We describe a case of intubation of both main-stem bronchi with a narrow-bore nasoenteric tube on two separate occasions, with the subsequent development of pleural effusions of enteral solution, in an elderly semicomatose woman with a properly positioned cuffed endotracheal tube. Neither aspiration of fluid from the tube nor propulsion of air with auscultation of gastric borborygmi are positive proof of proper positioning. We recommend that in obtunded patients, especially if there is the possibility of impaired mucosal integrity, appropriate placement of the tube should be confirmed by chest roentgenogram.