Nasogastric tube positioning
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Assessment of nasogastric (NG) tube positioning is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death.
Evaluation of Nasogastric tube
Plain radiograph
A correctly placed nasogastric tube should 10:
-
Descenddescend in the midline, following the path of the oesophagus and avoiding the contours of the bronchi -
Clearlyclearly bisect the carina or bronchi -
Crosscross the diaphragm in the midline -
Havehave its tip visible below the left hemidiaphragm
Ideally, the tip should be at least 10 cm beyond the gastro-oesophageal junction 1.
Malpositioning may include tip position:
- remaining in the oesophagus
- traversing either bronchus or more distally into the lung
- coiled in the upper airway
- intracranial insertion, possible in both patients with and without skull base trauma or surgery 2
- spinal canal insertion is very rare, occurring after skull base surgery in one case report 8,9
In some circumstances fluoroscopic nasojejunal tube insertion is necessary.
Ultrasound
Point-of-care ultrasonography may be used to guide the nasogastric tube in real time with the probe placed sequentially in the following locations 7:
- anterolateral neck
- cervical esophagus typically visualized to the left, posterolateral to the trachea
- an intraluminal curvilinear echogenic interface represents esophageal placement of the tube
- epigastrium
- with a longitudinal view of the gastroesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualization
- oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement
Complications
Overall, complications occur in 1-3% of cases, with complications leading to death occurring in approximately 0.3% of cases. Complications include 1-6,8,9:
- upper airway
- epistaxis from insertion trauma
- lower airway
- aspiration pneumonia
- pneumothorax
- haemorrhage
- empyema
- enteral
- viscus perforation and mediastinitis or peritonitis
- may further complicate with intravascular placement
- viscus obstruction
- knotting/tangling of the tube
- intramural oesophageal dissection
- viscus perforation and mediastinitis or peritonitis
- intracranial and spinal canal
- meningitis
- focal neurological deficits
-<li>Descend in the midline, following the path of the oesophagus and avoiding the contours of the bronchi</li>-<li>Clearly bisect the carina or bronchi</li>-<li>Cross the diaphragm in the midline</li>-<li>Have its tip visible below the left hemidiaphragm</li>- +<li>descend in the midline, following the path of the oesophagus and avoiding the contours of the bronchi</li>
- +<li>clearly bisect the carina or bronchi</li>
- +<li>cross the diaphragm in the midline</li>
- +<li>have its tip visible below the left hemidiaphragm</li>
References changed:
- 3. Isik A, Firat D, Peker K, Sayar I, et al. A case report of esophageal perforation: Complication of nasogastric tube placement. (2014) American Journal of Case Reports. 15: 168. <a href="https://doi.org/10.12659/AJCR.890260">doi:10.12659/AJCR.890260</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24803977">Pubmed</a> <span class="ref_v4"></span>
- 4. Tai CM, Wang HP, Lee CT, et al. Esophageal obstruction by a tangled nasogastric tube. (2010) Gastrointestinal endoscopy. 72 (5): 1057-8. <a href="https://doi.org/10.1016/j.gie.2010.03.1131">doi:10.1016/j.gie.2010.03.1131</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20605147">Pubmed</a> <span class="ref_v4"></span>
- 6. Duthorn L, Steinberg HS, Hauser H, et al. Accidental Intravascular Placement of a Feeding Tube . (1998) Anesthesiology: The Journal of the American Society of Anesthesiologists. 89 (1): 251. <span class="ref_v4"></span>
- 8. Hanna AS, Grindle CR, Patel AA, et al. Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. (2012) American journal of otolaryngology. 33 (1): 178-80. <a href="https://doi.org/10.1016/j.amjoto.2011.04.001">doi:10.1016/j.amjoto.2011.04.001</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21715048">Pubmed</a> <span class="ref_v4"></span>
- 3. Isik A, Firat D, Peker K, Sayar I, Idiz O, Soytürk M. A case report of esophageal perforation: Complication of nasogastric tube placement. (2014) American Journal of Case Reports. 15: 168. <a href="https://doi.org/10.12659/AJCR.890260">doi:10.12659/AJCR.890260</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24803977">Pubmed</a> <span class="ref_v4"></span>
- 4. Tai CM, Wang HP, Lee CT, Chang CY, Wang WL, Tseng CH, Lin JT. Esophageal obstruction by a tangled nasogastric tube. (2010) Gastrointestinal endoscopy. 72 (5): 1057-8. <a href="https://doi.org/10.1016/j.gie.2010.03.1131">doi:10.1016/j.gie.2010.03.1131</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20605147">Pubmed</a> <span class="ref_v4"></span>
- 6. Duthorn L, Steinberg HS, Hauser H, Neeser G, Prack Pi. Accidental Intravascular Placement of a Feeding Tube . (1998) Anesthesiology: The Journal of the American Society of Anesthesiologists. 89 (1): 251. <span class="ref_v4"></span>
- 8. Hanna AS, Grindle CR, Patel AA, Rosen MR, Evans JJ. Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. (2012) American journal of otolaryngology. 33 (1): 178-80. <a href="https://doi.org/10.1016/j.amjoto.2011.04.001">doi:10.1016/j.amjoto.2011.04.001</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21715048">Pubmed</a> <span class="ref_v4"></span>
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