Nasogastric Tube Position Confirmation Research Articles

A prospective observational study of pH testing to confirm ongoing nasogastric tube position.

To measure the reliability of pH testing to confirm ongoing nasogastric tube (NGT) position and to document associated complications. Confirming NGT position is essential, as use of an incorrectly positioned tube can cause harm. Substantial evidence examines initial confirmation of NGT position, yet limited evidence exists considers NGT displacement which is identified via ongoing NGT position tests. In the NHS, pH testing is recommended to confirm ongoing NGT position; however, there may be an association with excess X-rays and missed enteral nutrition and/or medications. Prospective observational study using STROBE checklist. Data collected from medical records of 136 patients with NGTs in a London NHS Trust included pH tests, test results and complications related to ongoing pH tests which failed to confirm the tube was positioned in the stomach, that is, X-rays, and disruptions to enteral nutrition and medication. Cohen's Kappa determined pH test reliability. Of 1381 pH tests conducted to confirm NGT position, five (0.3%) correctly identified an NGT displacement, and one (0.07%) failed to identify displacement before use. The reliability of ongoing pH tests using Cohen's Kappa was minimal (0.29). Ongoing pH tests that failed to confirm a correctly positioned NGT led to 31 (22.8%) patients having X-rays, 24 (17.6%) missing >10% of prescribed enteral nutrition and 25 (18.4%) missing a critical medication. Ongoing NGT position testing using pH tests did not prevent the use of a displaced tube, and more than one-fifth of patients required X-rays to confirm a correctly position NGT, contributing to missed medications and enteral nutrition. Caution should be used when confirming ongoing NGT position with a pH test. Future guidelines should balance the risk of using a displaced tube with potential delays to nutrition and/or medication. More research is needed to explore alternative methods of ongoing NGT position testing.

Improving the Knowledge and Competency of UK Foundation Doctors in Nasogastric Tube Placement: A National Study.

Objective This study aims to improve foundation doctors' knowledge of guidelines for confirming nasogastric (NG) tube position and to enhance their confidence and competency in NGtube placement. Methods A three-part educational approach was designed, which included an educational leaflet and allowed the assessment of a participant's knowledge of guidelines pertaining to NG tube positioning before and after education. This educational leaflet and accompanying pre- and post-learning assessments were distributed among NHS Foundation Trusts in the UK between January 2022 and June 2022. All participants were foundation doctors in the UK. Those who had entered further training after the completion of their foundation training, at the time of assessment distribution, were excluded. Results A total of 173 participants completed this assessment. We found a significant increase in confidence among participants following the education (p<0.05). There was also a significant improvement in objective knowledge of guidelines on NG tube position confirmation following education (p<0.05). Conclusions Current knowledge on NG tube positioning is lacking among foundation doctors, but this can be significantly improved with simple educational leaflets. Furthermore, many participants felt that more training is needed, and this topic should be included in an essential teaching program.

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era.

Background: Nasogastric tube (NGT) placement is a daily routine in the Intensive Care Unit (ICU), and misplacement of the NGT can cause serious complications. In COVID-19 ARDS patients, proning has emerged the need for frequent NGT re-evaluations. The gold standard technique, chest X-ray, is not always feasible. In the present study we report our experience with the use of ultrasonographic confirmation of NGT position. Methods: A prospective study in 276 COVID-19 ARDS patients admitted after intubation in the ICU. Ultrasonographic evaluation was performed using longitudinal or sagittal epigastric views. Examinations were performed during the initial NGT placement and every time the patients returned to the supine position after they had been proned or whenever critical care physicians or nurses considered that reconfirmation was necessary. Results: Ultrasonographic confirmation of correct NGT placement was feasible in 246/276 (89.13%) patients upon ICU admission. In 189/246 (76.8%) the tube could be visualized in the stomach (two parallel lines), in 172/246 (69.9%) the ultrasonographic whoosh test (“flash” due to air instillation through the tube, seen with ultrasonography) was evident, while in 164/246 (66.7%) both tests confirmed correct NGT placement. During ICU stay 590 ultrasonographic NGT evaluations were performed, and in 462 (78.14%) cases correct NGT placement were confirmed. In 392 cases, a chest X-ray was also ordered. The sensitivity of ultrasonographic NGT confirmation in these cases was 98.9%, specificity 57.9%, PPV 96.2%, and NPV 3.8%. The time for the full evaluation was 3.8 ± 3.4 min. Conclusion: Ultrasonographic confirmation of correct NGT placement is feasible in the initial placement, but also whenever needed thereafter, especially in the COVID-19 era, when changes in posture have become a daily practice in ARDS patients.

