Inpatient Placement and Management of Nasogastric and Nasoenteric Tubes in Adults - UpToDate

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Inpatient placement and management of nasogastric

and nasoenteric tubes in adults
AUTHORS: Richard A Hodin, MD, Liliana Bordeianou, MD, MPH
SECTION EDITOR: Amalia Cochran, MD, FACS, FCCM
DEPUTY EDITOR: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2023.

This topic last updated: Mar 20, 2023.
INTRODUCTION
Nasogastric and nasoenteric tubes are flexible double or single lumen tubes that are passed
proximally from the nose distally into the stomach or small bowel. Enteric tubes that will be
removed within a short period of time can also be passed through the mouth (orogastric).
This topic will review the indications, contraindications, placement, management, and
complications of nasogastric and nasoenteric tubes in the adult inpatient.
INDICATIONS
Nasogastric tubes are indicated for the following reasons:
● Treatment of ileus or bowel obstruction – Gastrointestinal decompression using

nasogastric tubes is important for the treatment of patients with bowel obstruction or
prolonged ileus. Nasogastric decompression improves patient comfort, minimizes or
prevents recurrent vomiting, and serves as a means to monitor the progress or
resolution of these conditions. (See "Postoperative ileus" and "Management of small
bowel obstruction in adults".)
● Administration of medications – A nasogastric tube may be needed to administer

medications, or oral contrast for computed tomography, to patients who cannot
swallow or who are neurologically impaired.
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● Enteral nutrition – Nasogastric and nasoenteric tubes are used to deliver enteral
nutrition into the stomach (gastric feeding) or into the small intestine (postpyloric). (See
'Enteral nutrition' below.)
● Stomach lavage – Lavage may be needed to remove blood or clots to facilitate

endoscopy. (See 'Gastric lavage' below.)
Contraindications — Nasogastric intubation is contraindicated in patients with esophageal

stricture because of the risk for esophageal perforation, and in patients with basilar skull
fracture or facial fracture due to the potential for intracranial misplacement [1,2].
Nasogastric tubes should also be avoided in patients with esophageal varices because tube
placement may trigger variceal bleeding, which can be life-threatening. In patients with a
bleeding diathesis, minimal trauma to the pharynx, esophagus, or stomach from nasogastric
tubes can also lead to severe bleeding, and, thus, tubes are avoided whenever possible.
TYPES OF TUBES
Nasogastric tubes are made of polyvinyl chloride (PVC), polyurethane, or silicone and come
in numerous sizes. A variety of tubes are available for gastrointestinal decompression or the
administration of medications or enteral formula ( table 1). Nasogastric tubes made of PVC
(eg, Salem Sump) are relatively stiff and therefore more irritating long-term and are used
primarily for gastrointestinal decompression. The most commonly placed nasogastric tube
size in adults is 16 Fr, although larger and smaller sizes are available.
The Salem Sump tube is the most commonly used tube for gastrointestinal decompression.
The tube has two lumens. The larger lumen is connected to intermittent wall suction for
aspiration of gastric contents, or, alternatively, it can be used for irrigation, delivery of
medications, or enteral feeding. The smaller lumen vents to atmosphere (equalizes the
pressure in the stomach once the gastric contents have been emptied), thus preventing the
distal holes from adhering to and damaging the stomach mucosa.
Nasoenteric tubes are more flexible, have a smaller diameter (3.5 to 12 Fr), vary in length (15
to 170 cm), and may be weighted or non-weighted. Although nasogastric tubes can be used
as enteric feeding tubes, a feeding tube cannot be used for gastric decompression because
its soft walls tend to collapse when suction is applied.
AREAS OF CONTROVERSY
Prophylactic placement — We do not recommend routine prophylactic use of nasogastric

tubes for gastric decompression following abdominal/gastrointestinal surgery. When
selectively applied, only approximately 10 percent of postoperative patients require

nasogastric decompression. If the patient develops a prolonged postoperative ileus or early
postoperative small bowel obstruction, then a nasogastric tube is indicated. (See 'Indications'
above.)
Postoperative nasogastric decompression after major abdominal or thoracic surgery has

been used extensively since its initial introduction by Levin [3]. It was thought that such
decompression might reduce postoperative ileus, pulmonary complications, and
anastomotic leakage after gastrointestinal and thoracic surgery [4]. However, data do not
support this belief and most clinicians argue against prophylactic use of nasogastric tubes
following surgery.
Numerous systematic reviews and meta-analyses have shown a lack of benefit from
prophylactic nasogastric tube decompression in the postoperative setting, including in a
wide range of abdominal and thoracic surgeries (eg, biliary, gastroduodenal, colorectal,
gynecologic, trauma, esophageal, and vascular surgery) [4-11]. A meta-analysis of
randomized trials and nonrandomized studies published prior to 1995 found that, although
vomiting and distension were more common when nasogastric tubes were not routinely
used, other parameters were improved [12]. Management of postoperative nausea and
vomiting has become more effective with the introduction of antiemetic agents that do not
cause drowsiness and respiratory depression (eg, ondansetron). The management of
postoperative nausea and vomiting is discussed elsewhere. (See "Overview of post-
anesthetic care for adult patients", section on 'Postoperative nausea and vomiting'.)
In light of these data, allowing a nasogastric tube to remain following recovery of anesthesia
should only be considered in cases where placement may be difficult or associated with
added risks, such as in patients with hiatal hernia, prior stomach or bariatric surgery,
esophagectomy patients, or in patients who may not be able to cooperate postoperatively.
Gastric lavage — Nasogastric tubes have traditionally been used to evaluate patients with
hematochezia, especially when no concomitant hematemesis is present. It was thought that
nasogastric intubation and lavage would distinguish upper from lower gastrointestinal
bleeding by confirming a gastric source for blood per rectum. However, the use of
nasogastric aspiration and lavage alone has a low sensitivity for predicting an upper
gastrointestinal bleeding source. (See "Approach to acute upper gastrointestinal bleeding in
adults" and "Approach to acute upper gastrointestinal bleeding in adults", section on
'Nasogastric lavage'.)
Although commonly used in the past, gastric lavage is no longer routinely used in the
treatment of poisoning. The specific indications for gastric lavage in these patients are
discussed elsewhere. (See "Gastrointestinal decontamination of the poisoned patient",
section on 'Gastric lavage'.)
Enteral nutrition — Nasogastric sump-type tubes are often initially inserted for
gastrointestinal decompression and then used to deliver medications or enteral nutrition
when decompression is no longer needed. Although less prone to clogging, use of a sump-
type nasogastric tube in this manner should be limited to a short period of time and the tube
replaced with a softer, specifically designed enteral feeding tube to minimize potential
complications. Whether to administer feedings into the stomach or postpyloric into the small
intestine is discussed in detail elsewhere. (See "Enteral feeding: Gastric versus post-pyloric".)
At what point a nasogastric or nasoenteric tube should be discontinued in favor of

