NG Feeding Tube
Description: Nasogastric (NG) tubes are flexible tubes that travel from the nose and enter into the stomach. At KGH, weighed tip NG tubes are typically used primarily for enteral feeding, whereas large bore (16Fr+) Salem sump NG tubes are used for gastric decompression. Both NG tubes can be used for medication delivery. In this article we will focus on weighted NG tube use.
Contraindications:
- Esophageal strictures (increased risk of perforation).
- Facial fractures/basal skull fractures.
- Review trauma history in detail
- Look for raccoon eyes/battle sign.
- History of esophageal varices = relative contraindication. Recent banding = absolute contraindicated (placing an NG carries risk of dislodging a band and causing recurrent bleed).
Key items to get on patient history:
- History of varices.
- History of esophageal surgery or stricture.
- History of hiatus hernia, gastric bypass surgery.
- Note: these patients may benefit from NG placed via fluoroscopy.
- History of prior difficult NG tubes or complications.
- Risks to discuss with patient: risks of nasal irritation, bleeding, rare risks of esophageal damage/airway damage.
Equipment to obtain:
- Note: All equipment here can be found in the Davies 4 ICU.
- 10 French Feeding NG tube
- Sterile saline bottle
- Basin/container (to empty saline)
- 50cc purple top syringe (to flush NG tube)
- Lubricant Jelly
- Regular tape
- NG tape
- Nonsterile gloves
- Blue pad to cover patient chest
- Cup with water and straw for patient to swallow (if not strict NPO).
- Note: Lidocaine spray (standard at KGH is banana flavor!) can be used to anesthetize the nasal passage.
- Proper PPE for the provider (at least facemask with shield).
Procedural steps:
1. Equipment Preparation
- Assess for any contraindications to the procedure.
- Place NG supplies on side table. Flush the NG tube with 50cc of sterile water through the purple port, watch for fluid to be discharged at the distal end.
- Determine length of NG tube to be inserted.
- Measure from tip of nose to tip of earlobe, to xiphoid process.
- Lubricate the NG tube.
- Place blue pad on patient’s chest.
- Prepare strip of regular tape and have ready.
- Don clean gloves.
2. Patient Preparation
- Patient seated upright (45-90 degrees) with head tilted downwards facing chest.
- If patient able to, manually occlude one nasal passage and ask them to sniff on the other side. Repeat for contralateral side. Determine which nasal passage seems more patent and use that side for NG insertion.
- Topical anesthesia with lidocaine spray can be used for patient comfort.
- Note: In intubated patients a laryngoscope can be used to guide the NG tube under direct visualization into the esophagus.
- Note: In intubated patients a reverse Sellick maneuver can also be employed (gentle lifting on the cricoid cartilage) to assist with NG insertion.
- If patient able to swallow, can have an assistant bring cup of water + straw for patient.
3. NG tube insertion:
- Use dominant hand and slowly advance NG tube into patient nares.
- At approximately 15cm can ask patient to swallow water and advance tube.
- At approximately 30cm (roughly past carina), tape the NG tube in place.
- Note: If significant coughing, desaturations or facial reddening = remove.
- Note: Measured distances are approximate and vary greatly based on patient size.
- Note: If there is slight resistance in the nasal passage, try rotating tube or switch nostrils.
- Call for portable chest/abdomen x-ray. Confirm that NG tube is past carina.
- Then advance NG to full desired length (i.e. 55cm).
- Call for portable x-ray again and confirm NG is in correct position.
- Secure with NG tape.
- Metal inner wire removed by nursing staff.
- Place communication order "NG ok to use" if appropriate position has been confirmed on x-ray.
Considerations for intubated patients:
NG tubes in intubated patient considerations:
- Orogastric (OG) tubes are often used in intubated patients. However, as patients prepare for extubation these should be exchanged for NG tubes prior to extubating if the provider anticipates that the patient will have ongoing issues with swallowing.
- NG tubes in intubated patients are often more challenging, and airway placement can be more challenging to notice (as patients may be highly sedated/paralyzed). A reverse Sellick maneuver can be employed (applying traction to cricoid) to improve success rate.
- Use of glidescope to directly visualize NG tube insertion through esophagus can help.
- Use of ultrasound may be helpful to identify the esophagus and visualize tube being inserted.
- Note: for patients with hiatus hernias/gastric bypass fluoroscopic or endoscopic guidance may be required.
Confirmation of placement
X-Ray Confirmation:
- Tube bifurcates the carina (passes centrally and doesn’t deviate).
- Crosses diaphragm in central position.
- Enters gastric region.
- Note: Post-pyloric Salem sump tubes long term are not ideal (unless this is intended) as stiff tubes can damage duodenal mucosa.
- Note: Only those trained to confirm NG positioning should do so. If there is doubt about placement, radiologist should confirm.
Methods not to rely on to confirm NG placement:
- Auscultation over epigastric during air injection = inaccurate.
- Assessment of aspirate pH.
- Assessment of fluid aspirate.
- Sole use of ultrasound alone to confirm NG is still controversial and area of ongoing research.
Ultrasound and NG confirmation:
- How to use US:
- RCT demonstrating potential benefits of US use:
Possible complications to be aware of:
- Gastric coiling or knotting of tubes.
- Esophagitis, stricture.
- GI tract perforation (especially if prior gastric/esophageal surgery).
- Cribiform plate perforation + intracranial intubation.
- Gastritis/GI bleeding.
- Pulmonary aspiration.
- Airway intubation + pneumothorax.
- Note: Weighted NG tubes have higher risk of perforation due to stiff guidewire.
- Inadvertent airway medication/nutrition delivery = pneumonia/abscess.
- Nasal ala ulceration/necrosis.
- Intermittent re-taping of tube = decrease pressure on any given area = can prevent.
- Tracheal perforation.
- Note: Although performed frequently, NG tube insertion carries substantial risks, and even experienced providers can cause complications. Even small tubes can cause major complications that, while rare, can be catastrophic. Carefully consider indications, contraindications, and be sure about proper placement before use.
- See attached reports: https://www.sciencedirect.com/science/article/pii/S000399930200045X
Procedural Steps Written by: Muralie Vignarajah MD
Staff reviewed by: Dr. Stephen Gauthier (Internal Medicine)