Download CHAPTER 203 - Nasogastric and Nasoenteric Tube Insertion

CHAPTER 203
NASOGASTRIC AND NASOENTERIC
TUBE INSERTION
Yong Sik Kim
Nasogastric intubation (nasogastric tube insertion) is a common
procedure performed in the hospital, emergency department, and
office settings. The nasogastric tube was initially developed for
gastric feeding in 1760. The indications were expanded to gastric
lavage in the case of poisoning in the early 1800s. One current
design, by Dr. Levin, became available in 1921 and soon became
popular for preventing intraoperative and postoperative gastric distention. In the 1960s, improved technology allowed the manufacture of a double-lumen tube, which later developed into special soft
tubes made of polyurethane and silicone. These tubes are also very
thin and have a noncomplicated, smooth surface, useful characteristics for prolonged nasoenteric feeding.
A nasogastric tube can be used for either diagnostic or therapeutic purposes. The Levin nasogastric tube is a firm, straight,
single-lumen tube with multiple distal side ports, and is used predominantly for diagnostic aspiration or to instill materials into the
stomach. Unfortunately, even when low–flow-rate suction is applied
to a Levin tube, or if it is applied for a very long time, the lumen
frequently becomes occluded with gastric mucosa, and this can
damage the gastric mucosa. In contrast, the Salem nasogastric sump
tube is a double-lumen tube. The second lumen, or vent lumen, is
smaller than the main suction lumen and runs alongside the larger
lumen, providing a low level of continuous airflow to the stomach.
This airflow prevents the main lumen from becoming occluded by
gastric mucosa when suction is applied, thereby minimizing the risk
of damage. The blue “pigtail” on the Salem sump is an extension
of this vent lumen (Fig. 203-1). Similar to the Levin tube, the
Salem sump has multiple distal side ports. Antireflux valves are
available to prevent gastric contents from leaking out of the vent
lumen and multiport adapters are available for the proximal end
so that the same tube can be used for feeding, irrigating, suctioning,
or medicating. Even though the Levin tube is still manufactured
and available, hospitals predominantly stock the Salem sump tube
because it can be used for most applications and is more effective
and safer.
Salem sump tubes are usually clear, yet radiopaque, and made
of polypropylene or Silicone, whereas Levin tubes are available
in various versions, including red rubber and clear polypropylene.
Levin tubes can be either radiopaque or radiolucent. Although
both can be used for short-term (up to 4 weeks) gastric or nasoenteric feeding, most facilities now have the longer and smallerdiameter polyurethane tubes specially designed for this purpose.
These softer tubes (especially softer at body temperatures) usually
have a tungsten-weighted tip or balloon near the tip to facilitate
passage beyond the pylorus. They may also have a stiffening wire
or stylet available for use during insertion; many have also
been designed to resist collapse when checking the gastric residual
(Fig. 203-2). Other styles of tubes include those equipped with a
large esophageal balloon that can be used to tamponade a bleeding
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esophageal lesion (e.g., esophageal varices). Larger gastric tubes are
also available for gastric lavage (see Chapter 202, Gastrointestinal
Decontamination).
ANATOMY
The nasal cavity is lined by highly vascularized and innervated
mucosa and continues posteriorly as the nasopharynx. Within the
nasal cavity are the superior, inferior, and middle nasal conchae
(turbinates), which divide the cavity into four passages (Fig. 203-3),
the meatuses. Traditionally, the nasogastric tube is inserted blindly
through middle and inferior meatuses. Beyond the nasal cavity, the
pharynx extends from the base of the skull to the inferior border of
the cricoid cartilage. It is divided into three parts: the nasopharynx,
oropharynx, and laryngopharynx (hypopharynx). The nasopharynx
gives rise to the oropharynx at the level of the soft palate, which
then gives rise to the laryngopharynx (hypopharynx) at the superior
border of the epiglottis (see Chapter 77, Nasolaryngoscopy, Fig.
77-6). The laryngopharynx becomes continuous with the esophagus
at the inferior border of the cricoid cartilage. The posterior part of
the upper nasopharynx is surrounded by the cribriform plate and the
body of the ethmoid and sphenoid bones, which can easily be
broken by a traumatic blow to the midface, resulting in a maxillofacial or basilar skull fracture. Such fractures can create a route into
the cranial vault, which is a prerequisite for one of the most disastrous complications of inserting a nasogastric tube, intracranial intubation. This can result in brain damage or death. Therefore,
placement of a nasogastric or nasoenteric tube in a patient with a
possible skull or maxillofacial fracture should be avoided, if possible
(an orogastric route may be a better option).