percutaneous or surgical gastrostomy tubes for enteral nutrition is unclear [13]. (See
"Gastrostomy tubes: Uses, patient selection, and efficacy in adults".)
TUBE PLACEMENT
Most nasogastric tubes are placed at the bedside in an alert patient. Placement is usually
straightforward; however, some patients who have unusual anatomy (eg, gastric bypass,
hiatal hernia repair) may require nasogastric tube placement with fluoroscopic or endoscopic
guidance [14].
Prior to nasogastric tube placement, the appropriate length can be estimated using several
means; however, no single method has been found to be foolproof [15]. A common
technique is to use the distance from the tip of the nose to the tip of the ear to the tip of the
xiphoid as the initial length of nasogastric tube for insertion. Investigators have found that
this method can underestimate or overestimate the length of nasogastric tube needed for
proper placement [15,16]. Other measurements such as tip of nose-tip of ear-umbilicus,
sternal notch-tip of the xiphoid, tip of nose-umbilicus, body length, and crown-rump length
and various formulas using these measurements have also been correlated to the internal
esophagogastric length, but these methods are unnecessarily cumbersome. We advise
initially placing the nasogastric tube no deeper than the tip of nose-tip of ear-xiphoid
distance and stress that all placements should be followed by a plain abdominal radiograph
to exclude kinking of the tube and to evaluate for correct placement. If the tube is in the
esophagus, it should be advanced into the stomach to ensure adequate stomach
decompression. If the tube is beyond the pylorus, it should be pulled back to minimize the
potential for electrolyte abnormalities. (See 'Confirmation of placement' below.)
Placement for decompression
Alert patient — In alert adult patients, a soft 14- to 16-Fr Salem sump nasogastric tube
provides an adequate diameter for gastrointestinal decompression. The tube, which is coiled
in its packaging, should be straightened by pulling on each end prior to placement, and
lubricated. Several small randomized trials have found that instillation of local anesthetic
spray (eg, preservative free 4% lidocaine spray) helps control gagging and will ease some of
the discomfort associated with tube placement [17]. The spray can be intermittently
repeated to help lessen discomfort associated with the ongoing presence of the tube. (See
'Management' below.)
The patient should be seated with the head tilted toward the chest. The tube is introduced
into one of the nares and advanced horizontally ( picture 1). If any resistance is met, the
contralateral nostril should be used. When the tube reaches the posterior nasopharynx, the
patient may feel like gagging. It is helpful to take advantage of the patient's swallowing
mechanism to help passage of the tube into the esophagus and then into the stomach. The
patient can be asked to swallow as the tube is being advanced, but it may be more helpful to
provide the patient with a cup of water to drink using a straw. If the patient gags excessively
or cannot speak, the tube may have entered the trachea. In this case, the tube should be
immediately withdrawn and placement re-attempted.
Once the tube is in the stomach and its location is confirmed, further manipulation of the
tube is performed depending upon the intended purpose. In general, tubes for
decompression are positioned in the gastric fundus and connected to low intermittent wall
suction, which decreases the risk of injury to the gastric mucosa. If the nasogastric tube has
a venting side-port (eg, Salem Sump), it may be practical to use continuous suction initially to
rapidly evacuate accumulated fluid from the stomach, but as the amount of drainage
lessens, the tube should be placed to intermittent suction. Although the vent port of these
tubes should theoretically prevent mucosal injury, the vent port frequently malfunctions or
gets capped inadvertently, essentially converting the tube from a dual lumen to a single
lumen tube.
Tubes intended for feeding can be positioned into the antrum, duodenum (postpyloric), or
jejunum. (See "Enteral feeding: Gastric versus post-pyloric".)
Intubated patient — When an intubated patient requires a nasogastric tube, we suggest

avoiding blind nasogastric tube placement due to the risk of inadvertently placing the tube
into the lung, which can occur even with an inflated endotracheal cuff [18]. The best
approach is to use a laryngoscope to advance the nasogastric tube into the esophagus
under direct vision. However, experienced clinicians, such as anesthesiologists who regularly
deal with intubated patients, often use an alternative technique of placing a finger inside the
patient's mouth to guide the tip of the nasogastric tube into the esophagus. If resistance is
felt or the tube begins to coil, a laryngoscopic is then used. Regardless of how the tube is
placed, its position should be verified before instilling anything into the tube. (See
'Confirmation of placement' below.)
A trial that included 216 anesthetized, intubated adult patients compared nasogastric tube
placement using the conventional methods with modified techniques, such as a guidewire,
neck flexion with lateral pressure, or the reverse Sellick's maneuver (ie, upward traction of
the thyroid cartilage to elevate the larynx anteriorly) [19]. In this study, assisted methods
were more reliable than conventional techniques for providing successful, quick nasogastric
tube insertion on the first attempt. A separate study of 195 intubated patients compared
nasogastric tube placement using conventional methods, placement of a slightly frozen
tube, or placement of a tube using the reverse Sellick's maneuver [20]. The reverse Sellick's
maneuver provided effective placement in 95.2 percent of the patients. Freezing the tube
improved successful insertion over traditional insertion (84.6 versus 69.2 percent). We
suspect that the combination of the nasogastric tube freezing plus the reverse Sellick
maneuver might further increase success rates.
There seems to be some interest in the experimental esophageal guidewire-assisted

