Nasogastric (NG) Tube Insertion
Main Text
Table of Contents
Nasogastric (NG) tube insertion is a crucial skill in medical practice, widely utilized across various clinical settings.1 This procedure involves the placement of a flexible tube through the nasal passage into the stomach, serving multiple purposes in patient care. The video above aims to provide a detailed overview of NG tube insertion, including its indications, contraindications, necessary materials, and the step-by-step process of placement.
The primary indications for NG tube insertion include decompression of the gastrointestinal tract, gastric lavage, nutritional support, medication administration, aspiration of gastric contents, and diagnostic purposes.2
Decompression of the gastrointestinal tract is often required to relieve pressure and prevent vomiting in patients with bowel obstruction, ileus, or severe vomiting.3 This is particularly essential in conditions such as small bowel obstruction, where relieving pressure can prevent perforation and other complications.4
Gastric lavage is another important indication for NG tube use, particularly in cases of toxic ingestion, gastric outlet obstruction, and GI bleeding. In gastric outlet obstruction, an NG tube helps decompress the stomach by removing accumulated gastric contents, relieving symptoms. It also facilitates the rapid removal of ingested toxins from the stomach, which is critical in acute poisoning cases.5 Additionally, gastric lavage is commonly used to help differentiate upper GI bleeding from lower GI bleeding as the cause of hematochezia or melena.
In terms of nutritional support, NG tubes provide a route for enteral feeding in patients who are unable to take oral nutrition due to conditions such as stroke, head injury, or severe dysphagia. This serves as a temporary solution for nutritional support until the patient can resume normal eating.6
NG tubes are also used for medication administration in patients who cannot swallow pills or liquid medications. This is particularly useful for critically ill patients who are intubated or have impaired consciousness. Additionally, in patients at risk for aspiration, such as those with impaired swallowing or decreased levels of consciousness, NG tubes can be used to aspirate gastric contents and prevent aspiration pneumonia.7
For diagnostic purposes, NG tubes can be used to obtain gastric contents for analysis, such as in the diagnosis of gastrointestinal bleeding or to measure gastric pH.8
Despite their utility, there are several contraindications to NG tube insertion that must be carefully considered to avoid complications. One major contraindication is the presence of a basilar skull fracture. Inserting an NG tube in patients with this condition can lead to intracranial placement of the tube, posing a significant risk of brain injury. Severe facial trauma also poses a contraindication, as it can alter the anatomy and increase the risk of incorrect placement or further injury during insertion.9
Patients with esophageal varices or strictures are at high risk for bleeding or perforation during NG tube insertion, making this another relative contraindication.10 Recent nasal surgery is another contraindication, as the insertion of an NG tube can complicate healing, potentially leading to bleeding or disruption of surgical repairs.11 Furthermore, patients with significant coagulation disorders are at an increased risk for bleeding complications with NG tube insertion, necessitating careful consideration before proceeding.
The following materials are necessary for NG tube insertion:12
- Bucket (for potential emesis)
- Suction tubing
- Gloves
- NG tube (18 French recommended for decompression)
- Cup of water with a straw
- Lubricating jelly
- Adhesive bandage
- Tape
The NG tube insertion procedure involves several steps. Before initiating the NG tube insertion procedure, it is crucial to thoroughly explain the process to the patient and obtain informed consent. This step is not merely a legal requirement but an essential aspect of patient-centered care. The healthcare provider should use clear, non-technical language to describe the purpose of the NG tube, the insertion process, potential discomforts, and possible complications. Patients should be encouraged to ask questions and voice any concerns. It's important to explain that while the procedure may cause temporary discomfort, there are ways to minimize this, such as the use of lubricating gel and proper positioning. The patient should be informed about what sensations to expect during the insertion, such as a feeling of pressure in the nasal passage and throat, and the possibility of gagging. Additionally, the healthcare provider should explain how the patient can assist in the procedure, such as by swallowing water when instructed. This comprehensive explanation not only fulfills ethical and legal obligations but also helps to reduce patient anxiety, improve cooperation, and ultimately contribute to a more successful and less traumatic insertion process.