Beyond the laryngopharynx and the larynx, the trachea lies
anterior to the esophagus at the level of the cricoid bone and is
supported by fibrocartilaginous tracheal rings. The superior aperture
is covered by the epiglottis of the larynx during swallowing.
The anatomy also confers the ability to estimate the length of
tube that should be inserted. Because the median distance from the
anterior aspect of the nasal septum to the cricopharyngeus muscle
(tracheoesophageal junction) is about 8 inches, and the esophagus
is on average about 10 inches long, and given that the tip of a
nasogastric tube should lie 4 inches below the gastroesophageal
junction when in place, the nasogastric tube should ideally be
secured at the 20- to 24-inch mark at the nasal vestibule. Alternatively, the distance can be approximated by holding the tube up to
the patient’s ear and across to the nose, and then extending it to 6
inches below the xiphoid process (8 to 10 inches for a nasoenteric
tube; this is described later in the Technique section).
The anatomy of children regarding the insertion of a nasogastric
tube warrants a special note. Children have larger tonsils and
adenoids, and their tongues are large compared to adults and may
203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION
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push into the oropharynx, all of which can hamper the insertion of
a tube. At the same time, these tissues are soft and easily injured,
thereby increasing the risk of bleeding with nasogastric intubation.
Limiting the size of the tube to the smaller sizes of the nostrils and
nasal cavity in children usually minimizes the difficulty with insertion, despite these anatomic differences.
INDICATIONS
Therapeutic
Figure 203-1 Sump suction (Salem) tube. (Argyle Salem Sump, courtesy
of Tyco Healthcare, Gosport, United Kingdom.)
• Drainage of gastric contents/gastric decompression. Examples:
small bowel or gastric outlet obstruction, paralytic ileus, upper
gastrointestinal bleeding, refractory vomiting, severe pan­
creatitis with obstruction, gastric lavage (for drug overdose), prevention of aspiration, or before diagnostic peritoneal lavage or
pericardiocentesis.
• Instillation of feedings or medications for patients unable to take
by mouth. Examples: antacids, nutritional supplements, and activated charcoal for drug overdoses.
Diagnostic
• Sampling gastric contents. Examples: gastrointestinal bleeding
and mycobacterial infection.
• Instillation of diagnostic agents. Examples: radiopaque contrast
media for delineation of a transdiaphragmatic hernia or an
abdominal radiologic procedure with air to assess for an intraperitoneal perforation.
• Radiologic procedure. Example: to visualize the stomach on chest
radiography for assessment of a diaphragmatic hernia.
CONTRAINDICATIONS
All the following contraindications are relative.
Figure 203-2 Feeding nasogastrostomy tube with weighted, radiopaque
tip. (COMPAT Nasogastric Tube, courtesy of Nestlé Nutrition, Minnetonka,
Minn.)
Figure 203-3 Pharyngeal anatomy: sagittal section
of the head and neck. (From Thibodeau C, Patton KT:
Structure and Function of the Body, 11th ed. St. Louis,
Mosby, 2000.)
Frontal air sinus
Nasal bone
Superior concha
Middle concha
Opening of auditory
(eustachian) tube
Inferior concha
Hard palate
Soft palate
Tongue
Lingual tonsil
Hyoid bone
Thyroid cartilage
(part of larynx)
Vocal cords
Trachea
• Facial fractures, especially midface, or basilar skull fractures with
possible cribriform plate injuries (may result in intracranial intubation; orogastric intubation may be a better option)
• Esophageal obstruction, strictures, or a history of alkali ingestion
(increases the possibility of esophageal perforation)
Sphenoidal
air sinus
Pharyngeal
tonsil (adenoids)
Nasopharynx
Uvula
Palatine tonsil
Oropharynx
Epiglottis
Laryngopharynx
Esophagus
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HOSPITALIST
• Esophageal varices (may lead to rupture and uncontrollable
hemorrhage)
• Comatose patients without protected airways (increases the risk
of aspiration)
• Penetrating neck wounds in the awake trauma victim (gagging
might stimulate increased bleeding from the wound)
• Choanal atresia
• Recent oropharyngeal, nasal, or gastric surgery
• Zenker’s diverticulum
• Percutaneous endoscopic gastrostomy tube indicated (see Chapter
200, Percutaneous Endoscopic Gastrostomy Placement and
Replacement).
• Severe coagulopathy (orogastric intubation may be a better
option)
• Tube feeding in patients with advanced dementia (there is little
evidence that the outcome will be improved)
EQUIPMENT
AND
SUPPLIES
• Gloves, mask, goggles, and an impervious gown
• Towel or surgical Chux for covering patient’s clothing
• Paper tissues
• Emesis basin
• Nasogastric tube (For adults, use a 16- or 18-Fr Salem sump [with
antireflux valve, if possible] or Levin tube. Use 10-Fr tube for
children.) For nasoenteric feeding tubes (5 to 12 Fr), see Table
203-1. Larger tubes (12 Fr) should be used for shorter periods
because they are less comfortable and more likely to become
occluded than smaller tubes (5 to 8 Fr).