technique, which was evaluated in a separate trial that randomly assigned 480 patients to
the experimental technique or a conventional control technique of nasogastric tube
placement with head flexion and lateral neck pressure [21]. The guidewire-assisted technique
consisted of esophageal guidewire placement with manual forward displacement of the
larynx. The first-attempt success rate was significantly improved for the guidewire-assisted
technique (99 versus 57 percent) compared with the control group. However, the technique
used in the control group (head flexion and lateral neck pressure) may not be the most
reliable blind technique. Also, there remains concern over the cost of the guidewire and the
potential that it could perforate the pharynx or esophagus.
Placement for feeding — Soft, small-caliber tubes are commonly used for feeding to
minimize patient discomfort. To place an enteral tube, the stylet (for tubes smaller than 12
Fr) is placed into the enteral feeding tube and the tube is lubricated. As with nasogastric
tubes, the tube is placed into one of the nares and advancement of the tip is aided by having
the patient swallow. Once the position of the tube is confirmed clinically, the stylet is
removed carefully, and radiography obtained to confirm the position of the tip.
If the tube is found to be malpositioned, it is important that the stylet is not replaced
because doing so can lead to gastrointestinal perforation. Rather, the tube should be
removed from the patient, the integrity of the tube verified, the stylet replaced, and the tube
reintroduced and positioned. (See 'Complications' below.)
Confirmation of placement
Radiographic confirmation — We always radiographically confirm the position of tubes

that will be used to administer tube feeding formula or medications. Although malposition of
nasogastric or nasoenteric tubes most commonly involves curling of the tube within the
esophagus, placement into the bronchial tree can occur and may lead to disastrous
consequences ( image 1). (See 'Complications' below.)
Various guidelines agree that the placement of all nasogastric and nasoenteric tubes should
ideally be documented with a radiograph of the lower chest/upper abdomen [22,23].
However, confirming the placement of nasogastric tubes used only for gastrointestinal
decompression (Salem Sump type) is probably not necessary provided the patient does not
have any respiratory complaints or difficulties, and the position of the tube is adequately
confirmed by clinical means. (See 'Clinical confirmation tubes used only for decompression'
below.)
When obtaining radiographs, it is important to inform the radiologist that the study is being
done to specifically to assess nasogastric tube placement. Absence of explicit request
regarding tube placement leads to a higher rate of misinterpreted radiographs and
unhelpful reports that fail to mention the tube location [24]. The entire course of the tube
within the gastrointestinal tract should be seen. Confirmation of proper nasogastric tube
placement on plain chest radiograph is made by noting that the tube is centrally located
distal to the carina (ie, does not deviate laterally) and continues inferiorly, crossing the
diaphragm in a central position into the gastric region below the level of the diaphragm.
While radiography is essential for assuring safe nasogastric tube use, there are some
limitations. In one review of 1934 radiographs performed to evaluate nasogastric tube
positioning after placement in 891 patients, gastric placement was confirmed in 85 percent,
but only 73 percent were deemed safely positioned to allow feeding without repositioning
and further radiographic confirmation [25]. Subsequent radiography delayed feeding and
drug treatment by over two hours in 51 percent of placements, and 33 percent of patients
required more than three radiographs during their enteral episode. These results led the
authors to argue in favor of other methods (eg, endoscopy, fluoroscopy, ultrasonography) to
guide and confirm tube placement. However, there are issues with these methods, as
illustrated in one systematic review that included 10 studies describing ultrasound guidance
for nasogastric tube placement (545 participants and 560 tube insertions), in which
ultrasound did not have sufficient accuracy as a single test to confirm gastric tube placement
[26]. A planned metaanalysis was not performed due to a high level of heterogeneity of
methods, including differences of echo window, the combination of ultrasound with other
confirmation methods (eg, saline flush visualization by ultrasound), and ultrasound during
the insertion of the tube. Other methods such as real-time video-guided placement are even
less well studied [27].
Thus, we still advocate routine radiography for patients who require enteral feeding. These
images should confirm that the tip of a decompressive nasogastric tube should be
positioned into the most dependent portion of the stomach and should not be seen to cross
the midline (ie, postpyloric position). If the tip of a Salem Sump type nasogastric tube is
found to be postpyloric, it should be withdrawn into the stomach. It should not be allowed to
remain in a postpyloric location because these stiff tubes have the potential to damage the
duodenal mucosa. Whenever possible, we prefer to place feeding tubes in a postpyloric

position to minimize risk of aspiration related to distention of the stomach with feeding.
However, the postpyloric placement of feeding tubes does not eliminate the risk of
aspiration. (See "Enteral feeding: Gastric versus post-pyloric".)
Clinical confirmation tubes used only for decompression — Once a Salem Sump tube
has been positioned, the main lumen is aspirated. Gastric contents are usually obvious based
on appearance and volume. Placement into stomach will provide enteric-looking contents
that are typically bilious (ie, green in color). Placement within the lung will not provide an
aspirate. If an insufficient amount of fluid returns, the tube should be readjusted and the test
repeated [28].
Once gastric contents are returned, the tube can be tested by flushing with 20 to 30 cc of
warm water with a large syringe (eg, Toomey), and the water immediately suctioned back
into the syringe. If most (approximately 70 percent) of the water can be retrieved, the tube is
likely in the proper position. It is important to realize that auscultating over the epigastrium
during air injection into any tube is not an accurate way to evaluate tube position since the
tube may be in too far, or not in far enough. Nursing staff should be informed that the tube
placement has only been confirmed clinically, and instructions should be given not to
administer any medicines or feeds through the tube without radiological confirmation of
placement. If there is any question about the position of the tube, a radiograph should be
obtained. (See 'Radiographic confirmation' above.)
While some have advocated using pH testing of the aspirate [29-31], this is also not likely to
be helpful and may provide confusing information given the ubiquitous use of proton pump
inhibitors. Testing may potentially be improved using a novel 6400 ester-impregnated pH
strip. In a study of 376 gastric samples in adult patients in 10 hospitals in the United
Kingdom, the ester strips detected 70.2 percent of the gastric samples compared with only
49.2 percent using the standard strip [32]. If these data can be replicated in future research,
the use of such strips could change clinical management. However, these strips are still in
the experimental stage.
Capnography is an alternative method for verifying nasogastric tube position in mechanically