Validation of sonographic assistance for placement of a nasogastric tube in pediatric patients.

Enteral access via nasogastric tube (NGT) placement can be essential in the provision of care in pediatric patients. Methods exist to confirm correct placement with success rates between 80% and 85%. Radiographic confirmation remains the "gold-standard," however; it exposes patients to ionizing radiation and fails to provide "real-time" information. In this study, we determined the feasibility of using sonography to assist in the placement of NGT insertions in pediatric patients that have difficulty cooperating. Thirty patients requiring NGT placement were stratified into three age groups. Upon NGT insertion, transverse and longitudinal ultrasound images were acquired to visualize tube progression through the esophagus. Subsequently, a focused ultrasonographic exam of the gastric antrum and body were performed. If amenable, an air bolus (1 mL/kg) was injected in the stomach if the NGT was not directly visualized. Following intubation, standard guidelines for NGT position confirmation were performed. The NGT was visualized in all esophageal views and 52% of gastric views. Subgroup analysis showed that successful visualization of tube placement in the stomach ranged from 40% (7-18 years) to 70% (3-6 years). Eighty percentage of air boluses injected were visualized. The use of ultrasonography may assist NGT placement in pediatric patients and reduce the incidence of suboptimal placement during insertion. We demonstrated successful NGT visualization through the esophagus regardless of age. NGT visualization in the stomach was challenging; however, injection of an air bolus may improve visualization. Further studies are required to improve the success rate of obtaining gastric views of the NGT.

Using color flow detection of air insufflation to improve accuracy in verifying nasogastric tube position

ObjectivesPrevious studies have shown that ultrasonography (USG), as an alternative to radiography, has a good accuracy in confirming nasogastric tube (NGT) position. Color flow detection of air insufflation is a novel approach in verifying NGT position. In our study, we aimed at evaluating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in confirming the NGT position, as compared with 2-dimensional (2D) USG. MethodsThe study was conducted on adult patients over a period of 38months in an emergency department in Hong Kong. 2D USG and color flow Doppler imaging were conducted for each subject. Chest X-ray was used as the gold standard for NGT position confirmation. Results100 patients (59 males and 41 females) were recruited totally. Their mean age was 82. The sensitivity, specificity, PPV and NPV of 2D USG were 11.1% (95% CI 4.6%–17.6%), 100% (95% CI 100%–100%), 100% (95% CI 100%–100%), and 11.1% (95% CI 4.6%–17.6%) respectively. For color flow Doppler USG, the sensitivity, specificity, PPV and NPV were 90% (95% CI 83.7%–96.2%), 80% (95% CI 55.2%–100%), 97.6% (95% CI 94.3%–100%), and 47.1% (95% CI 23.3%–70.8%) respectively. The overall accuracy of color Doppler imaging was 89%, which was higher than that of 2D USG (20% only). ConclusionsColor flow detection of air insufflation improves the diagnostic accuracy of ultrasound in verifying NGT position. It is a quick investigation such that fasting time of patients and their length of ED stay can be shortened.

