Nasogastric Tube Position Research Articles

Factors associated with insufficient nasogastric tube visibility on X-ray: a retrospective analysis.

Chest X-ray imaging is frequently used for verifying the position of a blindly inserted nasogastric tube. A high-quality X-ray increases the likelihood of conclusive visibility of tube tip positioning, thus avoiding risks due to a misplaced tube (e.g., pulmonary intubation, pneumothorax, small bowel insertion). Therefore, this study aims to determine patient-related and environmental factors affecting the visibility of nasogastric tubes on X-ray in adults. A retrospective descriptive analysis of routinely collected clinical data was performed on all included patients (N = 215) from a prospective randomized trial in a general hospital. A chest X-ray was taken of each patient needing a nasogastric feeding tube, after which visibility and positioning of the tube on X-ray was independently evaluated by 3 radiologists. In 14.9% (n = 32) of all patients, image quality was insufficient, so no conclusive visibility of nasogastric tube positioning could be found. A patient-related predictor regression model (sex, age, body mass index) explained 21% of variance for an insufficient visibility of the nasogastric tube (Nagelkerke R2 = 0.21). An environmental factor regression model demonstrates a guidewire being inside the tube or not during X-ray as a predictor for a conclusive visibility on X-ray. High body mass index, male sex, and the absence of a guidewire inside the nasogastric tube at the time of chest X-ray are associated with a risk of insufficient visibility of the tube on X-ray. Patient profiles can be defined in which supplementary attention is needed when obtaining chest X-rays whose purpose is to confirm nasogastric tube positioning. • The quality of chest X-rays to confirm the positioning of nasogastric tubes in adults can be improved considerably. • There are several factors influencing the confirmation of nasogastric tube positioning on X-ray. • Defining patient profiles at risk for an insufficient visibility of the tube on X-ray will indirectly contribute to an improvement of the chest X-ray quality.

Ultrasonography for nasogastric tube placement verification: an additional reference

Nasogastric tube (NGT) insertion is a common procedure performed by community nurses, but verifying correct placement can be challenging due to the limitations of conventional methods. This study aimed to investigate the effectiveness of point-of-care ultrasonography (POCUS) for verifying NGT placement and to explore the feasibility of using this imaging modality as the first-line reference for NGT placement verification. The validity of the gastric aspirate pH test was also evaluated. This was a single-centre, retrospective, single-blind study using a convenience sample of patients who required NGT placement in home settings. POCUS was performed by a trained community nurse, and the pH test was performed after tube insertion. The results of the POCUS and pH test were compared. A total of 68 patients with a mean age of 82.13±9.43 years were included. The sensitivity and specificity were found to be 95.45% and 100%, respectively, for POCUS, and 90.91% and 100%, for the pH test. POCUS can provide accurate diagnostic imaging of nasogastric tube position and avoid X-ray controls. This imaging modality can complement pH testing in community settings where X-ray scans are not readily available.

Compliance with pathway for confirmation of the position of nasogastric tubes for enteral nutrition in adults

Category: Other.

Enhancement of Chest Radiograph in Emergency Intensive Care Unit by Means of Reverse Anisotropic Diffusion-Based Unsharp Masking Model.

In intensive care units (ICUs), supporting devices play an important role, and the placement of these devices must be accurate, such as catheters and tubes. Taking portable chest radiograph (CXRs) for patients in ICU is a standard procedure. However, non-optimized exposure settings and misaligned body positions usually mean that portable CXRs are not in acceptable working condition. The purpose of this study was to enhance ICU CXRs to assist radiologists in the positioning of endotracheal, feeding, and nasogastric tubes in ICU patients. The unsharp masking model (USM) was a classical image enhancement technique. Because of the isotropic diffusion filter applied in this model, USM enhanced the edge information and noise simultaneously. In this paper, we proposed a reverse anisotropic diffusion (RAD)-based USM technique for enhancement of line structures in ICU CXRs. First, a RAD algorithm was applied to replace the Gaussian filter in the classical USM. The RAD algorithm only produced a smoothed image, in which edge information was smoothed while the noise was preserved. Then, the smoothed image was subtracted from the original image to produce the unsharp mask whereby only the edges were retained. Consequently, only edge information was enhanced in the final enhanced image by using the RAD-based USM model. The proposed method was tested for 87 ICU CXRs and the findings indicate that this approach can enhance image edges efficiently while suppressing noise.

