Placement and Verification of the Nasogastric Tube: An In-depth Analysis of Ultrasonographic Technique.

The NOVEL Project Update

BackgroundRadiation therapy (RT)-associated oral mucositis, xerostomia, thick mucoid saliva, nausea/vomiting, and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers (HNC). Feeding tube placement allows patients to receive enteral nutrition and continue the planned course of treatment.ObjectivesRT-associated oral mucositis, xerostomia, and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers. We sought to determine if reactive nasogastric (NG) tube placement was an effective strategy for nutritional support in these patients and if invasive percutaneous endoscopic gastrostomy (PEG) tube insertion could be avoided.MethodsThis is an institutional review board (IRB)-approved study of patients treated for head and neck cancer using definitive or adjuvant RT with or without concurrent chemotherapy between June 2017 and December 2020. We evaluated the indications for NG tube (Dobhoff) placement, time of placement during the course of RT, patient tolerance of NG tube, and median duration of NG tube placement. In addition, we followed weight loss during treatment, treatment interruptions, and treatment-related toxicities. Complications associated with having the NG tube, if the NG tube needed to be replaced during treatment, and if the patient had any hospitalization during the course of treatment were tracked.ResultsOf the 441 patients treated for head and neck cancer during the time period of this study, 47 required reactive NG tube placement for nutritional support. Patients included 40 with primary oropharynx, three with oral cavity, two with larynx, one with nasopharyngeal, and one was unknown. Chemotherapy was given concurrently with radiation in 87.2% (n=41) patients. The median time of NG tube placement was during Week 5 of the six to seven-week course of RT. The median percentage of weight loss from baseline to the date of NG tube placement was 12.9% (range, -0.9% to 25.9%). The median rate of weight loss decreased by 8.7% from the date of NG tube placement to the end of treatment. The median duration of NG tube placement was 29 days (range, 5 to 151 days). There were no serious medical complications associated with having the NG tube in place during treatment. Twenty-seven point six percent (27.6%; n=13) of patients had the NG tube dislodged or displaced and needed replacement. Thirty-eight point three percent (38.3%; n=18) of patients with an NG tube had to be hospitalized during the course of RT, with the predominant symptoms being failure to thrive (22.2%; n=4) and nausea/vomiting 22.2% (n=4). Six point four percent (6.4%; n=3) of patients requested the removal of the NG tube due to local irritation. Seventy-six point six percent (76.6%; n=36) of patients did not require further nutritional support with the placement of a percutaneous endoscopic gastrostomy (PEG) tube.ConclusionThis study indicates that clinic placement of an NG tube for patients receiving RT for head and neck cancer is a safe and effective way to maintain nutrition during treatment. The rate of weight loss decreased after the patient had an NG tube placed. The placement procedure is well-tolerated and there were no complications associated with having the NG tube during treatment. PEG tube insertion was avoided in approximately 80% of the patients.