Comparison of neck ultrasonography with a pH meter to confirm correct position of nasogastric tube

The aim of this study was to compare pH meter and neck ultrasonograph for evaluation of nasogastric tube (NGT) position. A total of 35 adult patients who required NGT insertion were included. The NGT was inserted by an anesthetist after endotracheal intubation, and the transducer was placed transversely on the neck, just superior to the suprasternal notch. The passage of the NGT in the esophagus was evaluated by a sonographer, and the stomach was emptied by nasogastric suction. Secretion from inside the NGT was analyzed using a pH meter. The tip of the NGT was accepted as being in the stomach if the pH measured between 1 and 5. Neck ultrasonography was compared with the pH meter analysis for confirmation of NGT position. Ultrasonography was highly sensitive (100% (95% CI 89.6-100%) and specific (97.2% (95% CI 85.4-99.5%)for evaluation of NGT position. The specificity for the pH meter was 100% (95% CI 16.6-100%), while the sensitivity was 76.5% (95% CI 58.8-89.2%). This study showed that neck ultrasonography is more sensitive than the pH meter for confirmation of NGT position.

Nurse Performed Ultrasonography in Confirming the Position of Nasogastric Tube in the Emergency Department: A Prospective Single Group Diagnostic Test Study

Introduction Emergency nurses often encounter patients with nasogastric tube (NGT) dislodgements who require reinsertion. Empirical evidence supporting the use of ultrasonography in verifying the position of NGT in local accident and emergency departments (AED) is scanty. There is also a lack of validation of nurse performed ultrasonography in Hong Kong. With the support from hospitals and medical personnel, a prospective, single group diagnostic test study was conducted to review the possibility of nurse performed ultrasonography in verifying the position of NGT in AED. Methods This study was conducted in the AED of three local hospitals. Investigators with specific ultrasound training performed ultrasonography scans to the subjects in addition to conventional pH test and “whoosh” test. Results were compared with chest or abdominal X-ray for evaluation of accuracies. Results This study confirmed a high sensitivity and specificity of nurse performed ultrasonography in confirming the position of NGT in the AED. The high positive predictive value and positive likelihood ratio supported the confirmation of NGT position by bedside ultrasound. The high specificities and minimal negative likelihood ratios of ultrasonography tests also suggested the application of bedside ultrasound in ruling out patients with misplaced NGTs. Conclusions Nurse performed ultrasonography allows immediate bedside confirmation of the position of NGT in the overcrowded AED. Considered the limitations of conventional methods, nurse performed ultrasonography can be incorporated into daily practice for providing extra evidence for the confirmation of NGT position.

Confirming nasogastric tube position: Methods and restrictions: A narrative review

Background and Purpose: Inserting a nasogastric tube, though a common clinical procedure with widespread use for critically ill patients, can produce unexpected complications so that tube misplacement into the lungs is a potential complication with serious consequences. The reliability of common bedside methods to differentiate between pulmonary and gastric placement has not been acceptable. The goal of this study was to review the diagnostic accuracy of methods in detecting inadvertent airway intubation and verifying correct placement of nasogastric tube and restrictions. Methods: A review of Pub Med, Medline and CINAHL databases has been conducted to identify peer-reviewed, English language, human subject research studies published between the years 1994 and 2013.The research was conducted on the confirmation, methods and restrictions of NGT in the adult's population. Out off 151 English publications, 29 were duplicates and 2 were animal studies. Quality assessments, data extractions and analysis were completed on all included studies. Results: Although methods for assessing correct NGT location at the bedside are available, each has its limitations. The methods include auscultation (the most common method), PH testing of aspirates, capnography, insertion under direct vision and magnetic detection. All studies used X-rays as the reference standard for comparison since auscultation is unreliable. Conclusion: While none of the existing bedside methods for testing the position of nasogastric tubes is totally reliable, the evidence suggest that using more than one method for confirmation of nasogastric tube position is necessary.

