2/4/2017 NasogastricIntubationTechnique:PlacementofNasogastricTube,Complications

Thissiteisintendedforhealthcareprofessionals

NasogastricIntubationTechnique
Updated:Jul26,2016
Author:GilZShlamovitz,MD,FACEPChiefEditor:VikramKate,MBBS,MS,PhD,FACS,FACG,
FRCS,FRCS(Edin),FRCS(Glasg),FIMSA,MAMS,MASCRSmore...

TECHNIQUE

PlacementofNasogastricTube
Explaintheprocedureofnasogastric(NG)intubation,aswellasitsbenefits,risks,complications,and
alternatives,tothepatientorthepatient'srepresentative.

Examinethepatient'snostrilforseptaldeviation.Todeterminewhichnostrilismorepatent,askthe
patienttooccludeeachnostrilandbreathethroughtheother.

Instill10mLofviscouslidocaine2%(fororaluse)downthemorepatentnostrilwiththeheadtilted
backwards(seetheimagesbelow),andaskthepatienttosniffandswallowtoanesthetizethenasal
andoropharyngealmucosa.Inpediatricpatients,donotexceed4mg/kgoflidocaine.Wait510
minutestoensureadequateanestheticeffect.

Aspirationofviscouslidocaineintoasyringe.
ViewMediaGallery

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Instillationofviscouslidocaine2%.
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Estimatethelengthofinsertionbymeasuringthedistancefromthetipofthenose,aroundtheear,
anddowntojustbelowtheleftcostalmargin.Thispointcanbemarkedwithapieceoftapeonthe
tube.WhenusingtheSalemsumpNGtube(Kendall,Mansfield,MA)inadults,theestimatedlength
usuallyfallsbetweenthesecondandthirdpreprintedblacklinesonthetube(seetheimagebelow).

Estimationofnasogastrictubelengthfromnostriltostomach.
ViewMediaGallery

Apartfromthenosetoeartoxiphisternum(NEX)method,severalothermethodsfordeterminingthe
lengthofthetubehavebeendescribed.Amongthevariousoptions,aformulabasedongender,
weight,andnosetoumbilicusmeasurementwhilelyingflatwasfoundtobesaferandmoreaccurate
inastudybySantosetal.[7]

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Positionthepatientsittinguprightwiththeneckpartiallyflexed.Askthepatienttoholdthecupof
waterinhisorherhandandputthestrawinhisorhermouth.LubricatethedistaltipoftheNGtube
(seetheimagebelow).

Nasogastrictubelubricationwithwaterbasedlubricant.
ViewMediaGallery

GentlyinserttheNGtubealongthefloorofthenose,andadvanceitparalleltothenasalfloor(ie,
directlyperpendiculartothepatient'shead,notangledupintothenose)untilitreachesthebackof
thenasopharynx,whereresistancewillbemet(1020cm).Atthistime,askthepatienttosiponthe
waterthroughthestrawandstarttoswallow(seetheimagebelow).ContinuetoadvancetheNGtube
untilthedistanceofthepreviouslyestimatedlengthisreached(seethevideobelow).

Patientflexinghisneckanddrinkingwaterwhileanasogastrictubeisinserted.
ViewMediaGallery

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Nasogastrictubeinsertion.
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Stopadvancingthetubeandcompletelywithdrawitif,atanytime,thepatientexperiencesrespiratory
distress,isunabletospeak,hassignificantnasalhemorrhage,orifthetubemeetssignificant
resistance.

FanetaldescribedanoswallowtechniqueofNGtubeintubationthatrelievespatientdiscomfort
duringtheprocedure.[8]Inthistechnique,whenthetubereachesthepharynx,patientswererequired
totakeadeepbreathandholdit,insteadofswallowingasintheconventionaltechnique.During
breathholding,theepiglottiscoversthethroatandtheglottiscloses,therebyreducingthelikelihoodof
thetubeenteringthetrachea.Whenthetubewasinserted1520cm,thepatientwasrequiredto
performabdominalbreathingtoreducediscomfortandavoidfailureoftubeintubation(somepatients
canonlyholdtheirbreathforashorttime).

Thisnoswallowtechniquewasfoundtoyieldanincreaseinthesuccessrateatfirstintubation,as
wellasreducedoccurrenceofnausea,tearing,mucosalinjury,andchangesinvitalsigns(heartrate,
breath,systolicpressure),whencomparedwiththetechniqueusedinthecontrolgroup.[8]

VerifyproperplacementoftheNGtubebyauscultatingarushofairoverthestomachusingthe60
mLToomeysyringe(seethefirstimagebelow)orbyaspiratinggastriccontent.Theauthors
recommendalwaysobtainingachestradiograph(seethesecondimagebelow)inordertoverify
correctplacement,especiallyiftheNGtubeistobeusedformedicationorfood
administration.ColorimetriccapnographyisanothervalidmethodforverifyingNGtubepositioningin
mechanicallyventilatedpatients.[9]

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Auscultationoverthestomach.
ViewMediaGallery

Nasogastrictubeinlung.
ViewMediaGallery

Applybenzoinoranotherskinpreparationsolutiontothenosebridge.TapetheNGtubetothenose
tosecureitinplace(seetheimagebelow).Ifclinicallyindicated,attachthetubetowallsuctionafter
verificationofcorrectplacement.