ventilated patients [33,34]. In a systematic review, calorimetric capnography
(semiquantitative CO2 monitoring) was a reliable predictor of misplacement of the
nasogastric tube into the airway, with a pooled sensitivity and specificity of 0.96 (95% CI 0.88,
0.99) and 0.99 (95% CI 0.96, 1.0), respectively [33]. (See "Carbon dioxide monitoring
(capnography)".)
Tube fixation — Once the nasogastric tube is in its proper position, it should be taped
securely to the nose, but care should be taken not to push the tube up against the nares
because pressure ulceration or necrosis can occur [35]. The nasogastric or nasoenteric tube
can then be secured to the patient's gown with a safety pin. (See 'Nasal alar ulceration or
necrosis' below.)
Various commercial tapes can be used for this purpose. A retrospective comparison of three
types of tape (pink tape, clear tape, "butterfly") in 264 taping episodes reported an
advantage for pink tape with a significantly increased time until failure of the securing
method (100 versus 56 and 30 hours, respectively) [36]. Duodenal tubes stayed secured
significantly longer than sump-type tubes for all taping methods (86 versus 41 hours). The
results were independent of patient alertness, confusion, mobility, or use of restraints.
Other, more aggressive methods of securing nasogastric or nasoenteric tubes have been
described, and these can be used when the risk of losing the tube justifies the intervention.
For example, placing a suture through the membranous nasal septum and securing it to the
tube has been described as an alternative to adhesive tapes. However, significant soft tissue
damage can occur with chronic tension on the columella [37]. Bridles that pinch the
membranous septum provide an anchoring point and are commercially available as an
alternative to suturing, but their safety has not been prospectively evaluated, and routine
use is not recommended. In patients with distorted anatomy such as due to facial trauma or
head and neck surgery, a fine bore suction catheter can be looped around the nasal septum
to secure the nasogastric tube in place ( figure 1) [38].
MANAGEMENT
The function of nasogastric and nasoenteric tubes should be checked frequently by irrigating
the tube with water every four to eight hours.
The drainage from nasogastric tubes placed for gastrointestinal decompression should be
documented to help judge the progression or resolution of obstruction/ileus and the need
for supplemental intravenous fluid. Fluid and electrolyte replacement for nasogastric losses
depends upon the volume and nature of the loss. (See "Maintenance and replacement fluid
therapy in adults".)
The measurement of gastric residual volume, while administering enteral nutrition, does not
appear to be necessary and is not feasible when the small flexible tubes are used. However,
if a larger-bore nasogastric tube is being used, gastric residuals should be periodically
checked in order to avoid problems related to gastric overdistension [39]. (See "Nutrition
support in critically ill patients: Enteral nutrition", section on 'Monitoring'.)
Many patients experience oropharyngeal discomfort, which usually resolves in 24 to 48

hours. Local anesthetic spray applied to the oropharynx may alleviate some of the gag reflex
and discomfort associated with the presence of a tube [17]. New onset of gagging or
respiratory difficulties in a patient with a nasogastric tube should raise the concern of
migration into the oropharynx and indicates the need to reevaluate the position of the tube.
Any tube that does not appear to be functioning properly should be evaluated and may need
to be removed, and replaced if still needed.
Nasogastric tubes should be removed when the indication for placement no longer exists.
For example, in patients with a small bowel obstruction, a decrease in nasogastric output
and the passage of flatus suggest a resolution of the obstruction and that the tube can be
safely removed. A trial of nasogastric drainage to gravity or nasogastric tube clamping are
advocated by some as interim maneuvers prior to nasogastric tube removal to minimize the
need for tube reinsertion. In contrast, others argue that clamping should not be performed,
because it increases the risk of aspiration by allowing gastric distention in the presence of an
impaired esophageal sphincter. There is little evidence to justify or discredit this practice. If a
clamping trial is used, one should check the gastric residuals at least every four hours. (See
'Pulmonary' below.)
Nasogastric tube removal is generally uneventful ( picture 2). If resistance is met upon
attempted removal of a nasogastric or nasoenteric tube, removal should be abandoned and
radiographs obtained. Nasogastric or nasoenteric tube knotting can occur [40]. (See
'Complications' below.)
COMPLICATIONS
Gastrointestinal — In the gastrointestinal tract, malposition, coiling, or knotting of tubes

can occur anywhere along the course of the tube, including pharynx, pyriform sinus,
esophagus, stomach, and duodenum [41]. Pharyngeal and pyriform sinus misplacement can
be recognized in a patient who complains of significant gagging or emesis. In patients who
may not be able to complain, a laryngoscopic examination easily reveals the misplacement.
Fluoroscopy or endoscopy may be needed to safely remove a knotted tube.
The presence of a nasogastric or nasoenteric tube impairs the normal function of the lower
esophageal sphincter, making the patient more susceptible to reflux of gastric contents that
may lead to esophagitis, esophageal stricture, gastrointestinal bleeding, or pulmonary
aspiration. The development of new-onset epigastric or chest pain suggestive of acid reflux
may indicate the development of esophagitis, and, ideally, the tube should be removed [42].
For patients who continue to require the tube, suppression of gastric acid secretion may be
indicated. The treatment of gastroesophageal reflux is discussed in detail elsewhere. (See
"Medical management of gastroesophageal reflux disease in adults".)
Nasogastric tubes can cause gastritis or gastric bleeding due to chronic irritation or pressure
necrosis due to suctioning of the gastrointestinal mucosa [43]. This is usually recognized
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when the aspirated gastric contents become guaiac positive or grossly bloody. Patients with
bloody gastric drainage require further evaluation, and, whenever possible, the nasogastric
tube should be removed. (See "Acute hemorrhagic erosive gastropathy and reactive
gastropathy".)
Esophageal bezoar has been reported as a consequence of improper nasogastric tube