The patient should be positioned in a semi-upright or high Fowler's position, with the head of the bed elevated to approximately 30–45 degrees. This positioning involves raising the entire upper body, not just the head. The patient's back should be supported by the raised bed or pillows. This semi-sitting position helps to reduce the risk of aspiration and makes it easier for the patient to swallow during the procedure.
The patient’s head should be positioned either in a neutral alignment or slightly flexed forward, as both approaches are effective and depend on clinical preference and patient comfort. A small pillow may be placed behind the neck to maintain a neutral cervical spine alignment, which facilitates the natural curvature of the nasopharynx and oropharynx, aiding the passage of the NG tube.
Alternatively, the patient may sit upright with their chin slightly tucked toward their chest during tube insertion. This position helps close off the trachea and open the esophagus, further reducing the risk of inadvertent tracheal intubation. Either technique can be used effectively based on the specific circumstances of the procedure.
It's important to ensure that the patient is as comfortable as possible in this position, as comfort can contribute to better cooperation and ease of insertion. The healthcare provider should also position themselves at a comfortable height relative to the patient, often standing to the side of the bed, to allow for smooth insertion of the tube.
The length of the tube to be inserted is then measured from the tip of the nose to the earlobe, and then to the xiphoid process. Most NG tubes have markings at 50, 60, and 70 cm from the tip for accurate placement. The distal end of the tube is lubricated with water-soluble jelly. The tube is then gently inserted through the nares and advanced as the patient swallows sips of water. The tube is advanced until the predetermined mark is reached. Proper placement is confirmed by auscultating the epigastrium during air injection, aspirating gastric contents, or using radiographic verification. Finally, the tube is secured to the patient's nose using the adhesive bandage and to the patient's gown using tape and a safety pin.13–15
After successful NG tube insertion, proper care and monitoring are essential for patient safety and effective treatment. Immediately following insertion, tube placement should be confirmed via radiographic verification.16 The tube must be securely fastened to prevent displacement, and the patient should be assessed for any immediate complications such as bleeding or respiratory distress. Regular assessments are crucial, including daily checks of the insertion site for irritation or infection, verification of tube position at least once per shift, and evaluation of patient comfort. Tube maintenance involves flushing with 30–50 mL of water every 4–6 hours during continuous feeds or before and after intermittent feeds and medication administration. Oral hygiene and nasal care are important to prevent infections and maintain skin integrity. During feeding, patients should be monitored for signs of intolerance such as nausea or abdominal distension, and the head of the bed should be elevated to reduce aspiration risk. Healthcare providers must remain vigilant for potential complications like aspiration pneumonia, tube displacement, or sinusitis. Patient and family education about tube care and warning signs is crucial, especially if the patient will be discharged with the NG tube in place. Accurate documentation of all assessments, interventions, and complications is essential.
While the basic principles of NG tube insertion remain consistent, certain patient populations require special considerations. In children, the size of the NG tube must be carefully selected based on the child's age and size. Typically, smaller French sizes are used. The insertion depth is also different; in neonates and infants, the distance from the nose to the earlobe to the midpoint between the xiphoid process and umbilicus is used.17 Parental presence and comfort measures are crucial. In some cases, mild sedation may be considered, though this should be done with caution and under close monitoring.18–20
Older adults may have anatomical changes that make NG tube insertion more challenging. These can include nasal septum deviation, decreased gag reflex, or cervical spine arthritis limiting neck movement. Extra care should be taken to prevent trauma, and a smaller tube size may be preferable. Cognitive impairments may necessitate additional explanation and reassurance throughout the procedure.21
For patients who are intubated or unconscious, the swallowing technique cannot be used to aid insertion. In these cases, gentle advancement of the tube with concurrent neck flexion can help guide the tube into the esophagus. Extra caution must be taken to verify correct placement, often requiring radiographic confirmation.22,23
Individuals with a history of head and neck surgery, radiation therapy, or anatomical abnormalities may require modified insertion techniques. In some cases, endoscopic guidance may be necessary for safe insertion.