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Securednasogastrictube.
ViewMediaGallery

Pearls

Duringinsertion,ifconcernexiststhattheNGtubeisintheincorrectplace,askthepatienttospeak.If
thepatientisabletospeak,thenthetubehasnotpassedthroughthevocalcordsand/orlungs.

TheNGtubemaycoilinthenasopharynxororopharynx.Ifthisoccurs,orifthetubeisdifficulttopass
ingeneral,trycurlingthedistalendandpartiallyfreezingitinacupoficesoittemporarilyholdsits
curledshapebetter.Insertthelubricatedtubetipthroughthenosewiththecurledendpointing
downward.Oncethedistaltippassesintothehypopharynx,thecurvedtipfacesanteriorly.Rotatethe
tube180sothatthecurvedendpointsposteriorlytowardtheesophagus.Continuetoinsertinthe
usualmannerbyhavingthepatientswallowwater.

Anotheroption(onlyinpatientswhoaresedatedandparalyzed)istoplacetwoorthreefingers
throughthepatientsmouthintotheoropharynx.ThefingersareusedtoguidetheNGtubeintothe
hypopharynx.

Liftingthethyroidcartilageanteriorandupwardmightopentheesophagusandallowpassageintothe
proximalesophagus.

AmethodoffreezinganNGtubewithdistilledwaterwasshowntoincreasethesuccessrateof
insertionforintubatedpatients.[10]

DirectlaryngoscopyorvideolaryngoscopycanaidinplacinganNGtubeinsedatedpatientsby
visualizationofthetipenteringtheesophagus.[11]

AlthoughpH,enzyme,bilirubin,andcarbondioxidetestinghavebeenusedtodistinguishrespiratory
fromgastrointestinalplacementofNGtubes,noneofthesemethodshasenableddetectionoftube
placementintheesophagusorgastroesophagealjunction.Therefore,theauthorsrecommendthe
routineuseofxrayverification.[12]

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AsurveyofcriticalcarenursesaroundtheUnitedStatesshowedthatrecommendationsfrommultiple
nationallevelorganizationstoobtainradiographicconfirmationthateachblindlyinsertedfeedingtube
iscorrectlypositionedbeforethefirstuseofthetubearenotadequatelyimplemented.Auscultationis
widelyuseddespiterecommendationstothecontrary.[13]

Inpatientswhoareanesthetized,AppukuttyandShrofffoundthatthreetechniquescanincreasethe
successrateofNGtubeplacement.Inrandomized,controlledstudyof200patients,theuseofa
ureteralguidewireasstyletoraslitendotrachealtubeasanintroducerincreasedthesuccessratein
comparisonwithcontrolsubjects,thoughthelattertechniquesignificantlylengthenedthetimefor
insertion.However,headflexionwithlateralneckpressureprovedtobetheeasiesttechnique,witha
highsuccessrateandfewestcomplications.[14]

Complications
Somedegreeofpatientdiscomfortiscommon.Generouslubrication,theuseoftopicalanesthetic,
andagentletechniquemayreducethepatientslevelofdiscomfort.Throatirritationmaybereduced
withadministrationofanestheticlozenges(eg,benzocainelozenges)priortotheprocedure.

Epistaxismaybepreventedbygenerouslylubricatingthetubetipandusingagentletechnique.Other
complicationsthatmayoccurarerespiratorytreeintubationandesophagealperforation.

References

1.CullenL,TaylorD,TaylorS,ChuK.Nebulizedlidocainedecreasesthediscomfortofnasogastric
tubeinsertion:arandomized,doubleblindtrial.AnnEmergMed.2004Aug.44(2):1317.
[Medline].

2.DucharmeJ,MathesonK.Whatisthebesttopicalanestheticfornasogastricinsertion?A
comparisonoflidocainegel,lidocainespray,andatomizedcocaine.JEmergNurs.2003Oct.
29(5):42730.[Medline].

3.MiddletonRM,ShahA,KirkpatrickMB.Topicalnasalanesthesiaforflexiblebronchoscopy.A
comparisonoffourmethodsinnormalsubjectsandinpatientsundergoingtransnasal
bronchoscopy.Chest.1991May.99(5):10936.[Medline].

4.WestHH.Topicalanesthesiafornasogastrictubeplacement.AnnEmergMed.1982Nov.
11(11):645.[Medline].

5.WolfeTR,FosnochtDE,LinscottMS.Atomizedlidocaineastopicalanesthesiafornasogastric
tubeplacement:Arandomized,doubleblind,placebocontrolledtrial.AnnEmergMed.2000
May.35(5):4215.[Medline].

6.UriO,YosefovL,HaimA,BehrbalkE,HalpernP.Lidocainegelasananestheticprotocolfor
nasogastrictubeinsertionintheED.AmJEmergMed.2011May.29(4):38690.[Medline].