Q: Is any evidence available to support practices for verifying nasogastric tube (NGT) placement in critically ill pediatric patients?A: Beth Lyman, RN, MSN, CNSC, replies: Yes, there is evidence to guide this practice; there is even an international work group addressing this issue.The American Society for Parenteral and Enteral Nutrition has a task force called the NOVEL (New Opportunities for Verification of Enteral tube Location) project. This group of physicians and nurses from Australia, Canada, and the United States is working to promote best practice for verification of NGT placement.Twenty-four percent of hospitalized pediatric patients require an NGT. Of those patients, approximately 18% are in a pediatric intensive care unit.1 A 1999 pediatric study by Ellett and Beckstrand2 documented that 22% to 44% of NGTs were misplaced when verified by abdominal radiography. A study by Quandt et al3 documented that the odds of an NGT being in the distal esophagus are 2.74 times higher if a neonate is intubated.A patient safety alert issued in 2012 recommended immediate discontinuation of the use of auscultation to verify correct NGT placement.4 Despite this recommendation, a study published by Metheny and colleagues5 in 2012 documented continued use of this method. The Lyman study conducted in 2015 asked the 63 participating centers to share their primary and secondary method(s) to verify NGT placement, with responses of aspiration (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and radiography (n = 6).1Although the gold-standard method for verification of NGT placement for adult patients is considered an abdominal radiograph, pediatric clinicians have been reluctant to embrace this practice because of concerns over the long-term cumulative effects of radiation exposure. In addition to the concerns about radiation exposure, there is growing evidence that radiographs can be interpreted incorrectly.6,7 A 2011 study looked at 4330 pH aspirates from NGTs along with 635 pH aspirates from pediatric intensive care unit patients with an endotracheal tube.8 In this population, 27% of the patients received an acid-suppressing medication, resulting in an average pH of 4.2, compared with 3.4 from those patients who did not receive any of these medications.Investigators also found nurses were not able to discern gastric from pulmonary secretions upon visual inspection. Gilbertson et al8 concluded that a pH of 5 or less predicted gastric placement 90% of the time. The average pH for aspirates from the endotracheal tube was 8.3 (95% CI, 6–9.5). A pH of 5 to 5.5 or less is what is used in Canada, Australia, and the United Kingdom as a means of verifying NGT placement. The pH measurement is to be done at the bedside even when an abdominal radiograph or other device, such as an electromagnetic device, is used.9Accurate measurement of how far to insert an NGT is associated with better outcomes. The previously mentioned patient safety alert recommended use of NEMU (nose-earlobe-midumbilicus, or the midpoint between the xiphoid process and umbilicus). Previous studies have documented that use of the NEX (nose-earlobe-xiphoid) method can result in the NGT being in the distal esophagus.10The use of an electromagnetic device to place an NGT or postpyloric feeding tube has been studied repeatedly in critically ill adults and the pediatric population, with mixed results due to the potential for misinterpretation of the screen and time needed to place the tubes.11–14 The National Patient Safety Agency’s (United Kingdom) recommendation to obtain an abdominal radiograph or pH in conjunction with such a device is echoed by others in the United States who have studied this device in adult patients.15,16 The recommendation to check an abdominal radiograph or pH, even when an electromagnetic device is used, should pertain to children as well.When placing an NGT, consider the following approach:

Diagnostic accuracy of ultrasonography for detecting nasogastric tube (NGT) placement in adults: A systematic review and meta analysis

To describe pneumothorax as a complication of nasogastric tube (NGT) misplacement in six dogs at a single institution and to discuss NGT placement techniques and pneumothorax prevention strategies found in the human and veterinary literature. Retrospective case series. Private referral center. Six client-owned dogs. Medical records at a private practice referral hospital were searched for cats and dogs with "nasogastric tube" and "pneumothorax" from January 2013 to May 2022. Data collected from the medical records, where available, included patient signalment, weight, primary disease process, relevant diagnostic test results, clinical signs before NGT placement, size of NGT, personnel performing tube placement, sedation administered before NGT placement, therapies administered for management of pneumothorax, duration of hospitalization, and outcome. Six dogs were included, having developed pneumothorax secondary to NGT misplacement during the 9-year period (incidence=0.0006). Four of the six dogs received IV sedation before NGT placement. Three of the six dogs displayed clinical signs of pneumothorax, including an abnormal breathing pattern and coughing. Thoracocentesis was required in three of the dogs, and one ultimately required a thoracostomy tube for 24h. Pneumothorax fully resolved in all patients, and four survived to discharge. Two dogs were euthanized due to worsening clinical conditions unrelated to pneumothorax. This retrospective study describes the complete resolution of iatrogenic pneumothorax in six dogs after NGT misplacement. Clinicians should be aware of the possibility of pneumothorax during NGT placement and warn clients of the risk. Fatalities have been reported secondary to this complication; however, due to lack of veterinary data, the survival rate is uncertain. Results of this case series indicate that the prognosis may be good for resolution of pneumothorax secondary to NGT misplacement with subsequent discharge from the hospital.

