Nasogastric Tube Position Research Articles

Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray and tube radio-opacity.

Recent evidence suggests official statistics greatly underestimate the occurrence of complications from misplaced nasogastric (NG) tubes, even when detected. Current methods of confirming tube position do not provide adequate protection from misplacement. In addition, some tubes are inadequately radio-opaque. We prospectively audited placement of Cortrak polyurethane tubes (PUTs) to determine: accuracy of the electromagnetic (EM) trace in confirming tube position, radio-opacity of PUTs compared with previously placed polyvinylchloride (PVC) Ryles tubes and whether 12 French PUTs can be used to aspirate gastric residual volumes (GRVs). A total of 127 PUTs were placed in 113 patients. EM traces accurately confirmed tube position compared with X-ray (100% agreement). A 'gastric' EM trace has been defined for future use by other operators. PUTs were adequately radio-opaque with good agreement between interpreters (>98%) whereas PVC Ryles tubes were insufficiently radio-opaque (57-73%), invisible in 23% of cases and with poor agreement between interpreters leaving risk of error. The alternative of using pH confirmation was not possible in 44%. In these cases subsequent X-ray incurred a 2-hour delay to feed and medicines. In addition, neither post-placement pH testing nor X-ray warn of lung placement and potential trauma, whereas the EM trace warned of lung placement prior to damage in 7% of placements. 12 French, single-port PUTs appear adequate to aspirate large GRVs. EM tracing may be considered a standalone method of confirming NG tube position. Corflo (Cortrak) PUTs are adequately radio-opaque. Use of PVC Ryles and other inadequately radio-opaque tubes should stop.

Postprocedural chest radiograph: Impact on the management in critical care unit.

Postprocedural chest radiograph is done to illustrate the position of endotracheal tubes (ETTs), nasogastric and drainage tubes, indwelling catheters, and intravascular lines or any other lifesaving devices to confirm their position. These devices are intended to save life, but may be life-threatening if in the wrong place. The incidence of malposition and complications ranges from 3% to 14%, respectively. The portable chest radiograph is of tremendous value, inexpensive and can be obtained quickly at the patient's bedside in any location of the hospital. A systemic literature search was performed in PubMed and the Cochranre library by setting up the search using either single text word or combinations. Those studies were also included where the chest radiograph was compared with other imaging modalities. Its clinical efficacy, cost-effectiveness and practicality allow anesthesiologist to evaluate the post-procedural position and complications of ETT, indwelling catheters, and multi lumen intravascular lines. Knowledge of the radiological features of commonly used devices is of utmost importance.

Diagnostic accuracy of the methods carried out to verify nasogastric tube position in mechanically ventilated adult patients: a systematic review protocol

Review question/objective The objective of this review is to evaluate the diagnostic accuracy of methods carried out to verify correct positioning of nasogastric (NG) tubes in mechanically ventilated adult patients. More specifically, the objectives are to compare: The diagnostic accuracy of all described methods versus chest X-ray as the gold standard to differentiate between respiratory and gastrointestinal (GI) placement of NG tubes in mechanically ventilated adult patients. Inclusion criteria Types of participants This review will consider studies that include adult mechanically ventilated patients with an NG tube, regardless of the purpose the NG tube serves. Studies concerning neonates and infants will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate any method (index test) performed to verify an NG tube was placed either in the GI tract or in the respiratory tract. Any method revealed by the literature search will be considered for inclusion. It could for example include auscultation, capnography or colorimetric capnography. Since chest X-ray is widely accepted as the gold standard for verifying NG tube placement, 21,22 it will also be considered as the gold standard by this systematic review. Types of outcomes This review will consider studies that include the following outcomes: a test's ability to correctly verify an NG tube to be placed in the GI tract versus the respiratory tract (specificity) and its ability to correctly identify a misplaced tube (sensitivity).

Nasogastric tube dislodgement: a problem on our ICU

It was noted on our unit that dislodgement of nasogastric tubes occurred commonly. This can lead to an increased risk of aspiration, interruptions in nutritional support, skin breakdown and radiographic exposure [1]. It is recommended that the position of nasogastric tubes should be confirmed by aspiration and pH testing, with radiographic confirmation used only when this is not possible [2].

PH testing to confirm nasogastric tube position on the ICU: are we wasting our time?

For such a simple procedure, the insertion and position checking of nasogastric (NG) tubes can be very problematic. The UK's National Patient Safety Agency declared that 'Placement of NG tubes together with confirmation of correct placement can carry significant risks' and recommends that measuring the pH of NG aspirate should be the first-line method of determining correct NG position (safe range ≤5.5) [1].