• Tincture of benzoin
• Hypoallergenic tape (e.g., Hy-Tape), NG Strip, or Tube Guard
• Stethoscope
• Large (60-mL) syringe with catheter tip (Toomey)
• Suction equipment
• Cup of water with drinking straw
• Decongestant such as phenylephrine (0.25% to 2%) spray (NeoSynephrine, Vick’s) or oxymetazoline hydrochloride 0.05% spray
(Afrin, Neo-Synephrine 12 hour)
• Water-soluble lubricant gel (Surgilube) or 2% lidocaine gel
(Xylocaine Jelly)
• Topical anesthetic spray such as benzocaine (Hurricaine) or tetracaine hydrochloride (Cetacaine), or both. Topical cocaine is
an option, and it works as both a decongestant and anesthetic.
However, its use may be a problem if the patient has to undergo
drug testing. In addition, purchase and storage by clinician or
hospital requires significant record-keeping, and may increase the
risk of theft.
• Laryngoscope for difficult insertions
• pH indicator strips with 0.5 gradations or paper with a range of
0 to 6 or 1 to 11
• Soft nasal trumpet airway (optional)
PREPROCEDURE PATIENT PREPARATION
Although the insertion of a nasogastric tube is a common and fairly
simple procedure, serious complications can occur. The risk for
complications can be minimized by taking a few precautions: obtainTABLE 203-1 ing the full cooperation of the patient, informing the patient carefully at each step of the process, using a decongestant and local
anesthesia for the nasal and retropharyngeal mucosa, premeasuring
and marking the length of the tube needed for insertion, using
gentle technique during insertion, and carefully confirming that the
tube is in the proper position before use.
Insertion of a nasogastric tube is considered by many patients to
be one of the most uncomfortable and distressful procedures they
have ever experienced. Although most hospitals do not require
written informed consent, the risks, benefits, indications, and any
possible alternatives should be explained to patients. Even with the
use of decongestants and anesthetics, patients should be prepared
for some discomfort. The unpleasant nature of the procedure should
not be minimized.
Patients should know that their eyes may water and they may
have some tearing. They may have an intense tickling sensation or
an urge to sneeze. During insertion, they may experience a gagging
sensation. Swallowing rapidly will minimize this response and
shorten the total length of the procedure. At some point during the
procedure, they will probably be asked to assist by sniffing or later
by swallowing. To help them swallow, give them a glass of water
and a straw. If they are not able to swallow, if they will mimic swallowing or make the sound “eeee” it may help. Patients should be
reassured that after the tube has been placed, they will usually adapt
to it very soon and no longer notice it.
Before nasogastric tube removal, the patient should be informed
of the procedure and what to expect. Towels, surgical Chux, or other
drapes should be placed around the patient’s neck and chest. He or
she should be handed an emesis basin and tissues.
TECHNIQUE
Observe universal blood and body fluid precautions during the procedure. Wear gloves, goggles, a face mask, and an impervious gown.
1. Elevate the head of the bed into a high Fowler (sitting) position. Rest the back of the patient’s head on a pillow or directly
on the bed for support. The patient’s clothing needs to be
protected with a towel or surgical Chux. An emesis basin
should be available on the patient’s lap.
2. Check for a clear nasal passage. Various conditions may cause
asymmetric nostril openings, for example, septal deviation,
nasal polyps, septal spurs. So examine both nostrils to determine which is the largest and most open. You can also watch
the patient inhaling through his or her nose to determine
which nostril is more open.
3. Choose an optimal tube for the patient. A large-bore nasogastric tube (16 or 18 Fr), Salem sump (with antireflux valve, if
available), or Levin tube should be used for adults. Select the
largest tube possible for the patient’s nostril size. The Salem
sump tube has marks at 18, 22, 26, and 30 inches from the
distal end. Measure the tube to fit the patient by holding the
nasogastric tube above the patient, with the distal end 6 inches
below the xiphoid process for a nasogastric tube and 8 to 10
inches for a nasoenteric tube; the proximal end extended to
the nose. Loop the mid-portion over the patient’s earlobe.