Acceptability of a new practice development for radiographers focussed on reducing ‘never events’ related to nasogastric feeding tubes in adult patients

IntroductionAscertain if a new practice development designed to reduce ‘never events’ from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce. MethodsDespite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of ‘never events’ still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system. ResultsThere was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession. ConclusionEvaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous ‘never events’. Large scale implementation of this system across the NHS Radiography workforce should be considered.

Verifying the Placement of Nasogastric Tubes at an Emergency Center: Comparison of Ultrasound with Chest Radiograph

The objective of this study was to verify the nasogastric tube position with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture and auscultation and to compare the effectiveness of these methods with chest radiography. This is a single-center, prospective, single-blind study. Patients who were admitted to our emergency department and had an indication of nasogastric tube placement were included. Nasogastric tube localization was verified with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture, auscultation, and direct radiography that was accepted as the ‘gold standard technique'. A total of 49 patients (27 Male, 22 Female) with a mean age of 58.3±22.7 years were included. Sensitivity of neck ultrasound was 91.5%, and positive predictive value was 100%. As for the subxiphoid ultrasound sensitivity was 78.72%. When neck ultrasound + subxiphoid ultrasound and giving water-air mixture were combined sensitivity reached 95.74%. Sensitivity of neck ultrasound + subxiphoid ultrasound + air-water mixture + auscultation was 97.87% and positive predictive value was 100%. In the light of our results, neck and subxiphoid ultrasound seem to be an alternative method for verifying nasogastric tube localization. Combination of the air-water mixture and auscultation with ultrasound improves the sensitivity.

An e-learning tool to improve confidence and competence in confirming the position of nasogastric feeding tubes

Nasogastric tube (NGT) insertion is commonly performed but mismanagement of NGTs can have disastrous consequences for patients. Administration of feed, fluid or medication through a tube which has been incorrectly placed in the respiratory tract has been and NPSA ‘Never Event’ since 2009. Despite the focus on safe usage, between 2011 and 2016 there were 95 reported incidences of fluid or medication being introduced into the respiratory tract via an incorrectly placed NGT1. There were two incidences of this in Lancashire Teaching Hospitals NHS Foundation Trust (LTHTr) in 2016. Improved education in the identification of incorrectly placed NGTs is required to help address this patient safety issue.

Never say never again – radiological assessment of nasogastric tube position

Category: General

Application of Manometry to Verify Nasogastric Tube Placement in Intubated, Mechanically Ventilated Patients: A Prospective Descriptive Study

Objective: Confirmation of nasogastric tube (NGT) placement is sometimes difficult in clinical practice. Hence, the purpose of this study is to validate the accuracy of manometry for intragastric NGT placement confirmation in intubated, mechanically ventilated patients. Methods: A total of 100 adult patients who underwent elective open abdominal surgery and required gastric decompression were enrolled in this prospective descriptive study at a university-affiliated teaching hospital. The position of NGTs was verified by two blinded investigators, of whom the first investigator used the manometric technique and the second investigator used a fiberscope for verification. The manometric technique involved using a cuff pressure manometer to verify NGT placement. The primary measurements, sensitivity and specificity of the manometric technique in verifying NGT placement were calculated according to the standard findings of fiberoptic inspection. Results: In 81 of 100 NGT placements, intragastric placement was interpreted by the manometric technique. All of these 81 placements were confirmed by fiberoptic inspection. The manometric technique was therefore 100% sensitive. The 19 placements interpreted as extragastric placement by the manometric technique were confirmed by fiberscopy as being in the oral cavity, trachea, or esophagus, indicating 100% specificity. These results revealed 100% accuracy of the manometric technique in verifying intragastric placement of NGTs in intubated, mechanically ventilated patients. Conclusions: The manometric technique is a convenient, inexpensive, and highly accurate method for verifying NGT placement. This technique may be used to verify correct NGT placement for the purpose of gastric decompression and in those environments where a roentgenogram is not available.

Interventions for maintaining nasogastric feeding after stroke: An integrative review of effectiveness and acceptability.