Proposed Non-Contact Inspection Method of Tip Position of Nasogastric Tube using Static Magnetic Field

Proposed Non-Contact Inspection Method of Tip Position of Nasogastric Tube using Static Magnetic Field

Traumatic ankle pain - adequacy of clinical information with reference to the Ottawa ankle rules

Traumatic ankle pain - adequacy of clinical information with reference to the Ottawa ankle rules

Contrôle échographique de la position de la sonde nasogastrique en préhospitalier

ObjectiveTo assess the feasibility and actual performance of ultrasound control in verification of the correct positioning of a nasogastric tube in pre-hospital settings. Study typeProspective, observational, single-centre study. Patients and methodsCorrect positioning of nasogastric tubes in patients intubated in a pre-hospital setting was verified by ultrasound and routinely compared with the results of two pre-hospital tests, namely a test involving insufflation of air through a syringe coupled with epigastric auscultation and a test involving aspiration of gastric fluid with a syringe. Routine x-ray control was carried out and compared with the pre-hospital results. ResultsNinety-six patients were included. Mean age was 52 years (median: 53.5 years, SD: 23 years). In 83% of the patients (n=80), the nasogastric tube was located by ultrasound immediately during the insertion procedure. The mean times to ultrasound confirmation of correct positioning of the nasogastric tube were 7s (median: 2s; SD: 16s) and 19s for the syringe tests (median 19s, SD: 5s). Eight ultrasound control tests were negative. Location coupled with insufflation of air through a syringe allowed detection of the nasogastric tube in the stomach but without providing confirmation of the actual gastric position. The pre-hospital ultrasound results were confirmed by subsequent radiological controls at the hospital. ConclusionThe ultrasound test performed in our study to verify correct positioning of a nasogastric tube is feasible in a pre-hospital setting. This technique is rapid and non-irradiating and is more sensitive and specific than the syringe tests commonly used in pre-hospital settings, and it may be performed in place of the latter tests.

Determination of a Practical pH Cutoff Level for Reliable Confirmation of Nasogastric Tube Placement

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.

Nasogastric Tube Position and Intragastric Air Collection in a Neonatal Intensive Care Population

For neonates receiving intensive care, nasogastric tube feeding is essential. Since nasogastric tube placement techniques are not well standardized and common verification methods can be unreliable, placement errors may lead to unsafe situations. In mechanically ventilated neonates and neonates on continuous positive airway pressure, malpositioning of the nasogastric tube may prevent excess air within the stomach to escape. In this study, we aimed to relate tube position to amount of air. The hypothesis was: the better the position of the tube, the smaller the amount of air in the stomach. A 1-year cohort of neonates in a level IIIc neonatal intensive care unit with a nasogastric tube. We retrospectively reviewed 326 radiographs and classified nasogastric tube position and gastric air. Descriptive statistics were used to describe demographic data. Kendal's tau statistic was applied to explore the relationship between nasogastric tube position and amount of gastric air. A Mann-Whitney U test was performed to confirm the differences in gastric air in neonates with Ch5 and Ch6 gastric tubes and neonates with Ch8 gastric tubes. One or both orifices of nasogastric tubes were in the esophagus in 7.1% of cases, tubes were curled up in the stomach in 35.3% of cases, and tube tips were beyond the pyloric sphincter in 5.5% of cases. Substantial or excessive air was found in 37.7% of cases. Kendal's tau value indicated that there was no significant correlation between nasogastric tube position and gastric air. The Mann-Whitney U value indicated that children with Ch5 and Ch6 gastric tubes had significantly more gastric air than children with Ch8 gastric tubes. Nasogastric tubes were malpositioned in nearly half of cases, and substantial or excessive air was found in more than one-third of cases. The hypothesis-the better the position of the tube, the smaller the amount of gastric air-was not confirmed by the data. However, a significant relationship was found between tube size and gastric air.

Automatic detection of supporting device positioning in intensive care unit radiography

This paper presents a computer-aided method for automatic detection of the positioning of endotracheal, feeding and nasogastric tubes, and the identification of tube types in radiography for intensive care unit (ICU) patients. Application of this method may allow clinicians to detect the tube tips more easily and accurately, and thus improve the quality of patient care in the ICU. One-hundred-and-seven portable X-ray images were collected from 20 patients, using a Kodak computed radiography system. It was determined whether each image did or did not have a tube and which kind of tube was present. In order to evaluate the performance of the proposed tube detection method, an experienced chest radiologist reviewed all images from the 20 patients and provided the true position of these tubes. The automatic detection results could then be compared with the actual results to determine the success rate. Preliminary results show that the computer-aided technique has a detection rate of 94% for endotracheal tubes, with 0.6 false positives per image, and 82% for both feeding and nasogastric tubes, with 0.4 and 0.5 false positives per image, respectively. The novel detection technique can accurately detect the tubes in ICU chest radiographs at a high sensitivity level with an acceptable false positive rate.