Note the tube marks based on these measurements or mark the
Enteral Alimentation Tubes
Trade Name
Material
Circumference
(French)
Length (inches)
Feeding
Duration of
Use
CORFLO (CORPAK MedSystems, Wheeling, Ill)
COMPAT (Nestlé Nutrition, Minnetonka, Minn)
Dobhoff (Kendall/Covidien, Mansfield, Mass)
Entriflex (Kendall/Covidien)
Ross Nasoenteric (Abbott Laboratories, Abbott Park, Ill)
Polyurethane
Polyurethane
Polyurethane
Polyurethane
Polyurethane
5, 6, 8, 10, 12
8, 9, 10, 12, 14
3, 5
5, 7
8, 10, 12, 14
15, 22, 36, 43, 55
42, 55
43, 55
43, 55
36, 45, 60
Gastric or intestinal
Gastric or intestinal
Gastric or intestinal
Gastric or intestinal
Gastric or intestinal
Up to 6 weeks
Up to 6 weeks
Up to 6 weeks
Up to 6 weeks
Up to 6 weeks
203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION
Mark 20–24˝
8˝
10˝
4˝
Xiphoid
process
Figure 203-4 Measuring the length of nasogastric tube for placement
into stomach.
tube with a piece of tape to avoid inserting the tube too far
(Fig. 203-4). The nasogastric tube should generally be secured
with the 20- to 24-inch mark at the nasal vestibule.
4. After application of a nasal decongestant such as phenylephrine or oxymetazoline, adding a topical anesthetic usually
increases the patient’s comfort. Although this procedure is
usually brief, application of the decongestant before the anesthesia usually results in the anesthesia lasting longer. The
decongestant may also may minimize damage to the nasal
mucosa and decrease the incidence of epistaxis.
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7. Introduce the lubricated tube tip into the nostril, pointing
straight to the back of the nasal cavity and toward the base of
the skull (Fig. 203-5). Recalling the anatomy, it should be
inserted horizontally, along the floor of the nasal passage, and
directed straight back, not upward. Feed the tube slowly with
the dominant hand into the nostril using continuous movement while unrolling the curled tube with the nondominant
hand. The patient can sniff to assist the insertion. Never force
a tube against resistance; however, spinning or twisting the
tube slightly may help overcome resistance.
8. Have the patient flex his or her head slightly forward to narrow
the pharyngeal airway. When the tip of the tube reaches the
nasopharynx a slight increase in resistance will be noted (Fig.
203-6). Continue to advance the tube, and when the resistance decreases again, ask the patient to swallow or drink some
water with a straw. Continue to push the tube with the same
motion while asking the patient to continue swallowing. If the
patient starts coughing or becomes distressed, or fog is seen in
the tube, the tube has probably entered the trachea. The tube
should be withdrawn a few inches, but not entirely, twisted
slightly, and the process started again. If a patient cannot
swallow, it is also helpful to mimic swallowing or to make the
sound “eeee.”
9. Continue to push the tube until the desired mark is reached
if the patient is not coughing. In adults, this is slightly past the
22-inch mark—the second mark—on a Salem sump tube. The
gastroesophageal junction is usually about 16 to 18 inches from
the nose—the first mark—and the tube should be inserted
about 4 inches beyond the gastroesophageal junction. If the
stomach is full, an immediate return of fluid may occur. Use
the emesis basin to collect this. If there is no return of fluid,
open the patient’s mouth to confirm that the tube is not curled
in the mouth or pharynx.
If significant resistance, respiratory distress, or a nasal
hemorrhage occurs, or the patient suddenly becomes unable to
speak, the tube should be withdrawn.
NOTE:
A randomized, controlled trial (Singer and Konia,
1999) showed improved comfort when a decongestant/
anesthetic was used, compared with plain lubrication for nasogastric tube insertion. In the study, topical anesthesia was
applied (after the decongestant) by injecting 5 mL of 2% lidocaine gel (Xylocaine Jelly) into the nostril before insertion.
The pharynx was then sprayed with both benzocaine (Hurricaine) and tetracaine hydrochloride (Cetacaine) spray to
minimize the gag reflex. If possible, allow time for the decongestants and anesthetics to take effect before inserting the
tube. Topical cocaine solution can also be used, but it often
causes a strong burning sensation on application (see Equipment section for other warnings). Application of topical anesthesia should be considered the standard of care except in
emergency situations where adequate lubrication alone may be
acceptable.
NOTE:
5. An alternative option is to lubricate a soft nasal airway with
2% lidocaine gel and allow the patient to insert the lubricated
airway into his or her nares. The nasogastric tube can then be
inserted through the soft airway. As the patient swallows the
gel, it will anesthetize the pharynx. A soft airway not only
minimizes patient discomfort, it can also decrease the risk of
severe epistaxis, intracranial intubation, and kinking of the
nasogastric tube into the mouth.
