I. Problem/Challenge.

The placement of a nasogastric tube (NG tube) involves placing a flexible 14-18 french plastic tube from the nose into the stomach. In patients with facial/nasal trauma, these tubes can be inserted orally. This tube allows for medication administration, enternal feedings, draining of stomach contents, treatment of bowel obstruction, prevention of aspiration from vomiting, use in diagnostic or mobility studies, assessing and diagnosing gastrointestinal bleeding. Nurses are trained in this procedure.

II. Identify the Goal Behavior.

The goal of placing a nasogastric tube is correctly intubating the stomach without complications. Nasogastric tubes should not be placed in patients with facial or skull trauma or patients who have undergone gastric bypass surgery. There is a relative contraindication to this procedure in patients with a coagulation abnormality, presence or recent banding/cautery of esophageal varices and a presence of esophageal strictures.

Complications of placing a nasogastric tube include aspiration of gastric contents, intubation of the respiratory airway, trauma or erosion of the nasal mucosa, sinusitis, otitis media, sore throat, epistaxis. The most severe complications include esphageal perforation, collapsed lung, and intracranial placement.

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III. Describe a Step-by-Step approach/method to this problem.

Step 1: Gather equipment: 14-18 french nasogastric tube, non-sterile gloves and protective eye shield, 60cc (toomey) catheter tip syringe, lubricant (2% xylocaine gel, water-based lubricant, adhesive tape, wall or portable suction device with tubing and yankauer tip, emesis basin, stethoscope, litmus paper (available), cup of water or ice chips.

Step 2: Sit patient as upright as tolerated.

Step 3: Explain the procedure to the patient including benefits, risks, potential complications, and alternatives.

Step 4: Put on non-sterile gloves and eye protection.

Step 5: Determine how many centimeters to advance the catheter (usually 50-60cm). To measure, place the distal tip of the catheter at the nasal vestibule, to their ear and down to the halfway point between the xyphoid process and the naval. Mark this measurement with a piece of tape or pen mark.

Step 6: Examine the nostril for the optimal side, free from obstruction or septal deviation.

Step 7: (If available) Instill 5-10cc of 2% xylocaine gel to the preferred nostril.

Step 8: Turn on portable or wall suction device to continuous and place yankauer tip near the patient.

Step 9: Place the water/ice chips and emesis basin near the patient.

Step 10: Cap the end of the nasogastric tube.

Step 11: Lubricate the first 6 inches of the tube.

Step 12: With the patient’s neck flexed, pass the tube into the preferred nostril as the patient swallows (using the ice chips or water). Advance to the taped mark. Do not force. Immedately withdraw if the tube coils in the mouth or the patient develops respiratory distress.

Step 13: Check placement with two methods. Attach the catheter syringe and aspirate looking for gastric contents. If litmus paper is available, check the ph of the contents (gastric pH 1-5.5). Perform the “whoosh test.” Using the catheter syringe, instill 10-20cc of air into the tube while simultaneously ascultating with the stethscope on the left upper quadrant of the abdomen. An audible “whoosh” indicates that that the nasogastric tube is correctly placed in the stomach. Caution: listening for the “whoosh” is not accurate 20% of the time. If the above is not available or if the patient requires medication administration or enteral feeding, perform chest x-ray to verify placement. On the x-ray, look to visualize the tube crossing the left hemidiaphragm and then deviating to the left.

Step 14: Once placement is verified, secure the tube to the nose with adhesive tape.

IV. Common Pitfalls.

  • If the tube coils in the mouth, curve the distal end and soak in ice water for few minutes. This will slightly stiffen the tube for easier passage.

  • The head can be rotated toward either shoulder during placement to bring the trachea from midline.

  • After insertion, ask the patient to speak. If the patient is able to speak, the tube has not passed through the vocal cords.

  • Once the tube is passed into the oropharynx, pause and let the patient relax with a few deep breaths. After this pause, instruct the patient to swallow while advancing the tube further.

  • Avoid fully advancing the tube to the hub. Always approximate the depth of insertion by measuring to the patient.

  • Do not instill anything except air into the tube until placement is verified.

  • More than 3 attempts per provider should be avoided.

  • Do not rely on cuffed endotracheal tubes for placement. Use the verification methods above.

  • If a nasogastric tube can not be placed at the bedside, interventional radiology can use fluoroscopy to assist placement or ENT/GI physicians can use endoscopy to visually intubate the stomach.

V. National Standards, Core Indicators and Quality Measures.

No national standards/benchmarks established yet.

VI. What's the evidence?

Benya, B, Langer, S, Morbarhan, S. “Flexible nasogastric feeding tube tip immediately after placement”. Journal of Parenteral and Enteral Nutrition. vol. 141. 1990. pp. 108-109.

Bourgault, AM, Halm, MA. “Feeding tube placement in adults: safe verification method for blindly inserted tubes”. Am J Crit Care.. vol. 18. 2009. pp. 73-6.

Chun, DH, Kim, NY, Shin, YS, Kim, SH. “A randomized, clinical trial of frozen versus standard nasogastric tube placement”. World J Surg.. vol. 33. 2009. pp. 1789-92.

Lamont, T, Beaumont, C, Fayaz, A. “Checking placement of nasogastric tubes in adults (interpretation of x-ray images): summary of a safety report from the National Patient Safety Agency”. MJ. vol. 342. 2011.

Shalamovitz, G.. 2011.