A study of reasons for failure to administer prescribed volume of nasogastric enteral feeds in a district general hospital

Background: A number of studies have demonstrated that the amount of enteral feed delivered is often significantly less than that prescribed (Park, 1992; Reid, 2006), which can impair nutritional status (National Institute for Health and Clinical Excellence, 2006). The aim of this survey was to establish the amount of feed administered versus that prescribed and identify the reasons for patients failing to receive the volume of feed prescribed.Methods: Data were collected prospectively on 20 consecutive patients on medical or surgical wards, who were commenced on nasogastric feeding (NGF). Feed requirements were determined by a clinical dietitian. The volume of feed administered versus that prescribed was calculated from the daily fluid balance charts. Medications and reasons for failure to administer prescribed feed were ascertained from medical, nursing and dietetic records and questioning staff. This was recorded on a data collection form.Results: Data were evaluated for 13 male and seven female patients, mean age 66 years (range 35–91 years) on gastroenterology, oncology and surgical wards. In total, 235 days of NGF were prescribed. Under‐delivery of feed occurred on 70 out of 235 (30%) days. Mean (SD) NGF delivered was 77% (39%) of feed prescribed. No feed was administered on 39 out of 235 days (17%). Fifty‐five percent of patients were on proton pump inhibitors (PPIs). Reasons for not administering feed or administering less than that prescribed are detailed in Fig. 1.Discussion: Inadvertent removal and inability to confirm correct positioning of nasogastric tubes (NGTs) accounted for significant interruptions to feeding resulting in under‐delivery of feed and lost feeding days (27%). Fifty‐five percent of patients were on PPIs because these are known to increase gut pH; this warrants further investigation of the possible cause of obtaining an unsuitable pH. The mean NGF delivered is similar to other studies mentioned. The limitations of this study include the small sample size and the possible inaccuracies of the fluid balance charts. image [ Reasons for failure to administer prescribed feed expressed as a percentage (n = 70). ]Conclusions: As a consequence, the nutrition support team is working on improving methods of securing NGTs, investigating aspiration practice, encouraging a review of PPIs and optimising radiography procedures. The study highlights the opportunities for improving practice to ensure that patients receive the feed prescribed.References National Institute of Health and Clinical Excellence (2006) Nutrition support in adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE, Available at http://www.nice.org.uk/guidance/CG32 (accessed on 3 December 2008).Park, R.H.R., Allioson, M.C., Lang J., Spence E., Morris A.J., Danesh B.J.Z., Russell, R.I. & Mills P.R. (1992) Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ304, 1406–1409.Reid, C. (2006) Frequency of under and overfeeding in mechanically ventilated ICU patients: causes and possible consequences. J. Hum. Nutr. Diet.19, 13–22.

The correct method of testing the position of nasogastric tubes in hospital: is the awareness any better?

The correct method of testing the position of nasogastric tubes in hospital: is the awareness any better?

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.

Errors regarding specific preventive measures of ventilator-associated pneumonia in the ICU

Prevention of aspiration-induced ventilator-associated pneumonia (VAP) includes, among other factors, head elevation, appropriate cuff pressure and correct positioning of nasogastric tubes. The purpose of the study was to identify errors regarding these prevention measures in critically ill ICU patients.

Home enteral feeding: Part 2 current issues in community practice

Part 1 provided an overview of enteral tube feeding and management in the community. Due to the limited evidence base there are many aspects of the practical management of patients on home enteral tube feeding (HETF) that has as yet not been standardized, particularly around issues such as the type of syringes and water that should be used in HETF. There are also some areas where the guidelines are clear but difficult to apply in the community (such as with maximum feed 'hanging times') or where further guidance is required (such as for confirming the position of nasogastric tubes in patients on acid-reducing therapy). Finally, as NHS trusts look at further ways to save money, enteral feeding is being increasingly scrutinised and needs to be carefully managed, with the involvement of healthcare professionals who understand patient needs and the commercial HETF market. This article is based on personal views and local discussions about the issues in question and, until further research and national standards are available, are subject to local interpretation.

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.

Using the Cortrak magnetic device to facilitate early enteral nutrition in critically ill patients

Confirmation of correct nasogastric tube (NGT) positioning is required before commencement of enteral nutrition (EN). In the ICU, however, the use of sedation, 24-hour feeding and proton pump inhibitors can make the standard confirmatory methods recommended by the UK National Patient Safety Agency (UKNPSA) [1] unreliable, and result in the need for multiple chest X-rays (CXR), increased cost and feeding delay. We studied the role of the Cortrak®(Viasys MedSystems, USA) against standard practice, and assessed the following outcomes: time required to confirm correct NGT position, time to starting feeding, and potential cost savings.

Safe placement of nasogastric tubes in children

Insertion of nasogastric tubes is a common nursing procedure but practice rituals and unfounded assumptions can compromise safety. Current methods for checking the position of nasogastric tubes are not always suitable in children but there is limited guidance on how to proceed when gastric placement cannot be determined. As a result of a local adverse incident, a working party challenged the assumptions and rituals of practice using an evidence-based framework. A nasogastric tube algorithm was developed using a risk assessment approach to improve the safety of children in hospital and community settings.

Risk management, or just a different risk?

Background: National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement...