Background: Many patients have a nasogastric feeding tube inserted during admission; however, misplacement is not uncommon. In this case report we present, to the best of our knowledge, the first documented fatality from pressure pneumothorax following nasogastric tube withdrawal.
Case Presentation: An 84-year-old Caucasian woman with dysphagia and at risk of aspiration underwent routine insertion of a nasogastric feeding tube; however, shortly after insertion she developed respiratory distress.