placement [44].
Pulmonary — The risk for pulmonary complications is increased in patients with nasogastric
tubes. Avoidance of prophylactic postoperative nasogastric decompression decreases
pulmonary complications and has other beneficial effects. (See 'Prophylactic placement'
above.)
A systematic review identified 28 trials in which patients were randomly assigned to no

nasogastric tube or selective nasogastric tube placement [4]. Among 19 of these trials
looking at pulmonary complications, a subanalysis identified a trend toward decreased
pulmonary complications in those patients who did not have a nasogastric tube, but the
difference was not significant. However, an updated meta-analysis that included four
additional trials did find an increased risk of pulmonary complications (odds ratio 1.45, 95%
CI 1.1-1.92) [5]. Pulmonary complications were increased in patients with a nasogastric tube
undergoing upper gastrointestinal surgery but not in patients undergoing colorectal
surgery.
Intubation of the lung and inadvertent administration of medications, radiocontrast media,

or enteral formula through the malpositioned tube ( image 1) can lead to pneumonia.
Pulmonary abscess may result [45]. Tracheal perforation and pneumothorax have also been
reported. Proper placement and positioning of these tubes and radiographic confirmation of
position for any tube used for the administration of medications or enteral nutrition can help
prevent these complications. (See 'Tube placement' above.)
Nasal alar ulceration or necrosis — As mentioned above, improperly securing the tube or
placement of too large a tube in an unconscious patient who cannot convey his/her
discomfort can lead to pressure ulcers and even alar necrosis [46]. Frequent retaping of the
tube to decrease pressure on any particular point may help to prevent this complication.
Other methods of tube fixation may be needed. (See 'Tube fixation' above.)
If irritation persists and gastric decompression is still needed, replacement of the tube into
the opposite nare should allow the affected side to heal with the understanding that the
same problem may occur on that side. If gastric decompression is still needed, placement of
a gastrostomy tube (percutaneous, surgical) represents a better long-term solution.
Other — There have been case reports of patients experiencing nasal congestion or
rhinosinusitis. Avoidance of routine nasogastric intubation during surgery, early removal
when they are used, and early placement of gastrostomy tubes for longer-term gastric
decompression has likely contributed to a decline in incidence [47-49]. If the patient's
symptoms are mild, removal of tube from one nare and repositioning in the other nare may
offer relief. More significant symptoms are managed in consultation with an otolaryngologist
[50].
In the context of endotracheal intubation, the diagnosis and treatment of nosocomial

rhinosinusitis is reviewed elsewhere. (See "Complications of the endotracheal tube following
initial placement: Prevention and management in adult intensive care unit patients", section
on 'Sinusitis'.)
Perforation — In addition to potential perforation of pulmonary structures or the

gastrointestinal tract, nasogastric and nasoenteric tubes can perforate other structures in
patients with certain pathologic conditions. Patients with prior esophageal or gastric surgery
are at risk for gastrointestinal perforation, and patients with facial trauma are at risk for
cribriform plate perforation and intracranial intubation [1,2].
SUMMARY AND RECOMMENDATIONS
● Nasogastric and nasoenteral tubes – Nasogastric and nasoenteric tubes are flexible
double or single lumen tubes that are passed proximally from the nose or mouth
distally into the stomach or small bowel. In adults, they are used for gastrointestinal
decompression in the treatment of small bowel obstruction or prolonged severe ileus,
administration of medications or enteral nutrition, and occasionally for gastric lavage.
(See 'Introduction' above and 'Indications' above.)
● Nasogastric tube use – We recommend not using prophylactic postoperative

nasogastric tubes after gastrointestinal or abdominal surgery (Grade 1B). Although
nasogastric or orogastric tubes are placed in the operating room for gastrointestinal
decompression during surgery, the majority of these tubes should be removed once
the patient is alert and recovered from anesthesia. In the past, routine postoperative
gastrointestinal decompression was thought to speed the return of gastrointestinal
function following thoracic or abdominal surgery. However, the time to return of bowel
function was not significantly changed and could even be delayed. (See 'Prophylactic
placement' above.)
● Contraindications – Nasogastric and nasoenteric tube placement is contraindicated in

patients with esophageal stricture, and every effort should be made to avoid their use
in patients with esophageal varices or a bleeding diathesis. Nasal intubation is
contraindicated in patients with basilar skull fracture or facial fracture; these patients
should undergo oral tube placement. (See 'Contraindications' above.)
● Types – Nasogastric and nasoenteric tubes are available in multiple sizes and lengths
( table 1). Dual lumen sump tubes are most commonly used for gastrointestinal
decompression. Although sump tubes can be used for the administration of
medications and for enteral nutrition, these tubes are stiff and irritating. Specifically
designed, flexible, small-diameter enteral tubes are preferred for long-term nutrition.
(See 'Types of tubes' above.)
● Placement – The majority of nasogastric and nasoenteric tubes can be placed at the
bedside. For tubes that will be used only for gastrointestinal decompression, initial
confirmation of the tube's position by clinical means is usually adequate. However, we
always radiographically confirm the position of any tube that will be used to
administer tube feeding formula or medications. (See 'Confirmation of placement'
above.)
● Routine care – The proper functioning of nasogastric and nasoenteric tubes should be
routinely checked every four to eight hours by irrigating the tube. The drainage from
tubes placed for gastrointestinal decompression should also be documented to help
judge the progression or resolution of obstruction/ileus and requirements for
supplemental intravenous fluid. Tubes are removed when the indication for their use is
no longer present. (See 'Management' above.)
● Complications – Complications of nasogastric tubes are a consequence of tube