In critical care, nasogastric (NG) tube placement is a routine procedure and is necessary for enteral feeding, medication administration, and gastric decompression. Regardless, misplacing NG tubes continues to be a common issue and can result in severe complications, such as aspiration, pneumothorax, and gastrointestinal perforation. Although chest radiographs are the gold standard imaging test to verify the placement of an NG tube, misinterpretation is still a problem, particularly for non-radiologists. Our case report is a quality improvement initiative that explores the role of radiologic verification in improving outcomes and preventing complications associated with misplaced NG tubes. We present the case of a patient whose NG tube was misplaced in his lung. We also examine the limitations of radiographic imaging as the standard method for confirming NG tube placement. We examine the potential for improving patient safety by providing radiographic training, standardizing interpretation protocols, and integrating advanced technologies such as artificial intelligence (AI)-assisted detection. Our case report explores the importance of continuous quality improvement efforts in optimizing NG tube placement accuracy and reducing associated risks, ultimately enhancing patient care and safety.

To determine what effect, if any, the presence or absence of a nasogastric (NG) tube in the same person had on the incidence of anterograde aspiration. Case series with planned data collection. Large, urban, tertiary care teaching hospital. Referred sample of 62 consecutively enrolled adult inpatients for fiber-optic endoscopic evaluation of swallowing (FEES). Group 1 (n = 21) had either small-bore (n = 13) or large-bore (n = 8) NG tubes already in place and had a FEES first with the NG tube in place and a second FEES after NG tube removal. Group 2 (n = 41) did not have an NG tube and had a FEES first without an NG tube and a second FEES after placement of a small-bore NG tube. Time between FEES was approximately 5 minutes. Patients were tested with thin liquid and puree food consistencies. Occurrence of aspiration for each consistency dependent on the presence or absence of an NG tube was recorded. There were no significant differences (P > .05) in aspiration status for both liquid and puree consistencies in the same person dependent on presence or absence of either a small-bore or large-bore NG tube. Since objective swallowing evaluation (eg, FEES) can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate for aspiration. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation until nutritional requirements are achieved.

Enteral feeding is a common method of nutrition support when oral intake is inadequate. Confirmation of correct nasogastric (NG) tube placement is essential. Risks of morbidity/mortality associated with misplacement in the lung are well documented. Studies indicate that pH ≤ 4 confirms gastric aspirate, but in pediatrics, a pH of gastric aspirate is often >4. The goal of this study was to determine a reliable and practical pH value to confirm NG tube placement, without increasing the risk of not identifying a misplaced NG tube. Pediatric inpatients older than 4 weeks receiving enteral nutrition (nasogastric or gastrostomy) were recruited over 9 months. Aspirate samples were pH tested at NG tube placement and before feedings. If pH >4, NG tube position was confirmed by chest radiograph or further investigations. In addition, intensive care unit (ICU) patients who required endotracheal suctioning were recruited, and endotracheal aspirate samples were pH tested. A total of 4,330 gastric aspirate samples (96% nasogastric) were collected from 645 patients with a median (interquartile range [IQR]) age of 1.0 years (0.3-5.2 years). The mean (standard deviation [SD]) pH of these gastric samples was 3.6 (1.4) (range, 0-9). pH was >4 in 1,339 (30.9%) gastric aspirate samples, and of these, 244 were radiographed, which identified 10 misplaced tubes (1 with pH 5.5). A total of 65 endotracheal aspirate samples were collected from 19 ICU patients with a median (IQR) age of 0.6 years (0.4-5.2 years). The mean (SD) pH of these samples was 8.4 (0.8) (range, 6-9.5). Given that the lowest pH value of endotracheal aspirate sample was 6, and a misplaced NG tube was identified with pH 5.5, it is proposed that a gastric aspirate pH ≤ 5 is a safer, reliable, and practical cutoff in this population.

