{Reference Type}: Case Reports {Title}: Respiratory symptoms due to a twisted nasogastric tube: A case report. {Author}: Edalatifard M;Roostaei G;Rahimi B;Abtahi H;Kazemizadeh H;Asadi S;Khoshnam Rad N; {Journal}: Nurs Crit Care {Volume}: 0 {Issue}: 0 {Year}: 2024 Apr 9 {Factor}: 2.897 {DOI}: 10.1111/nicc.13073 {Abstract}: Insertion of a nasogastric tube (NGT) is generally considered safe; however, it is not without risk, and in cases of misplacement, complications and even death may occur. In this article, we reported a case of NGT misplacement in a 75-year-old male, which resulted in aspiration pneumonia. We also reviewed published cases of NGT misplacement. Clinicians should pay enough attention to the confirmation of the proper placement of an NGT. A systematic approach for NGT insertion and confirmation is required to prevent misplacement.