6. Lubricate the tip of the tube with additional anesthetic jelly
or a water-soluble lubricant. Curl the tube by rolling 18 to 20
inches of the distal tube clockwise onto the first three fingers
of your nondominant hand.
Figure 203-5 Horizontal insertion of nasogastric tube into nasopharynx.
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HOSPITALIST
Figure 203-6 Have the patient flex his or her head. Next, gently advance
the tube while asking the patient to swallow.
• Nasogastric placement may be facilitated manually through
the oropharynx with three fingers, if necessary. However,
unless the patient is unconscious or paralyzed, a bite block
should be in place for this maneuver to prevent the clinician from being bitten.
• In difficult cases, a laryngoscope may be helpful for guiding
or confirming proper placement.
• Fluoroscopic or endoscopic assistance may be necessary.
11. Confirm the location of the tip as soon as possible after the tube
is passed. Ask the patient to speak after placement. If he or she
is unable to speak, the tube is in the trachea and should be
withdrawn. (Be aware that cases have been reported in which
the patient could talk despite tracheal placement of a smallbore feeding tube.) Otherwise, the position of the tip should
be confirmed by a chest radiograph. In addition, there are two
traditional methods for confirming proper nasogastric placement: checking for absence of rhythmic airflow and auscultating for gastric bubbling when air is injected into the stomach.
As it turns out, both of these techniques have been found to
be inaccurate and therefore they are not recommended. Even
if the tip of the tube is located in the esophagus, duodenum,
jejunum, pleural space, or respiratory tract, a bubbling sound
may be heard. If proper location is misdiagnosed, the instillation of feeds or air has been reported to result in a pneumonia
or pneumothorax with a high chance of an adverse outcome.
Fortunately, placement can also be confirmed by aspiration (to
check for gastric contents) and by ultrasonography.
If gastric juices are aspirated, correct placement has
been demonstrated. Testing the pH of the aspirate will further
verify placement. We recommend pH indicator strips with 0.5
gradations or paper with a range of 0 to 6 or 1 to 11. It is
important that the resulting color change on any indicator
strip or paper is easily distinguishable, particularly between the
pH 5 to 6 range. The old type of litmus paper should not be
used. Rakel and colleagues (1994) reviewed several studies
regarding the significance of the pH value of the aspirate. They
found that gastric fluid should have a pH of 0 to 4. If the
patient is on antacids, histamine type 2 inhibitors, or proton
pump inhibitors, the pH is between 0 and 6 approximately
70% to 80% of the time. Fluid aspirated from the duodenum
averaged a pH of 6.5. Fluid aspirated from tracheobronchial
secretions ranged from pH 6.74 to 8.79. In other words, suspect
that fluid from the respiratory tract has been aspirated when
the pH is greater than 6.
Neumann and colleagues (1995) concluded that when the
pH of the nasogastric tube aspirate is less than 4.0, radiographs
are not needed to confirm tube placement. In 2005, the
National Patient Safety Agency in the United Kingdom recommended the use of a pH value of less than 5.5 for tube
placement confirmation; they concluded a pH value of less
than 4.0 (as recommended by Neumann and associates) is too
low to evaluate patients practically. If the pH is greater than
5.5, a chest radiograph, still the gold standard, is required to
confirm tube placement (Fig. 203-7). However, it chest radio­
graphy adds cost and prolongs waiting time before use (it can
take up to 8 hours to receive notification from the radiologist).
It also increases radiation exposure. There are also case reports
of inaccurate confirmations by radiographs, with the tube
being located in the midline after perforating the esophagus,
subclavian vein, or atrium of the heart.
Recently, the bedside sonographic examination performed
by experienced clinicians has been reported to be a sensitive
method for confirming the position of nasogastric tubes. It is
faster than conventional radiography and can easily be taught
to nonradiologists. Confirmation must be done on all smallbore nasogastric or nasoenteric tubes used for feeding purposes
before starting feeding to avoid massive aspiration. The distal
NOTE:
10a. Extra steps to facilitate placement of a nasoenteric feeding tube
include the following:
• Having placed the tube into the stomach, leave some extra
tubing or slack to facilitate passage of the tip into the duodenum.
• Place the patient in a right lateral decubitus (right side
down) position.
• A 60-mL syringe (Toomey) can be used to inject 400 mL
of air to distend the stomach. This may allow a feeding tube
coiled in the fundus of the stomach to uncoil and pass more
freely into the duodenum.
• In refractory cases, metoclopramide (Reglan) 10 mg may be
given intravenously, with or without erythromycin 250 mg
intravenously, to increase gastric motility.
