(See also Nasogastric or Intestinal Intubation Nasogastric or Intestinal Intubation (See also How To Insert a Nasogastric Tube.) Nasogastric or intestinal intubation is used to decompress the stomach. It is used to treat gastric atony, ileus, or obstruction; remove ingested... read more and Enteral Tube Nutrition Enteral Tube Nutrition Enteral tube nutrition is indicated for patients who have a functioning gastrointestinal (GI) tract but cannot ingest enough nutrients orally because they are unable or unwilling to take oral... read more .)
Indications for Nasogastric Tube Insertion
To decompress the stomach and gastrointestinal (GI) tract (ie, to relieve distention due to obstruction, ileus, or atony)
To empty the stomach, for example, in patients who are intubated to prevent aspiration or in patients with GI bleeding to remove blood and clots
To obtain a sample of gastric contents to assess bleeding, volume, or acid content
To remove ingested toxins (rare)
To give antidotes such as activated charcoal
To give oral radiopaque contrast agents
To provide feeding of nutrients into stomach or feeding directly into small intestine with a long, thin, flexible enteral feeding tube
Contraindications to Nasogastric Tube Insertion
Severe maxillofacial trauma
Nasopharyngeal or esophageal obstruction
Esophageal abnormalities, such as recent caustic ingestions, diverticula, or stricture, because of a high risk of esophageal perforation
Uncorrected coagulation abnormalities
Complications of Nasogastric Tube Insertion
Nasopharyngeal trauma with or without hemorrhage
Sinusitis and sore throat
Traumatic esophageal or gastric hemorrhage or perforation
Intracranial or mediastinal penetration (very rare)
Equipment for Nasogastric Tube Insertion
Protective gown, gloves, and face shield
Nasogastric tube for decompression such as a Levin tube (single lumen) or Salem sump tube (double lumen such that second lumen vents to atmosphere)
If small intestine feeding planned, a long, thin, intestinal feeding tube (nasoenteric tube) for long-term enteral feeding (use with a stiffening wire or stylet)
Topical anesthetic spray such as benzocaine or lidocaine
Vasoconstrictor spray such as phenylephrine or oxymetazoline
Cup of water and straw
60-mL catheter-tipped syringe
Towel or blue pad
Tape and benzoin
Suction (wall or mobile device)
Additional Considerations for Nasogastric Tube
When placing a smaller, more flexible intestinal feeding tube, a wire or stylet is used to stiffen the tube. These tubes usually require fluoroscopic or endoscopic assistance for passage through the pylorus.
Positioning for Nasogastric Tube Insertion
Patient sits upright in the sniffing position with the neck slightly flexed.
If unable to sit upright, patient lies in the left lateral decubitus position.
If patient is ventilated through an endotracheal tube that protects the airway, the nasogastric tube can be placed with patient upright or, if needed, supine.
Relevant Anatomy for Nasogastric Tube Insertion
Nasal turbinates can block the nasal passage. There is usually adequate space below the inferior turbinate to pass the nasogastric tube.
Step-by-Step Description of Procedure
Put on gown, gloves, and face shield.
Check for patency of each nostril by holding one closed and asking patient to breathe through other nostril. Ask patient which provides better airflow.
Look inside the nose for any obvious obstructions.
Place a towel or blue pad over the patient’s chest to keep it clean.
Choose the side for tube insertion and spray topical anesthetic in this nostril and the pharynx at least 5 minutes before tube insertion. If time permits, give 4 mL of 10% lidocaine via a nebulizer or insert 5 mL of 2% lidocaine gel into the nares.
If available, spray a vasoconstrictor such as phenylephrine or oxymetazoline in the nostril, trying to reach the entire nostril surface, including the superior and posterior aspects; however, this step can be omitted.
Estimate the proper depth of insertion—about the distance to the earlobe or angle of the mandible and then to the xiphoid, plus 6 inches; note which of the black marks on the tube correspond to this distance.
Lubricate the end of the nasogastric tube.
Gently insert the tip of the tube into the nose and slide along the floor of the nasal cavity. Aim back then down to stay below the nasal turbinate.
Expect to feel mild resistance as the tube passes through the posterior nasopharynx.
Ask the patient to take sips of water through a straw and advance the tube during the swallows. The patient will swallow the tube, facilitating passage into the esophagus. Continue to advance the tube during swallows to the predetermined depth using the black marks on the tube as guidance.
Assess proper tube placement by asking the patient to speak. If patient is unable to speak, has a hoarse voice, is violently gagging, or is in respiratory distress, the tube is probably in the trachea and should be removed immediately.
Inject 20 to 30 mL of air and listen with the stethoscope under the left subcostal region. The sound of a rush of air helps confirms the tube’s location in the stomach.
Aspirate gastric contents to further confirm placement in the stomach (sometimes no gastric contents can be aspirated even when the tube is properly positioned in the stomach).
Sometimes a chest x-ray is needed to definitively confirm the location of the tube in the stomach. If the tube will be used for infusing any substances, such as a radiopaque contrast agents or liquid feedings, a chest x-ray is highly recommended.
Secure the tube to the patient’s nose. Apply benzoin to the skin if available. Use a 4- to 5-inch piece of adhesive tape that is ripped vertically for half of its length and attach the wide half to patient’s nose. Then wrap the tails of the tape in opposite directions around the tube.
Attach the nasogastric tube to suction and set to low suction (intermittent suction if possible).
Aftercare for Nasogastric Tube Insertion
Flush small tubes, such as intestinal feeding tubes, with 20 to 30 mL of tap water at least 2 to 3 times a day.
In patients receiving tube feedings, elevate the head of the bed to at least 30° to help prevent aspiration.
Warnings and Common Errors for Nasogastric Tube Insertion
Patients who are at increased risk of aspiration, such as those with altered mental status, should have their airway protected with an endotracheal tube with the cuff inflated before placement of the nasogastric tube.
A common error is inserting the tube upward where its passage may be blocked by the middle nasal turbinate. This can injure the turbinate and cause bleeding.
Maxillofacial trauma can disrupt the cribriform plate. This trauma increases the risk that a poorly placed nasogastric tube may perforate the cribriform plate and cause serious damage to the brain.
When placing an intestinal feeding tube, the wire or stylet should never be allowed to protrude beyond the end of the feeding tube because these stiff, small-diameter wires can injure the wall of the esophagus or other parts of the GI tract.
A common error is failure to optimally anesthetize the nasopharyngeal passageways.
When using suction, use low intermittent suction to prevent continuous suctioning of one area, which can lead to ulceration and bleeding.
Tips and Tricks of Nasogastric Tube Insertion
When inserting the nasogastric tube, it may be helpful to place your other hand behind the patient’s head to keep him or her from pulling back.
Asking the patient to take sips of water when passing the nasogastric tube through the pharynx into the esophagus and through the esophagus into the stomach can greatly improve the chance of success and reduce gagging. This technique allows the patient to swallow the tube.
Sometimes having the patient tuck their chin toward their chest (chin tuck) while sipping water can help facilitate tube passage from the oropharynx into the stomach.