Insert a Nasogastric Tube

INDICATIONS:

Use of a nasogastric tube is indicated to:

1. Decompress the stomach by aspiration of gastric contents (fluid, air, blood).
2. Introduce fluids (lavage fluid, tube feedings, activated charcoal into the stomach.
3. Assist in the clinical diagnosis through analysis of substances found in gastric contents.

CONTRAINDICATIONS:

Nasogastric tubes are contraindicated or used with extreme caution in people with particular predispositions to injury from tube placement.  These may include:

• Patients with sustained head trauma, maxillofacial injury, or anterior fossa skull fracture. Inserting a NG tube blindly through the nose has potential of passing through the criboform plate, thus causing intracranial penetration of the brain.
• Patients with a history of esophageal stricture, esophageal varices, alkali ingestion at risk for esophageal penetration.
• Comatose patients have the potential of vomiting during a NG insertion procedure, thus require protection of the airway prior to placing a NG tube.

Caution should be utilized when passing a NG tube in a patient with suspected cervical spine injury.  

• Excessive manipulation or movement by the patient during placement including coughing or gagging may potentiate cervical injury.  
• Manual stabilization of the head is required during the procedure.

It is important for the clinician to be aware that several other complications can occur as a result of NG tube placement.  These include:

1. Nasal irritation, sinusitis, epistaxis, rhinorrhea, skin erosion or esophagotracheal fistula secondary to NG placement.
2. Aspiration pneumonia secondary to vomiting and aspiration.
3. Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal intubation.

EQUIPMENT REQUIRED:

• Non-allergenic tape
• Protective pad or towel
• Rubber Band                       
• Gloves
• Curved Basin                      
• Safety pin
• Cup of water with straw               
• Stethoscope
• 60 cc Irrigating syringe           
• Water soluble lubricant
• NG tube (plastic or rubber) of appropriate size        
• Suction

PROCEDURE: Watch a Video demonstrating this technique.

1. If possible, explain the procedure to the patient
2. Position the patient as follows:
   1. If the patient is awake and alert-in a sitting position in high-Fowler’s.
   2. If the patient is obtunded or unconscious-head down, preferably in a left side lying position.
3. Place a protective pad/towel on the patient’s chest as well as provide the patient with a basin to minimize contact with aspirated gastric contents.
4. Using the NG tube as a measuring device determine the length of the NG tube to be passed by measuring the length from
   1. nose to earlobe
   2. earlobe to xiphoid process
5. Add the measurements together and mark this total distance with a small piece of tape.
6. Inspect both of the patient’s nostrils for patency.  Have the patient blow nose if able.
7. Lubricate the first 6 inches of the NG tube liberally with a water soluble lubricant.  Choose the largest patent nostril and begin to pass the NG tube through the nostril to the nasopharynx; direct the tube through the nostril aiming down and back.
8. Once in the pharynx instruct the patient to swallow either mimicking the action or by sipping on small amounts of water.  If awake and alert have the patient place chin to chest to facilitate easier passage of the tube.  Introduce the tube until the selected mark (indicated by the tape) is reached.  See Figure B.
9. Verify NG tube placement in the stomach by two of the following:
   1. Chest X-ray
   2. Aspirating gastric contents with the irrigation syringe
   3. While listening over the epigastrum with a stethoscope quickly instill a 30cc air bolus with the irrigation syringe.  Air entering the stomach will produce a “whooshing” sound.
   4. Ask the patient to hum or talk.  Coughing, cyanosis or choking may indicate that the NG tube has passed through the larynx.
   5. Place the open end of the NG tube in a cup of water.  Persistent bubbling may indicate that the NG tube has passed through the larynx.
10. If unable to positively confirm that the NG tube has been placed is in the stomach the tube must be removed immediately and re-attempted.
11. Once confirmed for placement, secure the NG tube by placing one end of tape on from the bridge to the tip of the nose and the other end wrapped around the tube itself.  If possible the nose should be clean and prepped prior to securing with tincture of benzoin.
12. Clamp or connect the NG tube as desired.  If a Salem sump tube is utilized it important to remember that the blue pigtail must be kept at the level of the fluid in the patient’s stomach.  This will prevent gastric contents from leaking back through vent lumen. 
13. To deter the NG tube from dangling and possible dislodgment:
    1. Curve and tape the tube to the patient’s cheek to prevent unnecessary tugging on the nostrils.  Attach the tube to the patient’s gown.  (Do not tape to the patient’s forehead as this will put pressure on the nares.
    2. Wrap a small piece of tape around the tube near the connection creating a tab.
    3. Loop a rubber band in a slip knot near the connection and pin to the patient’s gown.  

Contributed by LCDR Christopher Schmidt, NC, USN, Naval Medical Center, Portsmouth

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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