10b. Extra steps to facilitate any tube placement include the
following:
• If the tube persistently kinks or coils into the mouth,
cooling the tube in ice chips or a refrigerator for 5 minutes
may stiffen it to prevent coiling. A larger-bore tube is also
less likely to coil.
• Applying external and medially directed pressure on the
ipsilateral neck at the level of the thyrohyoid membrane
may increase the success rate in difficult insertions. This
maneuver collapses the piriform sinus and further clears the
way for the nasogastric tube. If the tube passes to the level
of the hypopharynx but then meets resistance, grasping the
thyroid cartilage and lifting it anteriorly and upward may
facilitate passage into the upper esophagus.
• Orotracheally intubated patients often present the most
difficult challenge for inserting a nasogastric tube. If nasogastric insertion is deemed impossible, a second endotracheal tube may facilitate orogastric tube placement. Remove
the respiratory adapter from the proximal end of the second
endotracheal tube, lubricate it liberally, and insert it
through the patient’s mouth and into the esophagus. A
well-lubricated nasogastric tube can then be inserted
through the second endotracheal tube, which can then be
removed over the proximal end of the nasogastric tube.
203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION
1. Check if on acid-inhibiting medication
2. Check for signs of tube displacement
and measure tube length
3. Reposition or repass tube if required
4. Aspirate using 50-mL syringe and gentle
suction
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Aspirate obtained (0.5–1 mL)
Aspirate not obtained
DO NOT FEED
1. If possible, turn adult onto side
2. Inject 10–20 mL air into the tube using
syringe
3. Wait for 15–30 minutes
4. Try aspirating again
Aspirate obtained (0.5–1 mL)
Aspirate not obtained
DO NOT FEED
Aspirate obtained (0.5–1 mL)
1. Advance tube by 10–20 cm
2. Try aspirating again
Test on pH strip or paper
pH 6 or above
Aspirate not obtained
pH 6 or above
pH 5.5 or below
DO NOT FEED
1. Leave for up to 1 hour
2. Try aspirating again
pH 5.5 or below
DO NOT FEED
1. Call for advice
2. Consider replacement/repassing of tube
and/or checking position by x-ray
Proceed to feed
CAUTION: If there is ANY query about position and/or the clarity of the color change on the pH strip,
particularly between ranges 5 and 6, then feeding should not commence.
Figure 203-7 Algorithm to confirm the correct position of nasogastric feeding tubes in adults. (From the National Patient Safety Agency [NPSA]: Reducing
the harm caused by misplaced nasogastric feeding tubes: Interim advice for healthcare staff—February 2005: How to confirm the correct position of nasogastric feeding
tubes in infants, children and adults. Available at www.nrls.npsa.nhs.uk/resources/?EntryId45=59794.)
tips of these tubes should be allowed to migrate to the duodenum before enteral feeding is initiated.
12. Secure the tube to the patient’s nose after confirmation of
proper placement. First, apply alcohol to the dorsum of the
nose. If available, tincture of benzoin may then be applied after
the alcohol dries. Next, obtain a 5-inch piece of 1-inch-wide
hypoallergenic tape. Make a 3-inch cut lengthwise in the
middle, thereby forming two narrow strips of tape at one end
of the 5-inch piece (Fig. 203-8). The two narrow strips of tape
should be applied in a spiral down and around the nasogastric
tube, going away from the patient’s nose. Attempt to tape the
tube so that it will rest in the middle of the nostril to minimize
direct contact of the tube with the skin of the nose and avoid
pressure necrosis. Recently, several commercial products, NG
Strip (Cardinal Health, Dublin, Ohio) and TubeGuard
(Mormac TubeGuard, North Loup, Neb), have been developed for this special purpose.
13. Also secure the nasogastric tube to the patient’s gown. Place
a slipknot over the tube with a rubber band, and then pin it
to the patient’s gown. This should reduce the risk of the nasogastric tube being tugged out of position. The Salem sump tube
vent, or blue pigtail, must remain above the patient’s waistline
at all times to prevent gravity from siphoning fluid. Inadvertent siphoning of gastric contents could block the sump vent.
When suction is discontinued during ambulation, the pigtail
should be attached to the connector of the main lumen to
close the system and avoid the spillage of gastric fluids.
14. For removal, again place the patient in the sitting (Fowler)
position and cover his or her neck and chest with towels,
surgical Chux, or other drapes. Disconnect the nasogastric
tube from the patient, from his or her nose, and from suction.
Hand the patient an emesis basin and some tissues. Fold over
the proximal end of the tube to prevent leakage and hold it
tightly. Ask the patient to flex the neck, breath in, and hold
his or her breath. Place a drape around the tube and withdraw
the tube from the patient’s nose through the drape. The
patient can then resume breathing. Discard the tube and the
drape.
