Nasogastric Intubation Technique

emedicine.medscape.com /article/80925-technique

Explain the procedure of nasogastric (NG) intubation, as well as its benefits, risks, complications, and
alternatives, to the patient or the patient's representative.

Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to
occlude each nostril and breathe through the other.

Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards
(see the images below), and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal
mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate
anesthetic effect.

Aspiration of viscous lidocaine into a syringe.

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Instillation of viscous lidocaine 2%.

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Estimate the length of insertion by measuring

the distance from the tip of the nose, around
the ear, and down to just below the left costal
margin. This point can be marked with a piece
of tape on the tube. When using the Salem
sump NG tube (Kendall, Mansfield, MA) in
adults, the estimated length usually falls
between the second and third preprinted black
lines on the tube (see the image below).

Estimation of nasogastric tube length from

nostril to stomach.
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Apart from the nose-to-ear-to-xiphisternum

(NEX) method, several other methods for
determining the length of the tube have been
described. Among the various options, a
formula based on gender, weight, and nose-to-
umbilicus measurement while lying flat was
found to be safer and more accurate in a study
by Santos et al. [7]

Position the patient sitting upright with the neck

partially flexed. Ask the patient to hold the cup
of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the NG tube (see the
image below).

Nasogastric tube lubrication with water-based lubricant.

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Gently insert the NG tube along the floor of the nose, and advance it parallel to the nasal floor (ie, directly
perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx,
where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and
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start to swallow (see the image below). Continue to advance the NG tube until the distance of the previously
estimated length is reached (see the video below).

Patient flexing his neck and drinking water while a nasogastric tube is
inserted.
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Nasogastric tube insertion.

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Stop advancing the tube and completely withdraw it if, at any time, the
patient experiences respiratory distress, is unable to speak, has
significant nasal hemorrhage, or if the tube meets significant resistance.

Fan et al described a no-swallow technique of NG tube intubation that

relieves patient discomfort during the procedure. [8] In this technique,
when the tube reaches the pharynx, patients were required to take a
deep breath and hold it, instead of swallowing as in the conventional
technique. During breath-holding, the epiglottis covers the throat and the
glottis closes, thereby reducing the likelihood of the tube entering the
trachea. When the tube was inserted 15-20 cm, the patient was required
to perform abdominal breathing to reduce discomfort and avoid failure of
tube intubation (some patients can only hold their breath for a short
time).

This no-swallow technique was found to yield

an increase in the success rate at first
intubation, as well as reduced occurrence of
nausea, tearing, mucosal injury, and changes
in vital signs (heart rate, breath, systolic
pressure), when compared with the technique
used in the control group. [8]

Verify proper placement of the NG tube by

auscultating a rush of air over the stomach
using the 60 mL Toomey syringe (see the first
image below) or by aspirating gastric
content. The authors recommend always
obtaining a chest radiograph (see the second
image below) in order to verify correct
placement, especially if the NG tube is to be used for medication or food administration. Colorimetric
capnography is another valid method for verifying NG tube positioning in mechanically ventilated patients. [9]

Auscultation over the stomach.

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Nasogastric tube in lung.

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Apply benzoin or another skin preparation solution to the nose bridge. Tape the NG tube to the nose to secure it
in place (see the image below). If clinically indicated, attach the tube to wall suction after verification of correct
placement.

Secured nasogastric tube.

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Pearls

During insertion, if concern exists that the NG

tube is in the incorrect place, ask the patient to
speak. If the patient is able to speak, then the
tube has not passed through the vocal cords
and/or lungs.

The NG tube may coil in the nasopharynx or

oropharynx. If this occurs, or if the tube is
difficult to pass in general, try curling the distal
end and partially freezing it in a cup of ice so it
temporarily holds its curled shape better. Insert
the lubricated tube tip through the nose with the
curled end pointing downward. Once the distal
tip passes into the hypopharynx, the curved tip
faces anteriorly. Rotate the tube 180 so that
the curved end points posteriorly toward the
esophagus. Continue to insert in the usual
manner by having the patient swallow water.

Another option (only in patients who are sedated and

paralyzed) is to place two or three fingers through the
patients mouth into the oropharynx. The fingers are
used to guide the NG tube into the hypopharynx.

Lifting the thyroid cartilage anterior and upward might

open the esophagus and allow passage into the
proximal esophagus.

A method of freezing an NG tube with distilled water

was shown to increase the success rate of insertion
for intubated patients. [10]

Direct laryngoscopy or video laryngoscopy can aid in

placing an NG tube in sedated patients by
visualization of the tip entering the esophagus. [11]

Although pH, enzyme, bilirubin, and carbon dioxide

testing have been used to distinguish respiratory from
gastrointestinal placement of NG tubes, none of these
methods has enabled detection of tube placement in
the esophagus or gastroesophageal junction. Therefore, the authors recommend the routine use of x-ray
verification. [12]

A survey of critical care nurses around the United States showed that recommendations from multiple national-
level organizations to obtain radiographic confirmation that each blindly inserted feeding tube is correctly
positioned before the first use of the tube are not adequately implemented. Auscultation is widely used despite
recommendations to the contrary. [13]

In patients who are anesthetized, Appukutty and Shroff found that three techniques can increase the success
rate of NG tube placement. In randomized, controlled study of 200 patients, the use of a ureteral guide wire as
stylet or a slit endotracheal tube as an introducer increased the success rate in comparison with control
subjects, though the latter technique significantly lengthened the time for insertion. However, head flexion with
lateral neck pressure proved to be the easiest technique, with a high success rate and fewest complications. [14]
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