placement (eg, perforation, pulmonary abscess), chronic irritation of the
gastrointestinal tract (eg, gastritis, ulcer), or altered physiology (eg, reflux) due to the
presence of the tube. Other less common complications can also occur. Proper
placement and confirmation of positioning should prevent many of these
complications. When gastrointestinal reflux, gastritis, or ulcer is identified, the tube
should be removed (ideally) and other treatment measures instituted as indicated. (See
'Complications' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Ferreras J, Junquera LM, García-Consuegra L. Intracranial placement of a nasogastric

tube after severe craniofacial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000; 90:564.
2. Başkaya MK. Inadvertent intracranial placement of a nasogastric tube in patients with
head injuries. Surg Neurol 1999; 52:426.
3. AL, L. A new gastroduodenal catheter. JAMA 1921; 76:1007.
4. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric

decompression after abdominal operations. Br J Surg 2005; 92:673.
5. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal
surgery. Cochrane Database Syst Rev 2007; :CD004929.
6. Inman BA, Harel F, Tiguert R, et al. Routine nasogastric tubes are not required following
cystectomy with urinary diversion: a comparative analysis of 430 patients. J Urol 2003;
170:1888.
7. Otchy DP, Wolff BG, van Heerden JA, et al. Does the avoidance of nasogastric
decompression following elective abdominal colorectal surgery affect the incidence of
incisional hernia? Results of a prospective, randomized trial. Dis Colon Rectum 1995;
38:604.
8. Yang Z, Zheng Q, Wang Z. Meta-analysis of the need for nasogastric or nasojejunal
decompression after gastrectomy for gastric cancer. Br J Surg 2008; 95:809.
9. Daryaei P, Vaghef Davari F, Mir M, et al. Omission of nasogastric tube application in
postoperative care of esophagectomy. World J Surg 2009; 33:773.
10. Rao W, Zhang X, Zhang J, et al. The role of nasogastric tube in decompression after
elective colon and rectum surgery: a meta-analysis. Int J Colorectal Dis 2011; 26:423.
11. Kunstman JW, Klemen ND, Fonseca AL, et al. Nasogastric drainage may be unnecessary
after pancreaticoduodenectomy: a comparison of routine vs selective decompression. J
Am Coll Surg 2013; 217:481.
12. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus
routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221:469.
13. Dennis M, Lewis S, Cranswick G, et al. FOOD: a multicentre randomised trial evaluating
feeding policies in patients admitted to hospital with a recent stroke. Health Technol
Assess 2006; 10:iii.
14. Kelly G, Lee P. Nasendoscopically-assisted placement of a nasogastric feeding tube. J
Laryngol Otol 1999; 113:839.
15. Hanson RL. Predictive criteria for length of nasogastric tube insertion for tube feeding.
JPEN J Parenter Enteral Nutr 1979; 3:160.
16. Beckstrand J, Cirgin Ellett ML, McDaniel A. Predicting internal distance to the stomach
for positioning nasogastric and orogastric feeding tubes in children. J Adv Nurs 2007;
59:274.
17. Gallagher EJ. Nasogastric tubes: hard to swallow. Ann Emerg Med 2004; 44:138.
18. Wang PC, Tseng GY, Yang HB, et al. Inadvertent tracheobronchial placement of feeding
tube in a mechanically ventilated patient. J Chin Med Assoc 2008; 71:365.
19. Mandal MC, Dolai S, Ghosh S, et al. Comparison of four techniques of nasogastric tube
insertion in anaesthetised, intubated patients: A randomized controlled trial. Indian J
Anaesth 2014; 58:714.
20. Mandal M, Karmakar A, Basu SR. Nasogastric tube insertion in anaesthetised, intubated
adult patients: A comparison between three techniques. Indian J Anaesth 2018; 62:609.
21. Kirtania J, Ghose T, Garai D, Ray S. Esophageal guidewire-assisted nasogastric tube
insertion in anesthetized and intubated patients: a prospective randomized controlled
study. Anesth Analg 2012; 114:343.
22. Metheny NA, Krieger MM, Healey F, Meert KL. A review of guidelines to distinguish
between gastric and pulmonary placement of nasogastric tubes. Heart Lung 2019;
48:226.
23. Baskin WN. Acute complications associated with bedside placement of feeding tubes.
Nutr Clin Pract 2006; 21:40.
24. Cohen MD, Ellett M. Quality of communication: different patterns of reporting the
location of the tip of a nasogastric tube. Acad Radiol 2012; 19:651.
25. Taylor S, Manara AR. X-ray checks of NG tube position: a case for guided tube
placement. Br J Radiol 2021; 94:20210432.
26. Tsujimoto H, Tsujimoto Y, Nakata Y, et al. Ultrasonography for confirmation of gastric
tube placement. Cochrane Database Syst Rev 2017; 4:CD012083.
27. Wischmeyer PE, McMoon MM, Waldron NH, Dye EJ. Successful Identification of
Anatomical Markers and Placement of Feeding Tubes in Critically Ill Patients via Camera-
Assisted Technology with Real-Time Video Guidance. JPEN J Parenter Enteral Nutr 2019;
43:118.
28. Ellett ML. What is known about methods of correctly placing gastric tubes in adults and
children. Gastroenterol Nurs 2004; 27:253.
29. Borsci S, Buckle P, Huddy J, et al. Usability study of pH strips for nasogastric tube
placement. PLoS One 2017; 12:e0189013.
30. Gilbertson HR, Rogers EJ, Ukoumunne OC. Determination of a practical pH cutoff level
for reliable confirmation of nasogastric tube placement. JPEN J Parenter Enteral Nutr
2011; 35:540.
31. Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the