Background: Aortoesophageal fistula (AEF) is a rare cause of massive upper gastrointestinal bleeding. We present a case of a female patient who developed massive upper GI bleeding due to an AEF that resulted from an anomalous right-sided aortic arch and nasogastric (NG) tube placement. Case: A 51-year-old female was admitted to the intensive care unit (ICU) for a severe COPD exacerbation that required intubation. A NG tube was placed for gastric decompression and feeding. The patient was treated with steroids and extubated after six days and transferred to the floor in stable condition. A few days later, she developed a seizure and was readmitted to the ICU for observation. She then had one episode of projectile hematemesis and became hemodynamically unstable with a significant drop in hemoglobin from 10 mg/dL at baseline to 3mg/dL. An upper endoscopy was performed showing an area of active bleeding in the proximal esophagus that was difficult to discern. Interestingly, her pressures stabilized during the procedure likely due to tamponading of the bleeding source with the endoscope. The patient continued to rapidly decompensate with continued exsanguination and had a cardiac arrest from ventricular fibrillation. The autopsy revealed a right-sided aortic arch with a fistula between the confluence of the aorta and an aberrant left subclavian artery and the proximal esophagus with a large hematoma surrounding the area. A review of her chest computed tomography showed the relationship of the right-sided aortic arch and the esophagus with the NG tube in place that was thought to be the culprit for the AEF formation. Discussion: The right-sided aortic arch is a rare anatomic variant with unknown prevalence but is often asymptomatic in the adult patient. The normal aortic arch and its branches normally do not interact with the proximal esophagus. In the setting of normal aortic anatomy, AEFs are most often due to descending aortic dissection, foreign body ingestion, or invasive esophageal cancer. In the case of a right-sided aortic arch, there is an intimate relationship between the aorta, the left subclavian artery, and the proximal esophagus. The pathogenesis of this life-threatening complication is probably related to the continuous and pulsatile pressure between the aorta and the esophagus. Placement of a NG tube likely resulted in pressure necrosis and a resultant fistula. Considering the catastrophic consequence, NG tube placement should be undertaken with great care in patients with a known right-sided aortic arch.

A Multidisciplinary Approach to the Reactive Placement of Nasogastric Feeding Tubes in Clinic During Treatment for Head and Neck Cancer

Background: Nasogastric tube (NGT) placement can be accomplished using a blind technique, but the failure rate is high, especially in anesthetized and tracheally intubated patients. Practically, mouth opening with a direct laryngoscopy is the alternative method attempted for guiding the NGT under direct visualization. However, limitations of this approach include the narrowing of the oral space and limited periglottic view, which should be resolved by using videolaryngoscope. Objective: To compare the success rate of a videolaryngoscope (C-MAC D-Blade; Karl Storz, Tuttlingen, Germany) with a direct laryngoscope for NGT insertion. Materials and Methods: Eighty-four adult patients were enrolled in the study and randomized into two groups, the videolaryngoscopy group and the direct laryngoscopy group. After induction of anesthesia and tracheal intubation, the participants in the videolaryngoscopy group and direct laryngoscopy group underwent laryngoscopy using a C-MAC D-Blade and Macintosh blade, respectively. The time from entrance of the NGT into the nostril until confirmation of the proper tip position was recorded and defined as successful insertion. The number of attempts was defined as the number of times the tube was withdrawn from the nostril and reinserted. Placement more than three times was defined as procedure failure. Bleeding was also observed. Results: The videolaryngoscopy group had a significantly higher success rate at the first attempt than the direct laryngoscopy group (78.57% versus 30.95%, respectively; p<0.001). The mean time for NGT insertion in the videolaryngoscopy group was significantly shorter than in the direct laryngoscopy group (80 versus 170 seconds, respectively, p<0.01). Direct laryngoscopy failed in five cases, however, all were successful by subsequent videolaryngoscopy. Videolaryngoscopy failed in two cases, but tube insertion was eventually successful by placement of a guide wire in the NGT. Bleeding occurred in 40.48% and 4.76% of patients in the direct laryngoscopy and videolaryngoscopy groups, respectively. The difference was statistically significant. Conclusion: Videolaryngoscopy is easier and faster for NGT placement and is associated with a lower incidence of bleeding complications and a higher success rate. Therefore, this method should be considered as an alternative option when encountering difficulty inserting the NGT using the conventional technique. Keywords: Videolaryngoscopy, Direct aryngoscopy, Nasogastric tube placement