Confirming Nasogastric Tube Position in the Emergency Department

The aim of this study was to determine whether pH testing is an accurate method of confirming nasogastric tube (NGT) position in children with and without gastroenteritis in the emergency department. A prospective observational study of NGT insertions was conducted at a tertiary pediatric emergency department, during a 9-month period in 2006. We evaluated methods of NGT position confirmation, pH of nasogastric aspirates from patients with and without gastroenteritis, and adverse events. A total of 404 patients were enrolled. For 393 patients (97.3%), NGT aspirates could be obtained to assess pH. Of these patients, 294 (74.8%) had a diagnosis of gastroenteritis and 99 (25.2%) did not. There was no difference in median pH between the patients with gastroenteritis (pH, 2; interquartile range, 2-4) and those without gastroenteritis (pH, 2; interquartile range, 2-4; P = 0.09). Overall, 341 patients (86.8%) had a pH of 4 or lower. The patients with gastroenteritis were more likely to have a pH of 4 or lower than the patients without gastroenteritis (P = 0.018). Tube position was confirmed by pH alone in 332 patients (84.5%). Nine (2.6%) of the 341 patients with a pH of 4 or lower also had radiography (7 for causes other than confirmation of NGT position) indicating correct placement of all NGTs. Fifty-two patients (13.2%) had a pH higher than 4, and 18 (34%) of these had the tube position confirmed by radiography, of which 3 had tubes misplaced in the distal esophagus. Irrespective of pH level, there were no respiratory placements clinically or by radiography. Overall, 22 patients (5.6% 95% CI 3.5%-8.3%) required more than 1 attempt for NGT insertion. There were 13 minor adverse events (3.3% 95% CI 1.8%-5.6%) and no major adverse events. Testing of gastric pH is a reliable way of confirming NGT position when the pH is 4 or lower. When the pH is higher than 4, a radiograph may be necessary.

Home enteral feeding part 1: an overview

Preventing or reducing malnutrition using nutritional support is proven to be effective both clinically and financially. The continuation of enteral tube feeding in the community continues to grow and the population are an increasingly elderly and disabled group, with the majority living in their own homes and requiring some or total help with their enteral tube feeding. Part 1 of this two-part article looks at some of the key aspects in the management of patients in the community, including routine monitoring, the administration of feed and medications and management of the various tubes. Part 2 will discuss some of the current areas of controversy/debate, including the use of syringes, water type, feed hanging times and confirmation of nasogastric tube position in patients on acid reducing therapy.

Confirmation of nasogastric tube position by pH testing

In 2004, the Medicines and Healthcare products Regulatory Agency (MHRA) advised that nasogastric (NG) tube position should be confirmed using pH strips or paper. However, gastric pH is raised by the use of H2-blockers and proton-pump inhibitors (PPIs) potentially producing false negative pH tests resulting in delayed feeding. In addition, colorimetric differentiation using pH strips may be more prone to bias and inaccuracy than direct pH measurements largely used to establish the threshold. To quantify this problem a 1 day survey of all the patients requiring NG and nasointestinal (NI) feeding was undertaken, to establish the numbers of patients receiving H2-Blockers or PPIs, with or without a safe swallow and the methods currently being used to confirm tube positioning. A second observational study was performed to establish the accuracy of six pH strips available to NHS trusts against four unlabelled pH solutions. Forty-two per cent of patients receiving NG feeding were on H2-blockers or PPIs, including 13% who had a safe swallow for acidic drinks that could be subsequently aspirated to confirm position. In the second study 'testers' correctly identified pH's 3, 4, 5 and 6 with Mackery-Nagel 0-6, BDH 0-6 and 0-14 strips but overestimated pH 4 as pH 5 with Johnson 0-11 paper, underestimated pH 6 as pH 5 with Pehanon 0-12 paper and with Litmus classified pH 3-5 as acid (all), but half also classified pH 6 as acid. Theoretically 29% of NG tube positions could not be confirmed by pH testing because of the usage of PPIs or H2-blockers and lack of swallow. Some pH strips are either inaccurate or their result misinterpreted by staff. Large surveys and trials of the actual efficacy and accuracy of pH testing are required.