Administering Polyethylene Glycol Electrolyte Solution Via a Nasogastric Tube: Pulmonary Complications

A search of the literature from 1993 through 2014 was performed with the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases, using various combinations of the following key words: cathartics, adverse events; colonoscopy, adverse events; intubation, gastrointestinal; intubation, intratracheal; polyethylene glycols, administration and dosage; polyethylene glycols, adverse events; pneumonia, aspiration; respiratory aspiration, etiology; respiratory distress syndrome, chemically induced; and therapeutic irrigation, adverse events. A Google search was performed with the same key words.

We found 12 case reports of patients who experienced adverse pulmonary events after the administration of PEG-ES via a nasogastric tube; none of the 12 patients had radiographs to document tube placement before the infusions. After the development of respiratory symptoms, the children described in cases 1 through 3 underwent radiography to check tube placement; the radiographs showed incorrect position of the nasogastric tubes (1 each in the right lung, left main bronchus, and esophagus; Table 1).^4–6  The ports of a fourth child’s tube were found in the oropharynx (Table 1, method not described).⁷  Three of the children (cases 1, 2, and 4) required intubation and mechanical ventilation following their adverse pulmonary events; fortunately, all eventually recovered. The remaining 8 patients (cases 5–12; age 5–86 years) did not have radiographic evidence of the location of the nasogastric tube at any time.^8–15  Pulmonary complications from the PEG-ES infusions contributed to the death of 5 of these patients (cases 6–10).

Although 12 cases in 21 years is a small number, it is likely that many others have occurred, because adverse events are often not reported in the literature. For this reason, it is helpful to review the circumstances of the case reports to identify possible strategies to prevent future adverse pulmonary events after the administration of PEG-ES via a nasogastric tube. A common factor in all 12 cases was the absence of radiographic confirmation of correct tube placement before the initiation of the PEG-ES infusion.

In cases 1 through 3, radiographs were obtained after respiratory symptoms occurred (usually after several hundred milliliters of the PEG-ES had been administered). No information was provided about bedside tests used to determine placement of the tubes later found to be positioned in the left main bronchus (case 1), esophagus (case 2), or oropharynx (case 4). The auscultatory method failed to detect tube misplacement in the right lung in case 3. Other authors have reported cases in which the auscultatory method failed to detect malpositioned nasogastric tubes^16,17 ; for example, it failed to detect nasogastric tubes inadvertently positioned in the respiratory tracts of 7 acutely or critically ill children.¹⁶ 

In cases 5 through 12, radiographic confirmation of tube location was never obtained, so it is impossible to know where the tubes were actually located. When the nasogastric tube was inserted, auscultation was used to test tube placement in cases 4, 7, and 12. Testing of fluid withdrawn from the tubes with litmus paper was reported in cases 7 and 12; however, pH values of the fluid were not provided. Fluid withdrawn from the nasogastric tube in case 7 was described as “acidic.”¹⁰  Although an aspirate with a low pH most likely rules out respiratory placement, it cannot rule out esophageal placement, given that fluid withdrawn from the esophagus could be refluxed acidic gastric contents.^18,19 

Signs of gastrointestinal intolerance were observed in multiple cases; for example, vomiting occurred in 6 patients (cases 2, 3, 6, 10, 11, and 12) before development of respiratory symptoms. Impaired ability to protect the airway was observed in case 4 and possibly in case 7 (due to sedation). It is noteworthy that the 5 deaths (cases 6–10) occurred in older patients (age 60–86 years).

Recommendations to prevent pulmonary complications associated with the infusion of PEG-ES via a nasogastric tube are provided in Table 2.

Although the infusion of PEG-ES via a nasogastric tube seems like an innocuous procedure, it is associated with significant risk for injury. Relatively simple maneuvers can be implemented to reduce the likelihood of adverse pulmonary events when administering large volumes of PEG-ES via a nasogastric tube.