BackgroundGiven the limited evidence available, the impact of nasogastric (NG) tube placement on swallowing in children is not well understood. When a child needs to be fed enterally, the current standard is to initially place an NG tube and leave it in place for the first few months of supplemental or total enteral nutrition. It is important to understand if placement of NG tubes has a negative effect on a patient’s swallow.MethodsWe retrospectively reviewed the charts of those children who had videofluoroscopic swallow studies (VFSS) to identify all children who had an NG tube in place at the time of swallow study. Age and sex matched children were identified who had undergone VFSS without an NG in place. These charts were reviewed for diagnosis at the time of the VFSS and presence or absence of aspiration or laryngeal penetrations.ResultsSixty-three children with NG tubes were identified, along with 63 age and sex matched children without NG tubes in place, at the time of VFSS. Ages ranged from 7 days to 13 years. The NG group had a significantly higher proportion demonstrating aspiration (46% vs. 23.8%, p = 0.0089).ConclusionsThis study supports the need for further prospective evaluation of NG tubes and their effect on swallow, as well as more careful consideration of prolonged NG tube placement in patients with feeding problems. Consideration should be given to removal of the NG prior to VFSS to prevent the impact of NG placement on results of the swallow study which could lead to inappropriate modifications to the patient’s care plan.

Nasogastric tube placement in the stomach is required for enteral nutrition, for medication in critically ill patients, and for evacuation of stomach content to prevent aspiration pneumonitis. Nasogastric tube placement is associated with mechanical complications such as ulceration and bleeding from the nose, pharynx, esophagus, and stomach (1). Accidental insertion of the nasogastric tube into the tracheopulmonary system during placement is associated with significant morbidity such as pneumothorax, hemothorax, or even death (2–4). We report a case of knotting of the nasogastric tube over the epiglottis leading to life-threatening respiratory distress in a spontaneously breathing postoperative patient having received a living related liver transplant. Case Report A 36-yr-old woman weighing 48 kg diagnosed with hepatitis C virus-related liver cirrhosis with portal hypertension was scheduled to undergo a living related liver transplant. Anesthesia and surgery were uneventful. Total duration of surgery was 18 h. After induction of anesthesia and endotracheal intubation, an 18F nasogastric (NG) tube was placed through the right nostril into the stomach in the first attempt without difficulty. Proper placement of the NG tube was checked by auscultation over the stomach while injecting 10 mL air with a disposable syringe into the NG tube and also by aspiration of stomach contents. Postoperatively the patient was shifted to the surgical intensive care unit for elective ventilation and monitoring. On the second postoperative day the patient was conscious, obeying commands, hemodynamically stable, had good respiratory efforts with satisfactory blood gases, and was thus tracheally extubated. Thereafter, the patient breathed 40% oxygen through a Ventimask. Her arterial blood gases were well maintained and pulse oximeter displayed a saturation of more than 98% throughout the case. Eight hours after extubation, the patient had a sudden bout of coughing after which she complained of choking, respiratory discomfort, tachypnea, dyspnea, and cyanosis. Therefore emergency reintubation was attempted. During laryngoscopy for intubation, the NG tube was observed to be coiling around the epiglottis. On withdrawing the NG tube for relieving the coiling, it formed a knot over the epiglottis. We therefore proceeded with the emergency intubation by directly lifting the epiglottis via the laryngoscope blade and the patient was connected to the ventilator. No part of the NG tube was seen passing through the vocal cords. Subsequently, the knot over the epiglottis was released with the help of the Magill’s forceps. The patient was given 100 mg hydrocortisone for any edema of the epiglottis. She died on the seventh postoperative day of fungal infection, septicemia and renal failure. Discussion Over the last two decades, the narrow bore enteral feeding tube has gained widespread acceptance as compared to the rigid large-bore type. The narrow tube is softer, made from polyvinyl chloride/silastic and generally provides greater patient comfort and fewer complications (such as ulceration and bleeding from the nose, pharynx, larynx, esophagus, and stomach) than the stiffer large-bore tube. Inadvertent placement of the NG tube into the tracheopulmonary system has been reported in 2% of cases (2,5). NG tube placement results in pneumothorax/hemothorax in 0.2%–0.7% of the patients (2,5–7). Mortality associated with NG tube insertion is approximately 0.3%(2–4). Fluoroscopy, laryngoscopy, and endoscopically guided insertion of the NG tube have been advised to circumvent these complications (3,4,7). However, all these techniques increase the cost of the treatment as well as the time taken for insertion and require the availability of a specialist. Chest radiography is recommended before initiation of feeding in all cases after NG tube placement in high-risk unconscious patients or those with tracheotomies. Pushing or pulling of the NG tube after it has been successfully placed into the stomach either by an operator or spontaneously via neck movement or deglutition/coughing may lead to formation of a loop in the pharynx. This loop may encircle the pharyngeal structures like the epiglottis in which case pulling the NG tube will further tighten its grip around the encircled structure. If the NG tube rotates in the pharynx it may form a knot around that particular structure. We report knotting of the NG tube over the epiglottis leading to respiratory distress in a spontaneously breathing patient. Though this is a rare occurrence it is a dangerous one. The possibility of NG tube knotting should be kept in mind with regard to any patients who have an NG tube in place and subsequently develop respiratory distress of sudden onset.