To investigate the effectiveness and acceptability of interventions for maintaining nasogastric tubes in adult stroke patients. Internationally, incidence of cerebral vascular disease continues to increase and stroke is the largest cause of complex disability in adults. Dysphagia is common following a stroke which necessitates feeding via a nasogastric tube. Nasogastric tubes are not well tolerated by stroke patients and may be frequently dislodged. Hence, interventions such as tape, the nasal bridle/loop or hand mittens may be used to maintain nasogastric tube position. However, evidence around the effectiveness and acceptability of these interventions has not been reviewed and synthesised. Integrative literature review. Database searches in MEDLINE, PubMed, CINAHL, Scopus, Cochrane and EMBASE; manual reference list searches. Seven studies met the eligibility criteria and were included in the review. Evidence for the effectiveness of nasal bridle/loop and hand mittens to maintain nasogastric tube position in patients after a stroke is spare and methodologically poor, and especially limited around hand mittens use. There is insufficient evidence about the acceptability of both nasal bridle/loop and hand mittens among stroke patients. Current clinical practice is underpinned by assumptions around the acceptability of nasal bridle/loop and hand mittens to secure nasogastric tubes. This results in reliance on consensual judgement between professional, patients and their families to guide their use among individuals with dysphagia after stroke. Further research is required to assess the effectiveness of hand mittens and acceptability of both nasal bridle/loop and hand mittens among stroke patients to inform guideline development. Given the lack of evidence on the acceptability of hand mittens and nasal bridle/loop among stroke patients to inform evidence-based guidelines and protocols, healthcare professionals should reach consensus on their use by exercising clinical judgement and through consultation with patients (if possible) and their families.

Radiographer workforce role expansion to improve patient safety related to nasogastric tube placement for feeding in adults

To determine whether the active involvement of radiographers in nasogastric tube (NGT) management at a large multisite healthcare institution can contribute to risk reduction regarding feeding through misplaced NGTs. Despite national guidance in the National Health Service advising on safe practice to confirm NGT position, a number of "never events" (feeding through misplaced NGT) continue to occur due to misinterpretation of the check radiograph. Practice change was introduced, including all plain film radiographers providing contemporaneous comments on NGT position on the check radiograph. The success of the system was assessed to determine the accuracy of radiographer comments against the reference standard of the radiologist report to see whether the system has helped reduce the number of "never events". During the first 27 months post-implementation, 4,675 check NGT radiography examinations were analysed. Two hundred and twenty-seven examinations were excluded due to absent or incomplete radiographer comments. The accuracy of the radiographer comments was 98.5% (95% confidence interval [CI]: 97.7-99.5%), sensitivity 97.4% (95% CI: 96.3-98.3%), specificity 98.9% (95% CI: 98.5-99.2%), positive predictive value 96.8% (95% CI: 95.6-97.7%), and negative predictive value 99.1% (95% CI: 98.8-99.4%). After focused training, radiographer comments are a safe, sustainable, and workable solution offering an effective solution for image misinterpretation issues relating to NGT "never events". This should be considered for wider implementation in healthcare.

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.

Does Bedside Sonography Effectively Identify Nasogastric Tube Placements in Pediatric Critical Care Patients?

A nasogastric tube (NGT) insertion is a common procedure in intensive care units, with some serious complications that result from the malposition of the NGT tip. This pilot study was designed to investigate the efficiency of ultrasound in verifying correct NGT placement and to compare these results with radiographic findings. This was a single-center, double-blind prospective study of patients who had received an NGT in the pediatric critical care unit. Twenty-one patients aged 1 month to 18 years were included in this study. All NGTs were inserted by the same critical care physician. After insertion, the physician first confirmed NGT placement by the auscultation of the epigastrium following the insufflation of air. Confirmation was supplemented with an abdominal radiograph. A radiologist who was unaware of the radiographic findings performed bedside sonography on all patients and verified the location of the NGTs. The findings from these 2 physicians were then compared. NGTs were inserted without any complications, and none of the NGTs were positioned in the respiratory tract in any of the patients. All NGT tips were visualized by radiography and sonography with a sensitivity of 100%. Bedside sonography performed by a radiologist is an effective and sensitive diagnostic procedure for confirming the correct NGT position in patients in the pediatric critical care unit.

