Nasogastric tube positioning
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- updated 19 Dec 2022:
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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.
Radiographic features
Plain radiograph
A correctly placed nasogastric tube should 10:
- descend in the midline, following the path of the oesophagus and avoiding the contours of the bronchi
- clearly bisect the carina or bronchi
- cross the diaphragm in the midline
- have 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 oesophagus typically visualised to the left, posterolateral to the trachea
- an intraluminal curvilinear echogenic interface represents oesophageal placement of the tube
- epigastrium
- with a longitudinal view of the gastrooesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualisation
- 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 fatal sequelae in ~0.3% of cases. Complications include 1-6,8,9:
- upper airway
- epistaxis from insertion trauma
- lower airway
- enteral
- GI perforation and mediastinitis or peritonitis
- may further complicate with intravascular placement
- GI obstruction
- knotting/tangling of the tube
- intramural oesophageal dissection
- GI perforation and mediastinitis or peritonitis
- intracranial and spinal canal
- meningitis
- focal neurological deficits
-<p>Assessment of <strong>nasogastric (NG) tube positioning </strong>is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death. </p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>A correctly placed nasogastric tube should <sup>10</sup>:</p><ul>-<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>-</ul><p>Ideally, the tip should be at least 10 cm beyond the <a href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction</a> <sup>1</sup>.</p><p>Malpositioning may include tip position:</p><ul>-<li>remaining in the <a href="/articles/oesophagus">oesophagus</a>-</li>-<li>traversing either bronchus or more distally into the lung</li>-<li>coiled in the upper airway</li>-<li>intracranial insertion, possible in both patients with and without skull base trauma or surgery <sup>2</sup>-</li>-<li>spinal canal insertion is very rare, occurring after skull base surgery in one case report <sup>8,9</sup>-</li>-</ul><p>In some circumstances <a href="/articles/fluoroscopic-nasojejunal-tube-insertion">fluoroscopic nasojejunal tube insertion</a> is necessary.</p><h5>Ultrasound</h5><p><a href="/articles/point-of-care-ultrasound-curriculum">Point-of-care ultrasonography</a> may be used to guide the nasogastric tube in real-time with the probe placed sequentially in the following locations <sup>7</sup>:</p><ul>-<li>anterolateral neck<ul>-<li>cervical oesophagus typically visualised to the left, posterolateral to the trachea</li>-<li>an intraluminal curvilinear echogenic interface represents oesophageal placement of the tube</li>-</ul>-</li>-<li>epigastrium<ul>-<li>with a longitudinal view of the gastrooesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualisation</li>-<li>oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement</li>-</ul>-</li>-</ul><h4>Complications</h4><p>Overall, complications occur in 1-3% of cases, with fatal sequelae in ~0.3% of cases. Complications include <sup>1-6,8,9</sup>:</p><ul>-<li>upper airway<ul><li>-<a href="/articles/epistaxis">epistaxis</a> from insertion trauma</li></ul>-</li>-<li>lower airway<ul>-<li><a href="/articles/aspiration-pneumonia">aspiration pneumonia</a></li>-<li><a href="/articles/pneumothorax">pneumothorax</a></li>-<li><a href="/articles/pulmonary-haemorrhage">haemorrhage</a></li>-<li><a href="/articles/empyema-1">empyema</a></li>-</ul>-</li>-<li>enteral<ul>-<li>GI perforation and <a href="/articles/mediastinitis">mediastinitis</a> or peritonitis<ul><li>may further complicate with intravascular placement</li></ul>-</li>-<li>GI obstruction</li>-<li>knotting/tangling of the tube</li>-<li><a href="/articles/oesophageal-dissection">intramural oesophageal dissection</a></li>-</ul>-</li>-<li>intracranial and spinal canal<ul>-<li><a href="/articles/leptomeningitis">meningitis</a></li>-<li>focal neurological deficits</li>-</ul>-</li>- +<p>Assessment of <strong>nasogastric (NG) tube positioning </strong>is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death. </p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>A correctly placed nasogastric tube should <sup>10</sup>:</p><ul>
- +<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>
- +</ul><p>Ideally, the tip should be at least 10 cm beyond the <a href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction</a> <sup>1</sup>.</p><p>Malpositioning may include tip position:</p><ul>
- +<li>remaining in the <a href="/articles/oesophagus">oesophagus</a>
- +</li>
- +<li>traversing either bronchus or more distally into the lung</li>
- +<li>coiled in the upper airway</li>
- +<li>intracranial insertion, possible in both patients with and without skull base trauma or surgery <sup>2</sup>
- +</li>
- +<li>spinal canal insertion is very rare, occurring after skull base surgery in one case report <sup>8,9</sup>
- +</li>
- +</ul><p>In some circumstances <a href="/articles/fluoroscopic-nasojejunal-tube-insertion">fluoroscopic nasojejunal tube insertion</a> is necessary.</p><h5>Ultrasound</h5><p><a href="/articles/point-of-care-ultrasound-curriculum">Point-of-care ultrasonography</a> may be used to guide the nasogastric tube in real-time with the probe placed sequentially in the following locations <sup>7</sup>:</p><ul>
- +<li>anterolateral neck<ul>
- +<li>cervical oesophagus typically visualised to the left, posterolateral to the trachea</li>
- +<li>an intraluminal curvilinear echogenic interface represents oesophageal placement of the tube</li>
- +</ul>
- +</li>
- +<li>epigastrium<ul>
- +<li>with a longitudinal view of the gastrooesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualisation</li>
- +<li>oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement</li>
- +</ul>
- +</li>
- +</ul><h4>Complications</h4><p>Overall, complications occur in 1-3% of cases, with fatal sequelae in ~0.3% of cases. Complications include <sup>1-6,8,9</sup>:</p><ul>
- +<li>upper airway<ul><li>
- +<a href="/articles/epistaxis">epistaxis</a> from insertion trauma</li></ul>
- +</li>
- +<li>lower airway<ul>
- +<li><a href="/articles/aspiration-pneumonia">aspiration pneumonia</a></li>
- +<li><a href="/articles/pneumothorax">pneumothorax</a></li>
- +<li><a href="/articles/pulmonary-haemorrhage">haemorrhage</a></li>
- +<li><a href="/articles/empyema-1">empyema</a></li>
- +</ul>
- +</li>
- +<li>enteral<ul>
- +<li>GI perforation and <a href="/articles/mediastinitis">mediastinitis</a> or peritonitis<ul><li>may further complicate with intravascular placement</li></ul>
- +</li>
- +<li>GI obstruction</li>
- +<li>knotting/tangling of the tube</li>
- +<li><a href="/articles/oesophageal-dissection">intramural oesophageal dissection</a></li>
- +</ul>
- +</li>
- +<li>intracranial and spinal canal<ul>
- +<li><a href="/articles/leptomeningitis">meningitis</a></li>
- +<li>focal neurological deficits</li>
- +</ul>
- +</li>
Images Changes:
Image 25 CT (bone window) ( create )
Caption
was added:
Case 23: within the right main bronchus
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25.
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