{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T12:33:17Z","timestamp":1778589197032,"version":"3.51.4"},"reference-count":24,"publisher":"AACN Publishing","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,3,1]]},"abstract":"Background<\/jats:title>Intrapulmonary placements of feeding tubes inserted with use of an electromagnetic placement device (EMPD) continue to occur.<\/jats:p><\/jats:sec>Objective<\/jats:title>To describe circumstances and outcomes associated with intrapulmonary feeding tube placements during use of an EMPD.<\/jats:p><\/jats:sec>Methods<\/jats:title>A retrospective review of reports to the US Food and Drug Administration\u2019s Manufacturer and User Facility Device Experience (MAUDE) database of intrapulmonary feeding tube placements during use of an EMPD from 2019 through 2021. Complications, outcomes, operator training, interference from anatomical variations and medical devices, and the use and accuracy of radiographs in identifying pulmonary placements were recorded.<\/jats:p><\/jats:sec>Results<\/jats:title>Sixty-two cases of intrapulmonary tube placement were identified; 10 were associated with a fatal outcome. Pneumothorax occurred in 35 cases and feedings were delivered into the lung in 11 cases. User error was cited in 6 cases and was implicit in most others. Little information was provided about operator training. Four intrapulmonary placements were associated with anatomical variations and 1 with a left ventricular assist device. Radiographic follow-up was described in 28 cases and correctly identified 23 of the intrapulmonary placements.<\/jats:p><\/jats:sec>Conclusions<\/jats:title>User error was a significant factor, which highlights the need for empirical data to clarify the amount of training needed to safely credential EMPD operators. Clearer information is needed about anatomical variations that may contraindicate use of an EMPD, as well as medical devices that may interfere with an EMPD. Use of follow-up radiographs, interpreted by qualified personnel, is supported to increase the probability of identifying intrapulmonary tube placements.<\/jats:p><\/jats:sec>","DOI":"10.4037\/ajcc2023527","type":"journal-article","created":{"date-parts":[[2023,3,1]],"date-time":"2023-03-01T03:10:49Z","timestamp":1677640249000},"page":"101-108","source":"Crossref","is-referenced-by-count":4,"title":["Intrapulmonary Feeding Tube Placements While Using an Electromagnetic Placement Device: A Review (2019\u20132021)"],"prefix":"10.4037","volume":"32","author":[{"given":"Norma A.","family":"Metheny","sequence":"first","affiliation":[{"name":"Norma A. Metheny is a professor emerita, Trudy Busch Valentine School of Nursing, Saint Louis University, St Louis, Missouri."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephen J.","family":"Taylor","sequence":"additional","affiliation":[{"name":"Stephen J. Taylor is a research dietitian, Southmead Hospital, Bristol, United Kingdom."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kathleen L.","family":"Meert","sequence":"additional","affiliation":[{"name":"Kathleen L. Meert is a pediatric specialist-in-chief, Children\u2019s Hospital of Michigan, Detroit, Michigan and chairman, Discipline of Pediatrics, Central Michigan University, Mt Pleasant, Michigan."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2471","reference":[{"issue":"1","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1002\/jpen.1015","article-title":"Feeding tube insertion and placement confirmation using electromagnetic guidance: a team review","volume":"42","author":"McCutcheon","year":"2018","journal-title":"JPEN J Parenter Enteral Nutr"},{"issue":"2","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1097\/SLA.0b013e318208f550","article-title":"A team-based protocol and electromagnetic technology eliminate feeding tube placement complications","volume":"253","author":"Koopmann","year":"2011","journal-title":"Ann Surg"},{"issue":"5","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"636","DOI":"10.1177\/0148607110386047","article-title":"Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location","volume":"35","author":"Rivera","year":"2011","journal-title":"JPEN J Parenter Enteral Nutr"},{"key":"2023030103104115600_","unstructured":"MAUDE\u2013Manufacturer and User Facility Device Experience. U.S. Food and Drug Administration. Accessed June 30, 2022. https:\/\/www.accessdata.fda.gov\/scripts\/cdrh\/cfdocs\/cfmaude\/search.cfm"},{"issue":"3","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"240","DOI":"10.4037\/ajcc2014954","article-title":"Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement","volume":"23","author":"Metheny","year":"2014","journal-title":"Am J Crit Care"},{"issue":"2","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"157","DOI":"10.4037\/ajcc2017390","article-title":"Update on effectiveness of an electromagnetic feeding tube\u2013placement device in detecting respiratory placements","volume":"26","author":"Metheny","year":"2017","journal-title":"Am J Crit Care"},{"issue":"2","key":"2023030103104115600_","doi-asserted-by":"crossref","first-page":"149","DOI":"10.4037\/ajcc2017369","article-title":"CORTRAK-assisted feeding tube insertion: a comprehensive review of adverse events in the MAUDE database","volume":"26","author":"Bourgault","year":"2017","journal-title":"Am J Crit Care"},{"key":"2023030103104115600_","unstructured":"FDA Issues Letter to Health Care Providers About Pneumothorax Events. 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The case of the malpositioned feeding tube\u2026 while in plain sight","volume":"21","author":"Lynch","year":"2018","journal-title":"Crit Care Shock"},{"key":"2023030103104115600_","unstructured":"Avanos Medical, Inc . Urgent Field Safety Notice: Cortrak* 2 Enteral Access System (EAS). Published March 25, 2022. Accessed September 7, 2022. https:\/\/www.hpra.ie\/docs\/default-source\/field-safety-notices\/april-2022\/v50968_fsn.pdf?sfvrsn=2"},{"key":"2023030103104115600_","unstructured":"US Food and Drug Administration . Avanos Medical Recalls Cortrak*2 Enteral Access System for Risk of Misplaced Enteral Tubes Could Cause Patient Harm. Published May 16, 2022. 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