While severe coagulopathy is a relative contraindication, in cases where NG tube insertion is necessary, extra precautions should be taken. This may include correcting the coagulopathy if possible, using a smaller tube size, and having measures ready to manage potential bleeding.
This comprehensive guide to NG tube insertion is important for medical practitioners, particularly those in surgical and critical care settings. The video serves as a valuable educational resource for medical students, residents, and practicing clinicians who may need to perform this procedure. Providing a clear, detailed explanation of the procedure helps ensure that healthcare providers can perform NG tube insertion safely and effectively, minimizing risks to patients. This guide is particularly beneficial for medical students learning about basic clinical procedures, surgical and emergency medicine residents honing their skills, nurses who may be involved in NG tube care and management, and practicing physicians who need a refresher on the procedure. By emphasizing patient safety, proper technique, and the importance of understanding both indications and contraindications, this guide contributes to improved patient care and outcomes in clinical settings where NG tube insertion is frequently performed.
Citations
- Hsu CY, Lai JN, Kung WM, et al. Nationwide prevalence and outcomes of long-term nasogastric tube placement in adults. Nutrients. 2022;14(9). doi:10.3390/nu14091748.
- Ernsmeyer, Christman. Open resources for nursing (open RN). In: Nursing Fundamentals [Internet]. ; 2021.
- Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007 Jul 18;2007(3):CD004929. doi:10.1002/14651858.CD004929.pub3.
- Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA. Routine nasogastric decompression in small bowel obstruction: is it really necessary? Am Surg. 2013;79(4). doi:10.1177/000313481307900433.
- Gong EJ, Hsing L chang, Seo H Il, et al. Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding. BMC Gastroenterol. 2021;21(1). doi:10.1186/s12876-021-01690-z.
- Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut. 2003;52(SUPPL. 7). doi:10.1136/gut.52.suppl_7.vii1.
- Metheny NA, Davis-Jackson J, Stewart BJ. Effectiveness of an aspiration risk-reduction protocol. Nurs Res. 2010;59(1). doi:10.1097/NNR.0b013e3181c3ba05.
- Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2). doi:10.7326/0003-4819-152-2-201001190-00009.
- Fremstad JD, Martin SH. Lethal complication from insertion of nasogastric tube after severe basilar skull fracture. J Trauma. 1978 Dec;18(12):820-2. doi:10.1097/00005373-197812000-00009.
- Al-Obaid LN, Bazarbashi AN, Cohen ME, et al. Enteric tube placement in patients with esophageal varices: risks and predictors of postinsertion gastrointestinal bleeding. JGH Open. 2020;4(2). doi:10.1002/jgh3.12255.
- Georgiou A, Zargaran D. Rhinoplasty and nasogastric tube insertion in the emergency department. JPRAS Open. 2022;31. doi:10.1016/j.jpra.2021.10.001.
- Romer C, Bischoff S. Inserting a nasogastric tube. Laryngorhinootologie. 2024;103(2). doi:10.1055/a-2029-6300.
- Boeykens K, Holvoet T, Duysburgh I. Nasogastric tube insertion length measurement and tip verification in adults: a narrative review. Crit Care. 2023;27(1). doi:10.1186/s13054-023-04611-6.
- Judd M. Confirming nasogastric tube placement in adults. Nursing (Brux). 2020;50(4). doi:10.1097/01.NURSE.0000654032.78679.f1.
- Bloom L, Seckel MA. Placement of nasogastric feeding tube and postinsertion care review. AACN Adv Crit Care. 2022;33(1). doi:10.4037/aacnacc2022306.
- Fan EMP, Tan SB, Ang SY. Nasogastric tube placement confirmation: where we are and where we should be heading. Proceed Singapore Health. 2017;26(3). doi:10.1177/2010105817705141.
- Cirgin Ellett ML, Cohen MD, Perkins SM, Smith CE, Lane KA, Austin JK. Predicting the insertion length for gastric tube placement in neonates. JOGNN. 2011;40(4). doi:10.1111/j.1552-6909.2011.01255.x.
- Irving SY, Lyman B, Northington LD, et al. Nasogastric tube placement and verification in children: Review of the current literature. Crit Care Nurse. 2014;34(3). doi:10.4037/ccn2014606.