Changing how we confirm ngt placement: impact on nutrition delivered

Confirming the position of Nasogastric tubes (NGT) in critical care is a controversial area. The National Patient Safety Agency (NPSA) guidance [1] advocates pH testing although use is limited in ICU due to continuous enteral feeding and proton pump inhibitor therapy. Chest X-ray is therefore commonly used with trainee doctors often being responsible for confirming tube position. Following three incidents of undetected NGT misplacement (outside of our ICU), our trust stipulated a change in practice so that only radiologists or ICU consultants were allowed to confirm placement. We were concerned that this could negatively influence tube confirmation times and enteral nutrition (EN) provision. Cumulative calorie deficits contribute to malnutrition [2]. Under-nutrition in critically ill patients is associated with increased mortality, infections and length of stay [3].

MON-PP014: Blackcurrant Test is a Practical Method to Confirm Position of Nasogastric Tube

MON-PP014: Blackcurrant Test is a Practical Method to Confirm Position of Nasogastric Tube

Diagnostic accuracy of methods used to verify nasogastric tube position in mechanically ventilated adult patients: a systematic review.

Nasogastric tubes are widely used in hospitals, e.g. for the administration of nutrients. However, nasogastric tubes can be inserted accidently into the airways leading to complications like pneumonia, pneumothorax and even death. Mechanically ventilated patients are at high risk of having a nasogastric tube misplaced, since they often have reduced consciousness and weak cough reflex. A variety of methods have been used for determination of nasogastric tube placement, but with varying success. The present systematic review was carried out to evaluate the diagnostic accuracy of methods used to determine nasogastric tube placement in mechanically ventilated adult patients. Studies including mechanically ventilated adult patients with a nasogastric tube were considered for inclusion, regardless of the type of nasogastric tube.All methods (index tests) used to verify nasogastric tubes placed in the airways and in the gastrointestinal tract were included. As a reference standard, X-ray was used to verify the accuracy of each index test.The studies that were included in the present systematic review were designed based on diagnostic test accuracy studies.The outcome was the accuracy (sensitivity and specificity) of the methods to discriminate between respiratory and gastrointestinal placement of the nasogastric tube. The search strategy aimed to find both published and unpublished studies before September 2013. Eleven electronic databases were searched including CINAHL, PubMed, Scopus and Embase. Methodological quality was assessed independently by two reviewers using QUADAS as a critical appraisal tool. Data were extracted by two reviewers independently using a modified Joanna Briggs Institute data extraction form including specific details such as: population, setting, index test, sensitivity and specificity. Sensitivity and specificity were extracted from the studies and presented in tables. When these were not written in the studies, calculations were performed based on data presented in the studies. Five relevant papers describing two different methods for determining nasogastric tube position were identified: colorimetric capnography (four studies) and capnography (one study).In all four studies examining colorimetric capnography the sensitivity was 100% when nasogastric tubes were inserted intentionally into the airways through an already existing tracheal tube, thereby imitating misplaced nasogastric tubes. When inserted through the nose, the sensitivity was 88-100% and specificity was 99-100%.Capnography obtained a specificity of 100% but sensitivity for when the nasogastric tube was inserted through the nose could not be calculated based on available data. We found evidence (Level 2b) for colorimetric capnography to be a valid method for verifying nasogastric tube placement.Capnography also detected nasogastric tube position with very high accuracy. However, since these methods were tested in only a single study with a limited sample size, further research is required before clinical recommendations can be made.Despite the impressive results obtained by using colorimetric capnography, implication for practice is not straightforward. A concern is that the colorimetric capnograph is not produced by the manufacture to fit a NG tube and therefore has to be connected to the NG tube by an adaptor-system. Practical issues therefore have to be resolved if the method is supposed to become a standard procedure in a clinical setting.The execution of the procedure using colorimetric capnography differs between the studies. This systematic review therefore recommends that further research should be done to optimize the execution of the procedure.We also recommend that further research be done to reproduce the results obtained using capnography, since this method was tested only in a single study with a limited sample size.

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.

Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients.

Sir, During bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple-line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re-insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis. NGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magill's forceps to advance the tube 1–2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of the oesophagus secondary to the inflated endotracheal bulb.[1] Several techniques to simplify this procedure have been recommended in the literature.[2,3,4,5,6,7] Of these a quick and easy way often adopted intra-operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma.[2,3,4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length. We would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra-operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure ​[Figure1a1a and ​andb].b]. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure ​[Figure2a2a and ​andbb]. Figure 1 (a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the ... Figure 2 (a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus, (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus Portex® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1-cm wide tape at the proximal end of tube and secure it to the connector or use a one-size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube.[8] Furthermore, the Portex® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra-operative complication.