auscultatory method to confirm the position of a nasogastric tube. Int J Nurs Stud 2014;
51:1427.
32. Ni M, Adam ME, Akbar F, et al. Development and validation of ester impregnated pH
strips for locating nasogastric feeding tubes in the stomach-a multicentre prospective
diagnostic performance study. Diagn Progn Res 2021; 5:22.
33. Bennetzen LV, Håkonsen SJ, Svenningsen H, Larsen P. Diagnostic accuracy of methods
used to verify nasogastric tube position in mechanically ventilated adult patients: a
systematic review. JBI Database System Rev Implement Rep 2015; 13:188.
34. Chau JPC, Liu X, Choi KC, et al. Diagnostic accuracy of end-tidal carbon dioxide detection
in determining correct placement of nasogastric tube: An updated systematic review
with meta-analysis. Int J Nurs Stud 2021; 123:104071.
35. Banerjee TS, Schneider HJ. Recommended method of attachment of nasogastric tubes.
Ann R Coll Surg Engl 2007; 89:529.
36. Burns SM, Martin M, Robbins V, et al. Comparison of nasogastric tube securing methods
and tube types in medical intensive care patients. Am J Crit Care 1995; 4:198.
37. McGuirt WF, Strout JJ. "How I do it"--head and neck. A targeted problem and its solution:
securing of intermediate duration feeding tubes. Laryngoscope 1980; 90:2046.
38. della Faille D, Schmelzer B, Hartoko T, et al. Securing nasogastric tubes in non-
cooperative patients. Acta Otorhinolaryngol Belg 1996; 50:195.
39. Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume
on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation
and early enteral feeding: a randomized controlled trial. JAMA 2013; 309:249.
40. Palta S. Nasogastric tube knotting in open heart surgery. Acta Anaesthesiol Scand 1999;
43:790.
41. Agarwala S, Dave S, Gupta AK, Mitra DK. Duodeno-renal fistula due to a nasogastric tube
in a neonate. Pediatr Surg Int 1998; 14:102.
42. Newton M, Burnham WR, Kamm MA. Morbidity, mortality, and risk factors for
esophagitis in hospital inpatients. J Clin Gastroenterol 2000; 30:264.
43. Metheny NA, Meert KL, Clouse RE. Complications related to feeding tube placement.
Curr Opin Gastroenterol 2007; 23:178.
44. Tawfic QA, Bhakta P, Date RR, Sharma PK. Esophageal bezoar formation due to
solidification of enteral feed administered through a malpositioned nasogastric tube:
case report and review of the literature. Acta Anaesthesiol Taiwan 2012; 50:188.
45. Malik NW, Timon CI, Russel J. A unique complication of primary tracheoesophageal
puncture: knotting of the nasogastric tube. Otolaryngol Head Neck Surg 1999; 120:528.
46. Lai PB, Pang PC, Chan SK, Lau WY. Necrosis of the nasal ala after improper taping of a
nasogastric tube. Int J Clin Pract 2001; 55:145.
47. O'Connell F, Ong J, Donelan C, Pourmand A. Emergency department approach to gastric

tube complications and review of the literature. Am J Emerg Med 2021; 39:259.e5.
48. Stein M, Caplan ES. Nosocomial sinusitis: a unique subset of sinusitis. Curr Opin Infect
Dis 2005; 18:147.
49. Salord F, Gaussorgues P, Marti-Flich J, et al. Nosocomial maxillary sinusitis during

mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal
route for intubation. Intensive Care Med 1990; 16:390.
50. Adeyemo AA, Fasunla AJ, Adeosun AA, Abdullahi H. Rhinosinusitis; a potential hazard of
nasogastric tube insertion. Ann Ib Postgrad Med 2007; 5:44.
Topic 15070 Version 24.0
GRAPHICS
Nasogastric tubes
Tube Sizes Length Lumen Function Material Comments
Salem- 6-18 F 60-122 Double Gastric PVC Second lumen

sump cm decompression vents to
atmosphere to
Medication prevent suctioning
delivery of tube to gastric
mucosa. Radio
opaque line along
Enteral feeding
its length.
Levin tube 8-20 F 122 cm Single Gastric PVC Markings at 45, 55,
decompression 65, 75 cm. Radio
opaque line along
Medication
its length.
delivery
Enteral feeding
Ryle's tube 8-20 F 105 cm Single Gastric PVC Markings at 50, 60,
aspiration 70 cm. Radio
opaque line along
its length.
Enteral feeding
Weighted end.
Enteral 3.5-12 31-240 Single to Enteral feeding Polyurethane, Various features

feeding F cm triple silicone, PVC may be present:
tubes Stylet used for
(Examples: <12 F tubes to
Abbot stiffen the tube
Nutrition for insertion
enteral and confirm
feeding placement
tube; Cook radiographically
Endoscopy Radio opaque
NJFT; markers each
Corpak cm
Medical Weighted tip to
Systems allow
CORFLO propulsion into
tubes; duodenum by
Covidien peristalsis
tubes; Magnets to
Teleflex facilitate jejunal
Medical placement
tubes)
Suture loops to
allow
endoscopic
placement
PVC: polyvinyl chloride.
Graphic 52488 Version 2.0
Nasogastric tube placement
(A) Lubricate the nasogastric (NG) tube and offer the patient a cup or glass
of water with a straw (unless contraindicated). Place the tube into one of
the nares, gently advance the tube but stop before it reaches the
nasopharynx. Direct the patient to sip and swallow as the tube is advanced
which helps pass the tube into the esophagus. If water is not being used,
ask the patient to swallow.
(B) Once the tube is in place, aspirate using a suction tip syringe and
examine the aspirate. It should have a typical gastric fluid appearance
(grassy green, clear and colorless with mucus shreds, or brown). If needed,
place a small amount on the pH test strip; the pH should be ≤5.0.
Alternatively, instill about 15-20 cc warm water and then aspirate. If the
tube is in good position, at least 1/2 of the fluid should be returned.
(C) Secure the NG tube to the patient's nose with hypoallergenic tape (or an
NG tube holder). If the patient's skin is oily, wipe the bridge of the nose with
an alcohol pad and allow to dry. Split one end of the tape up the center
about 1 1/2 inches. Make tabs on the split ends (by folding the sticky sides
together). Apply the unsplit tape end on the patient's nose so the split in
the tape starts about 1/2 to 1 1/2 inches from the tip of the nose. Crisscross
the tabbed ends around the tube. Apply another piece of tape over the
bridge of the nose to secure the tube.
Reproduced with permission from: Springhouse. Lippincott's Visual Encyclopedia of Clinical

