area of dense consolidation and volume loss. 

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TREATMENT

0 No prospective controlled studies have evaluated the efficacy of therapies for radiation pneumonitis in humans.

0 Many experts recommend the use of glucocorticoids for symptomatic patients with a subacute onset of radiation lung injury.

0 Patients who have established fibrosis due to prior irradiation are unlikely to benefit from glucocorticoid therapy.

0 Prednisone (at least 60 mg/day) is generally given for two weeks, with a gradual taper over three to twelve weeks.

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