2. NASOGASTRIC TUBE
A nasogastric (NG) tube is a flexible plastic/silicone
tube inserted through the nostrils, down the
nasopharynx-oesophagus, and into the stomach or
the upper portion of the small intestine
3. PIONEERS/HISTORY
•Ancient Greek & Egyptian civilization
•Fabricius - Nasopharyngeal feeding patients with tetanus
•Hunter - Orogastric feedings
•1867- Kussmaul - flexible orogastric tube for gastric decompression
•1921, the Levin tube was introduced, stiff single-lumen tube that
could be used for either decompression or feeding.
• Dr John Alfred Ryle is credited with the discovery of Nasogastric
intubation
4. TYPES
Fine bore tubes (8-12 French)
Less discomfort
Easier insertion
enteral feeding > decompression
usually contain a guidewire to aid insertion
Wider bore tubes (14-20 French)
Used for aspiration
6. USES OF NG TUBE
•Enteric feeding
•Drug administration
•Small and large bowel obstruction
•Gastric outlet obstruction
•Acute gastric dilation
•Paralytic ileus
•To prevent aspiration from gastro-oesophageal reflux distal to an
oesophageal anastomosis (placed under direct vision intra-
operatively)
•Postoperative gastrointestinal surgery (placed intra-operatively).
These can also be naso-jejunal tubes, where the end lies more
distally in the jejunum.
7. FEEDING
(NICE) used in people who are malnourished or at risk of malnutrition and
have:
Inadequate or unsafe oral intake, and
A functional, accessible gastrointestinal tract.
Neurological conditions causing dysphagia/unsafe swallow such as stroke.
Lowered consciousness level
Following upper gastrointestinal surgery where a high anastomosis must be protected
in the initial post-operative period
Occasionally, NG feeding is used to prepare malnourished patients for major abdominal
surgery in the pre-operative period
Specialist assessment by Speech and Language therapists and dieticians,
to ascertain necessity and safety, monitor progress once started (when it
can be stopped and how to proceed)
In general, enteral tube feeding is only advised for up to 4 weeks. After
this time, the aim would be for the patient to begin feeding orally, or to
change to more long-term measures such as percutaneous endoscopic
gastrostomy (PEG).
If the patient’s nutritional needs are not being met or it transpires that the
8. ASPIRATION
•Nasogastric aspiration is the process of draining the stomach's contents via
the tube.
•Mainly used to remove gastrointestinal secretions and swallowed air in
patients with gastrointestinal obstructions.
•Also used in poisoning situations, for preparation before surgery
under anaesthesia, and to extract samples of gastric liquid for analysis.
•If used for continuous drainage, it is usually appended to a collector bag
placed below the level of the patient's stomach; gravity empties the stomach's
contents. It can also be appended to a suction system, however this method is
often restricted to emergency situations, as the constant suction can easily
damage the stomach's lining. In non-emergency situations, intermittent
suction is often applied giving the benefits of suction without the untoward
effects of damage to the stomach lining.
•Suction drainage is also used for patients who have undergone
a pneumonectomy in order to prevent anesthesia-related vomiting and
possible aspiration of any stomach contents. Such aspiration would represent
a serious risk of complications to patients recovering from this surgery.
9. CONTRAINDICATIONS
•Basal skull fracture: Intracranial placement risk. Orogastric
placement is the route of choice unless you have excluded a
cranial fracture
•Facial trauma
•Upper GI tract perforation
•Previous trans-ethmoidal/trans-sphenoidal neurosurgery
•Oesophageal anastomosis and gastric surgery in postoperative
patients (unless a specialist performs insertion with direct
endoscopic insertion)
•Patient refusal
10. RELATIVE CONTRAINDICATIONS
(Depending on experience and specialty):
•Coagulopathy
•Oesophageal varices
•Oesophageal stricture
•Recent alkaline ingestion (due to risk of oesophageal
rupture)
12. PASSAGE
The nasogastric tube passes backwards
along the base of the nasal passages
through the nasopharynx. It then slides
over the superior surface of the soft palate
and uvula and into the oropharynx.
The swallowing reflex assists passage of
the tube as it passes over the epiglottis
and via the piriform fossa into the upper
part of the oesophagus. Further
coordinated swallowing movements assist
passage into the stomach.
13. PREPARATION
Prepare the necessary
equipment on a small trolley
placed next to the patient
Take universal precautions and
perform thorough hand
washing before attempting the
procedure
14. EQUIPMENT
oPlastic apron and gloves
oRadio-opaque NGT with externally
visible length markings
oCE marked for human gastric aspirate
pH indicator strips/paper with a range
of 0 to 6 and 0.5 gradations
oOral analgesic spray
oSyringe, 10 mL
oToomey syringe, 60 mL
oTape
oEmesis basin or plastic bag
oWall suction, set to low intermittent
suction
oWater based lubricating jelly
oFreshly drawn water to flush
oReceiver/kidney bowl
oGlass of water and a straw (only if the
patient has a safe swallow reflex
oNG Tube Insertion and Management
form
15.
16. STEPS
Refer to medical notes to ensure a clear purpose for the NGT has
been documented.
Prior to insertion of the NGT refer to notes to check for any potential
complications/contraindications
Prior to insertion, check the NG tube is patent with a 50 ml sterile
bladder syringe filled with air.
Explain the procedure and associated risks to the patient. Where the
patient demonstrates lack of capacity - a best interest decision must
be documented in the medical notes and a mental capacity
assessment completed.