Skills. Philadelphia: Wolters Kluwer Health, 2009. Copyright © 2009 Lippincott Williams &
Wilkins.
Misplaced nasogastric tube
This adolescent had a nasogastric tube placed after a polydrug

ingestion. Charcoal was administered, and the patient's respiratory
status deteriorated. The chest radiograph shows the nasogastric
tube in the left lower lung (arrow) and alveolar opacification
(asterisk).
Reproduced with permission from: Fleisher GR, Ludwig S, Baskin MN. Atlas of
Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins, 2004.
Copyright © 2004 Lippincott Williams & Wilkins.
Nasal bridle
A flexible piece of material is looped around the nasal septum from

one nostril to the other as a bridle. The nasoenteric tube is secured
to the bridle which prevents movement or dislodgement of the tube.
Reproduced with permission from: Mulholland MW, Maier RV, et al. Greenfield's
Surgery: Scientific Principles and Practice, Fourth Edition. Philadelphia: Lippincott
Williams & Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Nasogastric tube removal
After placing an absorbant pad, gently remove the tape fixing the
tube to the patient's nose. Use a catheter-tip syringe to flush the
tube with 10 mL of air or normal saline solution to ensure the tube
doesn't contain stomach contents that could irritate tissues during
tube removal. Clamp the tube by folding it in your hand, then gently
and steadily pull the tube out. Provide a tissue to the patient with
which to clean and blow their nose, if needed.
Reproduced with permission from: Springhouse. Lippincott's Visual Encyclopedia of

Clinical Skills. Philadelphia: Wolters Kluwer Health, 2009. Copyright © 2009
Lippincott Williams & Wilkins.
Contributor Disclosures
Richard A Hodin, MD No relevant financial relationship(s) with ineligible companies to
disclose. Liliana Bordeianou, MD, MPH Grant/Research/Clinical Trial Support: American Society of
Colon and Rectal Surgery Research Foundation [Rectal prolapse]; Crohn's & Colitis Foundation [Ileoanal
anastomosis (J-pouch) surgery]. Consultant/Advisory Boards: Cook Medical [Fecal incontinence]. All of
the relevant financial relationships listed have been mitigated. Amalia Cochran, MD, FACS,
FCCM Other Financial Interest: JAMA Surgery [Web and social media editor]. All of the relevant financial
relationships listed have been mitigated. Kathryn A Collins, MD, PhD, FACS No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

Inpatient Placement and Management of Nasogastric and Nasoenteric Tubes in Adults - UpToDate

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11/11/23, 14:13 Inpatient placement and management of nasogastric and nasoenteric tubes in adults - UpToDate

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Inpatient placement and management of nasogastric

Literature review current through: Oct 2023.

Nasogastric tubes are indicated for the following reasons:

● Treatment of ileus or bowel obstruction – Gastrointestinal decompression using

● Administration of medications – A nasogastric tube may be needed to administer

● Stomach lavage – Lavage may be needed to remove blood or clots to facilitate

Contraindications — Nasogastric intubation is contraindicated in patients with esophageal

Prophylactic placement — We do not recommend routine prophylactic use of nasogastric

selectively applied, only approximately 10 percent of postoperative patients require

Postoperative nasogastric decompression after major abdominal or thoracic surgery has

At what point a nasogastric or nasoenteric tube should be discontinued in favor of

Placement for decompression

Intubated patient — When an intubated patient requires a nasogastric tube, we suggest

There seems to be some interest in the experimental esophageal guidewire-assisted

Radiographic confirmation — We always radiographically confirm the position of tubes

duodenal mucosa. Whenever possible, we prefer to place feeding tubes in a postpyloric

Capnography is an alternative method for verifying nasogastric tube position in mechanically

Many patients experience oropharyngeal discomfort, which usually resolves in 24 to 48

Gastrointestinal — In the gastrointestinal tract, malposition, coiling, or knotting of tubes

Esophageal bezoar has been reported as a consequence of improper nasogastric tube

A systematic review identified 28 trials in which patients were randomly assigned to no

Intubation of the lung and inadvertent administration of medications, radiocontrast media,

In the context of endotracheal intubation, the diagnosis and treatment of nosocomial

Perforation — In addition to potential perforation of pulmonary structures or the

SUMMARY AND RECOMMENDATIONS

● Nasogastric tube use – We recommend not using prophylactic postoperative

● Contraindications – Nasogastric and nasoenteric tube placement is contraindicated in

● Complications – Complications of nasogastric tubes are a consequence of tube

Use of UpToDate is subject to the Terms of Use.

1. Ferreras J, Junquera LM, García-Consuegra L. Intracranial placement of a nasogastric

4. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric

31. Boeykens K, Steeman E, Duysburgh I. Reliability of pH measurement and the

47. O'Connell F, Ong J, Donelan C, Pourmand A. Emergency department approach to gastric

49. Salord F, Gaussorgues P, Marti-Flich J, et al. Nosocomial maxillary sinusitis during

Tube Sizes Length Lumen Function Material Comments

Salem- 6-18 F 60-122 Double Gastric PVC Second lumen

Enteral 3.5-12 31-240 Single to Enteral feeding Polyurethane, Various features

PVC: polyvinyl chloride.

Graphic 52488 Version 2.0

Nasogastric tube placement

Reproduced with permission from: Springhouse. Lippincott's Visual Encyclopedia of Clinical

Graphic 76398 Version 2.0

Misplaced nasogastric tube

This adolescent had a nasogastric tube placed after a polydrug

Graphic 62549 Version 4.0

A flexible piece of material is looped around the nasal septum from

Graphic 51735 Version 2.0

Nasogastric tube removal

Reproduced with permission from: Springhouse. Lippincott's Visual Encyclopedia of

Graphic 64523 Version 2.0

Conflict of interest policy

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