Nasogastric tubes (NGTs) are commonly used in the intensive care unit (ICU) and are often inserted blindly at the bedside. Previous studies have highlighted various complications associated with NGT misplacement, including epistaxis, pneumothorax and even fatal perforations. To reduce the incidence of complications, guidelines recommend confirming the correct position of the NGT through radiography, pH testing, end‐expiratory carbon dioxide monitoring, ultrasonography, etc. Herein, we present the case of a 78‐year‐old man who experienced sudden dyspnoea, was brought to the ICU and subsequently developed gastrointestinal bleeding following improper NGT placement. In this patient, air was rapidly injected down the NGT while auscultating for a ‘whooshing sound’ over the epigastrium. However, the correct position of the NGT was eventually confirmed by X‐ray. Urgent upper gastrointestinal endoscopy revealed an oesophagogastric submucosal tunnelling of the NGT. This case emphasizes that auscultation may be unreliable and no longer encouraged. Additionally, various verification methods may not detect such rare complications related to NGT placement, making it necessary to focus on the emerging clinical manifestations following NGT insertion. Moreover, gaining further insight into the history of gastrointestinal diseases in patients may be beneficial.Relevance to Clinical PracticeThis case underscores the importance of noting resistance during a blind nasogastric tube (NGT) insertion in the intensive care unit (ICU). Additionally, the ‘whooshing testing’ for tube placement verification is not recommended. Although radiographic confirmation remains the gold standard, it may not effectively identify rare complications. Furthermore, emerging clinical signs (such as the abnormal nature of the gastrointestinal decompression drainage fluid, hypotension and anaemia) after insertion may suggest NGT misalignment. Finally, in urgent ICU settings, the patient's history of gastrointestinal disease should not be overlooked, as it can lead to complications such as gastrointestinal bleeding.

Background: This study was designed to compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and ultrasonography as physical examination methods to verify nasogastric tube(NGT) placement in emergency room patients with low consciousness who require NGT insertion. Methods: The study included 47 patients who were all over 18 years of age. In all patients, tube placement was verified by chest X-rays. Auscultation, pH analysis of gastric aspirates, and ultrasonography were conducted on each patient in random order. The mean patient age was 57.62±17.24 years, and 28 males (59.6%) and 19 females (40.4%) were included. The NGT was inserted by an emergency room resident. For pH testing, gastric aspirates were dropped onto litmus paper, and the resulting color of the paper was compared with a reference table. Ultrasonography was performed by an emergency medicine specialist, and the chest X-ray examination was interpreted by a different emergency medicine specialist who did not conduct the ultrasonography test. The results of the auscultation, gastric aspirate pH, and ultrasonography examinations were compared with the results of the chest x-ray examination. Results: The sensitivity and specificity were 100% and 33.3%, respectively, for auscultation and 86.4% and 66.7%, respectively, for ultrasonography. Kappa values were the highest for auscultation at 0.484 compared to chest x-rays, followed by 0.299 for ultrasonography and 0.444 for pH analysis of the gastric aspirate. The ultrasonography has a positive predictive value of 97.4% and a negative predictive value of 25%. Conclusions: Ultrasonography is useful for confirming the results of auscultation after NGT insertion among patients with low consciousness at an emergency center. When ultrasound findings suggest that the NGT placement is not gastric, additional chest X-ray should be performed.