Arrange a signal so that the patient can communicate with the nurse
during the procedure e.g. raise a hand.
17. Wash hands and put on non-sterile gloves and an apron.
Assist the patient in a semi-upright position. Support the head in a
slightly forward position.
Check that the nostrils are patent by completing The Sniff Test,
asking the patient to cover on nostril and sniff through the alternative
nostril. Repeat with the other side.
Ask the patient to clean nose by blowing prior to placement/if patient
unable to do this - please assist as required.
Alternate nostrils if replacing a tube.
Check packing prior to opening.
Noting the description of the device, size expiry date, Lot Number.
Unpack the tube, observe full length of NGT observing for any
damage and that the NGT is not kinked. Gently manipulate the
guidewire to ensure it can move freely ensure the guidewire is
18. Estimate length of tube using NEX measurement
Nose, Earlobe & Xiphisternum
Lubricate the tube
Insert the tip of the tube into the chosen nostril, advancing it horizontally and
gently along the floor of the nostril; parallel to the nasal septum, to the
nasopharynx and then oropharynx.
At this point ask the patient to swallow fluid if it is safe and they have capacity to
follow instruction. In the absence of a safe swallow ask to them to try a dry
swallow. A chin tuck may also assist.
Continue advancement to NEX measurement.
If resistance is felt, stop the procedure pull back slightly before attempting to re-
insert (check the patients mouth in case the tube has coiled).
If the patient sneezes or coughs pull back slightly on the NGT wait until the
patient is settled.
If the patient becomes distressed it is advised to stop NGT insertion and seek
specialist advice.
19. If difficulty is found in obtaining a gastric aspirate follow
manufactures advice.
To gain an aspirate (check for a aspirate after each technique is
attempted):
Check mouth for coiling of NGT
Position patient on their side
Re-flush the tube with air to dislodge debris from insertion
If patient has a safe swallow offer a drink then wait 15-20 minutes and re-
check aspirate;
Advance or withdraw NGT by 10-20 cm
Fix the NGT
Document in the NG Tube Insertion & Management form
20. PLACEMENT CONFIRMATION
First line testing: pH testing of NGT aspirate
Second line testing: Chest Radiography
Electromagnetic sensor-guided nasogastric tube placement
Test the aspirate, using pH strips that are CE
marked for human gastric aspirate.
The pH reading must be 5.5 or below to
confirm the position of NGT.
21. A maximum of 3 attempts should be made at one time to insert the
NGT - PLEASE SEEK SENIOR/SPECIALIST ADVICE.
Flush NGT with 10ml of air to clear the tip of any debris
Confirm the position of the NGT by
24. Methods not recommended anymore:
Auscultation of air insufflated through the tube (‘whoosh test’)
(Bedside - Commonly used)
Testing aspirate with Blue Litmus paper
Presence / absence of respiratory distress
Monitoring bubbling at the end of the tube
Observing the appearance of the aspirate
25. RE-ASSESS POSITION
At least once daily during continuous (pump) feeds; before starting the next
feed
Before all administration of medication or flushes
Before administering each bolus feed
Following episodes of vomiting/retching/coughing or suction
If the patient complains of a change in level of discomfort
If the patient develops difficulty in breathing during administration of
feeds, medicines or flushes
In the presence of any new or unexplained respiratory symptoms or
reduction in oxygen saturation
Following any evidence or suggestion of tube displacement (e.g. loose tape
or portion of visible tube appears longer).
26. NGT BLOCK
POSSIBLE CAUSES –
INTERVENTIONS*
Not flushing or inadequate flushing after feed and medication.
-Flush with 50ml water before and after feed or medication.
Unsuitable medicine preparations for giving via an NGT, e.g. large particles,
viscous liquids.
-Review medication and consider alternative medication.
All medication given via NG tube should be in either liquid or dissolvable
form if possible. -----Liaise with pharmacist.
Multiple medications being given together without a flush in between each
drug.
-All medications should be given separately, flushing about 10ml of water in
between each medication.
Kinked NGT
-NGT may be kinked in the stomach, pull back slightly (1-2cm) and confirm
NGT position.
27. COMPLICATIONS
Minor complications
Nose bleeds
Sinusitis
Sore throat
More significant complications (rare)
Erosion of the nose
Esophageal perforation
Damage to a surgical anastomosis
Pulmonary aspiration, a collapsed lung, or intracranial
placement of the tube
28. POST-PROCEDURE
DOCUMENTATION
Indication for the NG tube
Patient consent
Type of tube inserted
External length marking at the nostril
Batch number of NG tube
Date and time of insertion
Nature, amount, and pH of any aspirate
Any complications or difficulties
How you confirmed the position of the tube.
29. NGT REMOVAL
Collect supplies
Verify patient using two identifiers. Explain procedure to patient and
place patient in high Fowler’s position
Perform hand hygiene
Depending on the purpose of the tube either:
stop from feeding tube tubing/disconnect from suction tubing
30. Flush tube with air and then kink tube
Unclip NG tube from patient’s gown
Remove securement device from nose
Hold the NG tube near the naris and gently pull out tube in a
swift, steady motion. Dispose of tube in garbage bag
Offer tissue or clean the nares for the patient, and offer mouth
care as required.
Remove gloves and place patient in a comfortable position.
Assess patient’s level of comfort. Perform hand hygiene.