COMPLICATIONS
The most common complication is discomfort of the patient. The
traumatic insertion of a nasogastric tube can cause epistaxis, but this
is often avoided by using careful technique and a decongestant.
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HOSPITALIST
With long-term use, sinusitis, erosion of nasal tissue, or even a
tracheoesophageal fistula can occur. Tracheoesophageal fistulas are
usually associated with simultaneous use of an endotracheal tube.
Sinusitis can cause a fever of unknown origin in patients.
If the tube is forced against resistance, cribriform plate fracture
may result, with subsequent intracranial intubation. Individuals
with mid-facial or maxillofacial trauma or a basilar skull fracture
have a significantly increased risk of inadvertent intracranial intubation. The risk of this complication can be reduced by using the
orogastric route or by initially introducing a nasotracheal tube or a
soft rubber nasal airway, through which a smaller-diameter nasogastric tube can then be passed. This technique decreases the danger
of penetrating the cranium, reduces discomfort during insertion,
decreases epistaxis, and decreases the frequency of the nasogastric
tube kinking into the mouth. The long-term use of nasoenteric tube
feeding may result in diarrhea, infection, electrolyte imbalance, and
malnutrition.
POSTPROCEDURE MANAGEMENT
Figure 203-8 Secure the tube with a 5-inch piece of 1-inch-wide hypoallergenic tape, partially cut lengthwise. Apply to the dorsum of the nose and
spiral the cut portions down the tube away from the nose.
Epistaxis can be massive and requires packing. It can even compromise the airway. Gagging can occur and induce vomiting with aspiration of gastric contents. This can cause an aspiration pneumonitis
or pneumonia with a mortality rate as high as 30%. Patients with
an altered mental status from severe trauma or other causes should
have their airway secured with an endotracheal tube before placement of a nasogastric tube.
Another common complication is misplacement into the respiratory tree, which is estimated to occur in 15% of cases. This should
be recognized rapidly in the conscious patient when it causes him
or her to cough, choke, or develop respiratory distress or an inability to talk. The vocal cords may also be traumatized. In a patient
with decreased consciousness, tracheal intubation can go undetected, creating multiple complications such as atelectasis, pulmonary edema, pneumonia, or lung abscess.
The “nasogastric tube syndrome” is a reported life-threatening
complication with laryngeal and upper airway obstruction and vocal
cord abduction paralysis. The nasogastric tube syndrome results from
postcricoid ulceration and its effect on the posterior cricoarytenoid
muscles. This can be prevented by early recognition and by checking the patient every day when making rounds. It is treated with
emergent tracheostomy, immediate removal of the nasogastric tube,
and administration of systemic antibiotics.
Penetration of a nasogastric tube into the pleural space is a rare
but reported complication, with further possible complications
including lung abscess, pneumothorax, isocalothorax, empyema,
and sepsis. Intravascular penetration of the internal jugular and
subclavian vessels has also been reported.
Perforation of the esophagus is a very serious reported complication that often results in mediastinitis, with a mortality rate of up
to 30%. This may occur when the esophagus has been damaged by
chemical burns, esophageal cancer, and multiple attempts, or if
strictures are present, or with insertion after esophageal surgery.
Prompt recognition of this complication, surgical repair, and parenteral antibiotics can significantly reduce the mortality rate. Bleeding
from esophageal varices is not usually caused by nasogastric intubation. Duodenal perforation has also been reported. Tube knotting,
coiling, kinking, obstruction, and rupture can occur.
The nares should be assessed for skin irritation, erosion, or necrosis
by health providers at regular intervals. The patient should be asked
if he or she has any pain or pressure in the nose, throat, or sinuses.
Any old or detached tape should be replaced after cleaning the skin
of the nose with alcohol and applying tincture of benzoin. On a
regular basis, the nursing team should record the patency of the tube,
the level of graduated marks on the tube, any symptoms or patient
complaints, the volume and nature of anything infused, and any
residual volume. If it becomes difficult to aspirate from the tube, it
should be flushed with 30 mL water. If patency is still uncertain, it
should be repositioned by advancing 1 inch or withdrawing 1 inch.
The same maneuver should then be tried again to confirm patency.