- Farrington M, Lang S, Cullen L, Stewart S. Nasogastric tube placement verification in pediatric and neonatal patients. Pediatr Nurs. 2009;35(1).
- Irving SY, Rempel G, Lyman B, Sevilla WMA, Northington L, Guenter P; American Society for Parenteral and Enteral Nutrition. Pediatric nasogastric tube placement and verification: best practice recommendations from the NOVEL Project. Nutr Clin Pract. 2018 Dec;33(6):921-927. doi:10.1002/ncp.10189.
- Chauhan D, Varma S, Dani M, Fertleman MB, Koizia LJ. Nasogastric tube feeding in older patients: a review of current practice and challenges Faced. Curr Gerontol Geriatr Res. 2021;2021. doi:10.1155/2021/6650675.
- Mahoney C, Rowat A, Macmillan M, Dennis M. Nasogastric feeding for stroke patients: practice and education. Brit J Nurse. 2015;24(6). doi:10.12968/bjon.2015.24.6.319.
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Cite this article
Rothman D. Nasogastric (NG) tube insertion. J Med Insight. 2024;2024(482). doi:10.24296/jomi/482.
Procedure Outline
Table of Contents
- Indications
- Contraindications
- Common Pitfalls
Transcription
CHAPTER 1
Hi, everyone. My name is Deanna Rothman. I'm a general surgery resident at Massachusetts General Hospital, and welcome to our session on NG tubes. First, let's talk about what is an NG tube. An NG tube, or nasogastric tube, as its name implies, is a flexible tube that goes from a patient's nose into their stomach. There are multiple indications for why a patient may require an NG tube, so let's talk a little bit about what those indications are. The most common indication that you're likely to see on the surgery clerkship is GI decompression. In this case, an NG tube is used to decompress a GI system from above. For example, if a patient has a small bowel obstruction or an ileus after surgery, in both of those situations, the patient is not able to move their GI contents forward naturally through their intestines, and so we use an NG tube to decompress them from above. The next most common indication is for evaluation of a GI bleed. So if a patient presents with hematemesis, hematochezia or melena, usually we'll place an NG tube to exonerate the stomach as the source of the GI bleed. The next most common indication is postoperative care. If a patient had an esophageal, stomach, or a large GI surgery, sometimes we'll place an NG tube intraoperatively. because either we anticipate they have an ileus or it can be protective for the anastomoses that they now have. The last most common indication is feeding or medications. There are several reasons why patients may not be able to take in food orally. For example, if they're sedated or if they're unable to swallow on their own. If both of these situations, we'll keep an NG tube in to assist with their feeds and with getting their medications. Sometimes patients will need this NG tube and this medication and food support for a longer amount of time, so we may exchange a larger NG tube for a more flexible tube like a Dobhoff a little bit later. These are the most common indications for an NG tube, but let's talk about some of the contraindications to placing one. First is severe facial trauma. In cases of severe facial trauma or fractures, there's concern that if you place an NG tube, it won't go the correct way and may end up damaging other nearby structures. So in those situations, we avoid placing NG tubes. Another common contraindication for NG tube placement is recent GI surgery. I mentioned when talking about indications that one of the common reasons why we place NG tubes is postoperatively after a patient had either an esophageal, stomach, or large GI surgery. If this NG tube were to fall out, however, and this patient recently had esophageal or gastric surgery, we would not place another one just in case it would go through that now healing anastomosis, so that would be another contraindication to NG tube placement. Another contraindication to NG tube placement is esophageal varices. In patients that have esophageal varices, it's more challenging and more dangerous to place an NG tube. Potentially the NG tube could injure one of these varices and cause the patient to severely bleed. Therefore, in these situations, we do not place NG tubes. The last most common contraindication to NG tube placement is coagulopathy. Like patients with esophageal varices, patients with severe coagulopathies are at higher risk of severe bleeding after NG tube placement, so we usually hold off on placing NG tubes in these patients. Now, let's review all the materials you'll need for your NG tube placement.