7.SantosSC,WoithW,FreitasMI,ZeferinoEB.Methodstodeterminetheinternallengthof
nasogastricfeedingtubes:Anintegrativereview.IntJNursStud.2016Jun15.61:95103.
[Medline].

8.FanL,LiuQ,GuiL.EfficacyofNonswallowNasogastricTubeIntubation:aRandomized
ControlledTrial.JClinNurs.2016May24.[Medline].

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2/4/2017 NasogastricIntubationTechnique:PlacementofNasogastricTube,Complications

9.BennetzenLV,HkonsenSJ,SvenningsenH,LarsenP.Diagnosticaccuracyofmethodsusedto
verifynasogastrictubepositioninmechanicallyventilatedadultpatients:asystematicreview.
JBIDatabaseSystemRevImplementRep.2015Feb13.13(1):188223.[Medline].

10.ChunDH,KimNY,ShinYS,KimSH.Arandomized,clinicaltrialoffrozenversusstandard
nasogastrictubeplacement.WorldJSurg.2009Sep.33(9):178992.[Medline].

11.MoharariRS,FallahAH,KhajaviMR,KhashayarP,LakehMM,NajafiA.TheGlideScope
facilitatesnasogastrictubeinsertion:arandomizedclinicaltrial.AnesthAnalg.2010Jan.
110(1):1158.[Medline].

12.BourgaultAM,HalmMA.Feedingtubeplacementinadults:safeverificationmethodforblindly
insertedtubes.AmJCritCare.2009Jan.18(1):736.[Medline].

13.MethenyNA,StewartBJ,MillsAC.Blindinsertionoffeedingtubesinintensivecareunits:a
nationalsurvey.AmJCritCare.2012Sep.21(5):35260.[Medline].

14.AppukuttyJ,ShroffPP.Nasogastrictubeinsertionusingdifferenttechniquesinanesthetized
patients:aprospective,randomizedstudy.AnesthAnalg.2009Sep.109(3):8325.[Medline].

15.ReichmanEF,SimonRR,eds.EmergencyMedicineProcedures.Columbus,OH:McGrawHill
Professional2004.

MediaGallery

Equipmentfornasogastricintubation.
Aspirationofviscouslidocaineintoasyringe.
Instillationofviscouslidocaine2%.
Estimationofnasogastrictubelengthfromnostriltostomach.
Nasogastrictubelubricationwithwaterbasedlubricant.
Patientflexinghisneckanddrinkingwaterwhileanasogastrictubeisinserted.
Auscultationoverthestomach.
Securednasogastrictube.
Nasogastrictubeinlung.

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Nasogastrictubeinsertion.

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ContributorInformationandDisclosures

Author

GilZShlamovitz,MD,FACEPAssociateProfessorofClinicalEmergencyMedicine,KeckSchoolof
MedicineoftheUniversityofSouthernCaliforniaChiefMedicalInformationOfficer,KeckMedicineof
USC

GilZShlamovitz,MD,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanMedicalInformaticsAssociation

Disclosure:Nothingtodisclose.

Coauthor(s)

NiravRShah,MD,MPHSVPandCOO,KaiserPermanenteSouthernCalifornia

NiravRShah,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Physicians,NewYorkAcademyofMedicine,SocietyofGeneralInternalMedicine

http://emedicine.medscape.com/article/80925technique 9/10
2/4/2017 NasogastricIntubationTechnique:PlacementofNasogastricTube,Complications

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard

MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:Nothingtodisclose.

LuisMLovato,MDAssociateClinicalProfessor,UniversityofCalifornia,LosAngeles,DavidGeffen
SchoolofMedicineDirectorofCriticalCare,DepartmentofEmergencyMedicine,OliveViewUCLA
MedicalCenter

LuisMLovato,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
CollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

ChiefEditor

VikramKate,MBBS,MS,PhD,FACS,FACG,FRCS,FRCS(Edin),FRCS(Glasg),FIMSA,MAMS,
MASCRSProfessorofGeneralandGastrointestinalSurgeryandSeniorConsultantSurgeon,
JawaharlalInstituteofPostgraduateMedicalEducationandResearch(JIPMER),India

VikramKate,MBBS,MS,PhD,FACS,FACG,FRCS,FRCS(Edin),FRCS(Glasg),FIMSA,MAMS,
MASCRSisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofSurgeons,AmericanSocietyofColonandRectalSurgeons,RoyalCollegeof
PhysiciansandSurgeonsofGlasgow,RoyalCollegeofSurgeonsofEdinburgh,RoyalCollegeof
SurgeonsofEngland

Disclosure:Nothingtodisclose.

AdditionalContributors

AndrewKChang,MDAssociateProfessor,DepartmentofEmergencyMedicine,AlbertEinstein
CollegeofMedicine,MontefioreMedicalCenter

AndrewKChang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanAcademyofNeurology,AmericanCollegeofEmergencyPhysicians,
SocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

Acknowledgements

TheChiefEditorwouldliketoacknowledgetheassistanceofDrMohsinaSubair,Postgraduate
Resident,DepartmentofSurgery,JawaharlalInstituteofPostgraduateMedicalEducation&Research
(JIPMER),Pondicherry,India,inupdatingthereviewofthisarticle.

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