Because the use of acidic substances for flushing can cause wholeprotein formulas to coagulate and clog the tube, this practice should
be discouraged. The tube should be flushed before and after each
intermittent feeding, after medication administration, or every 4 to
6 hours in case of continuous infusion. When the volume of residual
is higher than 300 to 400 mL or there is significant gastric distention, the clinician should be notified and any infusions held. Infusions should be held for several hours and the residual rechecked
before restarting. For the infusion of medications, liquid forms
should be used if possible. If pills are used they should be crushed to
a fine powder and mixed with water. If the result is sticky or highly
concentrated, dilute it further with water. When the tube is clogged,
it can be irrigated with warm water or, if unsuccessful, a pancreatic
enzyme solution injected. Reinsertion of a device, for example a
stylet or guidewire, into a nasoenteric tube should never be tried
because it can result in gastrointestinal tract injury. If there are
unusual gastrointestinal symptoms like nausea, cramping, abdominal
distention, or severe diarrhea, the infusion should be stopped and
the clinician notified immediately. The clinician must assess the
patient and the tube at this point.
When the nasogastric tube is used for gastric decompression or
postoperative drainage, clinicians should understand the mechanics
of nasogastric suction. Suction strength is inversely proportional to
flow; therefore, the lower the flow rate through the suction lumen,
the higher the suction strength. In addition, a suction force of more
than 25 mm Hg causes tissue capillary fragility and may damage the
gastric mucosa. One advantage of the double-lumen Salem sump
tube over the Levin tube is that it allows constant airflow through
the secondary lumen, keeping the necessary suction in the main
lumen at a minimum. Therefore, the vent lumen must not be
clamped or plugged. When the Levin tube is used, an intermittent
suction pump should be connected to prevent injury of the gastrointestinal mucosa. The length of time the tube can be used depends
on the patient’s condition, feeding needs, and the tube design. With
proper care and maintenance, most nasogastric tubes can be used
for up to 30 days. For longer use, a percutaneous endoscopic gastros-
203 —— NASOGASTRIC AND NASOENTERIC TUBE INSERTION
tomy tube should be considered (see Chapter 200, Percutaneous
Endoscopic Gastrostomy Placement and Replacement).
CPT/BILLING CODES
43219
43752
44500
74340
89100
89130
91105
Endoscopic guided insertion of plastic tube or stent
Nasogastric or orogastric tube placement, necessitating
physician’s skill and fluoroscopic guidance
Introduction of long gastrointestinal tube (e.g., MillerAbbott)
Introduction of long gastrointestinal tube (e.g., MillerAbbott) with fluoroscopic guidance
Duodenal intubation and aspiration; single specimen plus
appropriate test procedure
Gastric intubation and aspiration, diagnostic, each specimen, for chemical analysis or cytopathology
Gastric intubation, and aspiration or lavage, for treatment
(e.g., for ingested poisons)
ICD-9-CM DIAGNOSTIC CODES
014.82
261
263.9
536.2
537.0
560.1
561.81
577.0
577.1
578.0
578.1
578.9
787.01
787.03
977.9
Tuberculosis, gastrocolic, labs pending
Calorie deficiency, severe
Malnutrition, protein-calorie
Vomiting, persistent, nonpregnant
Gastric outlet obstruction, acquired or adult
Ileus, paralytic
Small intestine obstruction, due to adhesions
Pancreatitis, NOS or acute
Pancreatitis, chronic
Hematemesis or gastrointestinal hemorrhage
Hematochezia
Gastrointestinal bleeding, unspecified
Vomiting, NOS with nausea
Vomiting, NOS
Poisoning, unspecified drug or medicinal substances
ACKNOWLEDGMENT
The editors wish to recognize the contributions by Julie Graves Moy,
MD, and Ramiro Sanchez, MD, to this chapter in the previous two
editions of this text.
SUPPLIERS
(See contact information online at www.expertconsult.com.)
Feeding tubes
Cook Incorporated (including percutaneous endoscopic gastrostomy tubes)
CORPAK MedSystems/VIASYS Healthcare/Cardinal Health
1399
Latex-free, zinc oxide tape
Hy-Tape International
Levin, Salem sump, and feeding tubes
The Kendall Company (Covidien)
Nasogastric tube guard
Mormac TubeGuard
NG Strip (Cardinal Health)
pH indicator
pHion Nutrition
60-mL syringe with catheter tip (Toomey)
Becton, Dickinson and Co.
Topical anesthetic
Cetacaine
Cetylite Industries, Inc.
Xylocaine Jelly
AstraZeneca L.P.
ONLINE RESOURCES
National Patient Safety Agency (NPSA) UK: Reducing the harm caused by
misplaced nasogastric feeding tubes: Interim advice for healthcare staff—
February 2005. Available at www.npsa.nhs.uk/advice. Accessed May 15,
2010.
Thomsen TW, Shaffer RW, Setnik GS: Nasogastric intubation. Videos in
Clinical Medicine. N Engl J Med 27 April, 2006. Available at http://
content.nejm.org/cgi/video/354/17/e16/. Accessed May 15, 2010.
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