CHAPTER 2
Let's go through all of the materials you'll need for your NG tube placement. First is a bucket. Oftentimes, these patients are already nauseous and placing the NG tube can make them even more nauseous, so it's good to have a bucket just in case. The bucket is also helpful to help carry everything to the room you're going to. Next is a chuck. Similarly, sometimes there can be spillage of GI contents, and so it's good to have a chuck to keep the patient and the bed clean. Next is our suction tubing. This is what we'll use to connect the NG tube to the suction canister in the hospital room. Next are gloves. Gloves are important for our own safety and protection to make sure that we keep ourselves clean. Next is our actual NG tube. There are different kinds of NG tubes, and they all come in different sizes. For this situation where we have a patient that has a small bowel obstruction, we'll be using the NG tube for GI decompression, and so I recommend using an NG tube with a large French. This one is an 18 French NG tube. Sometimes you'll see 12 or 14 Frenches available as well, but those smaller Frenches may end up getting actually clogged more easily since they have a smaller diameter of the tube. So an 18 French is a larger diameter, less likely to get clogged, better for GI decompression. Next is a cup of water with a straw. This is what we'll ask the patient to drink from while we're placing the NG tube. It's helpful to have a straw. It makes it a little bit easier for them to drink the water. Next is our lubricating jelly. This is what we'll be placing on the NG tube to help it go down the nares. Once the NG tube is placed, there are several ways that we can adhere the NG tube to the patient. First is with this specific bandage. This bandage goes over the nose and then adheres to the NG tube to prevent it from falling out. Then we also have tape and a safety pin, which we use to wrap around the NG tube and adhere the NG tube to the patient's johnny to also prevent it from coming out and also to make it a little bit more comfortable for the patient. Now that we have all of our materials, let's go see our patient.
CHAPTER 3
There are several steps to placing an NG tube besides the actual NG tube procedure. These steps are consenting and discussion with your patient, making sure you have all your materials at the ready, having the patient positioned appropriately, then placing the actual NG tube, and then post-procedure steps. Let's go through each of those steps together. First is having a discussion with your patient. In this case, this patient has a small bowel obstruction, and so we'll be placing an NG tube for GI decompression. At this point, I've already had a discussion with my patient and consented them for the procedure. They understand why we're doing the procedure and why we think it's most appropriate and are willing to proceed with the next steps. Next is to make sure you have all your materials at the ready. As you can see, I have a bucket, a chuck just in case. I have my NG tube, and you can see the NG tube is already lubricated. And I also have my suction canister ready to suction. Most hospital rooms have a suction canister similar to this one. It's important to make sure it's all ready to suction and that you have your suction tubing ready to go. I also like to make sure I have a cup of water with a straw for our patients to drink from. I'll usually have either the patient hold it, or I'll have a nurse or someone else assisting me able to hold the cup for us. Now that I have all my materials ready, I'll position the patient appropriately. So as you can see here, the patient is positioned upright and usually I will recommend that they tuck their head as well. That helps close the airway and open the esophagus to make sure the NG tube goes the right way. I sometimes will also have my hand behind the patient's head to encourage them to maintain that position. Once I have everything positioned and all my materials at the ready, you can place your NG tube. I usually do the the placement in two steps. First, I advance the NG tube up to the posterior nasopharynx. At that point, you'll feel a little bit of resistance. Once you pop through that resistance, that means you're in the right place, and that's usually around 12 centimeters of the NG tube. At that point, once I feel that release, I'll ask the patient to start drinking water. As they're drinking water, they help swallow the NG tube and go down into the esophagus. At that point, you keep pushing up until about 60 to 65 centimeters on the NG tube, and then you know you're probably in the right place. There are some common NG tube pitfalls you may encounter when placing your NG tube. So let's go through three common ones and how you can tackle them. So first is a deviated septum. Oftentimes, patients may have a deviated septum, which will make it more challenging to get through the nose. How oftentimes how this will present is that you'll be trying to get your NG tube to the posterior nasopharynx and encountering a lot of resistance. In that situation, it's worth trying the other nostril to see if you can get an easier passage. Usually there's one nostril that's a little bit easier than the other in most patients. Second is NG tube coiling. Sometimes you'll find that the NG tube gets coiled in the patient's mouth. In this situation, it's best to immediately pull back the NG tube, let the patient have a little bit of a breather, and then encourage them once again to maintain their head tucked. That tucked position will help the NG tube go into the esophagus instead of coiling in the mouth. A third common pitfall that can happen with placing an NG tube is that the NG tube goes down the airway instead of the esophagus. Some signs of this is that your patient may start coughing or you might have increased resistance around 20 centimeters of the NG tube. If this happens, it's important to draw back your NG tube pretty quickly. If you're not sure if you're in the airway or the esophagus, something you can ask your patient to do is to say something. If they're not able to verbalize, usually that's a sign that their vocal cords aren't able to oppose and you are in the airway. So it's important to pull your NG tube back pretty quickly, let your patient regain their breath and then try again. So now let's go through placing the NG tube together.
