Enteral feeding is a common and necessary practice in critical care. Clinical practice for verification of small- and large-bore feeding tubes is variable. Although radiographic confirmation is the reference standard for blindly inserted small-bore tubes, it is not consistently performed to verify large-bore tubes before administration of formula or medication.

These practices raise concerns; both small- and large-bore tube placement in the tracheobronchial tree have been reported.1,6 Malpositioning has also involved the intracranial cavity.7 In a review of more than 2000 insertions of small-bore tubes, 50 pulmonary placements (3%) were detected.6 In another study,1 the incidence of inadvertent pulmonary placement did not differ between small- and large-bore tubes. Of note, endotracheal or tracheostomy tube cuffs do not prevent pulmonary malposition.6 

Unfortunately, pulmonary malplacement may occur silently, without coughing, dyspnea, or oxygen desaturation.3 Adding confusion, aspirated fluids that resemble gastric fluids have...

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