CHAPTER 4
So I start by introducing the NG tube to the nare, and what you'll see is that I'm actually pushing directly towards the back of the head rather than up the nose, which is a common mistake most people make. As I'm pushing to the back of the head, I'll reach some resistance right around 10 to 12 centimeters, and that's when I'm hitting the posterior nasal pharynx. I let the patient know this is probably gonna be a little bit uncomfortable. Once I pop through and I feel that release, that's when I'll start asking the patient to start drinking water. As they're drinking water, I'm gonna continue to advance the NG tube. I'll keep advancing up until I reach about 60 to 65 centimeters. It's also important to note, as I mentioned, if you get any resistance at any point during here, it's important to stop and pull back. Now that we're at 65 centimeters at the nare, I'm gonna hold onto my NG tube and try to adhere it to place to make sure it's not gonna go anywhere. What I'm gonna be using for that is this kind of bandage that's specifically designed for NG tubes. As you can see, it goes around the nose and wraps around the tube as well to prevent it from moving. Now that I know that my NG tube is not gonna go anywhere, I'm gonna put it to suction. At this point, I should be seeing gastric content coming out. If I don't or if I see anything else, I'll take it off of suction. Now that I'm seeing gastric content, I try to position the NG tube so that it's comfortable for the patient. To do that, I'll make a little loop with tape. And then adhere it with a safety pin to the patient's johnny. I usually like to loop it up like this just so it's not pulling down on their nose. And once the NG tube is positioned, you're all set. Last step will be to get a chest x-ray to make sure that your NG tube is in the correct position. So let's go look at a chest x-ray now together.
CHAPTER 5
So this is an example of a patient who had an NG tube placed and then got a chest x-ray afterwards to confirm its placement. First, let's review the chest x-ray. As you can see, we have both lung fields, the right lung here and the left lung. You can also see the trachea here in the midline leading to the right main stem bronchus and the left main stem bronchus. Here you also see the heart and the heart border, as well as both diaphragms. Here's the right diaphragm and the left diaphragm. The left diaphragm here looks a little bit translucent, and that's because of a large stomach bubble underneath, which is why we placed the NG tube. Now we can look at the NG tube, which as you can see through the radiopaque stripe is going down the esophagus here following through the GE junction, which we assume is right here where the diaphragms are, and then into the stomach. Here, we can't actually see the tip of the NG tube. It goes beyond the chest x-ray. But what we can see is a small gap in the radiopaque line. All NG tubes have that gap, and that's where the last port is. So you ideally wanna see that this gap is below the GE junction as well. So this is a well-placed NG tube. On the other hand, this is an NG tube that is not properly placed. Once again, we're following the NG tube's radiopaque stripe going down to the esophagus, but here we see that the radiopaque strip, the little gap that indicates the last port is actually above the GE junction, and we could see that because our diaphragms are right here, and so therefore we expect our GE junction to be right around here. So since that port is up here, that means that the tip of the NG to which you could see here is not advanced far enough into the stomach, and so it needs to be advanced more, probably a few centimeters. So this is an improperly placed NG tube. We'd go back and advance it farther in this patient, probably at least a couple centimeters. Then repeat a chest x-ray to confirm it's now in the correct position.