Nasogastric Feeding Tube Placement Research Articles

Complication rates associated with nasoesophageal versus nasogastric feeding tube placement in dogs and cats: a randomised controlled trial.

To determine the rate of accidental placement of nasoenteric tubes into the respiratory tract. To compare the methods of checking correct tube placement. To compare the complication rates between nasoesophageal and nasogastric tubes. Animals requiring nasoenteric feeding tubes were prospectively randomised to have either nasoesophageal or nasogastric tube placement. Various techniques for assessing tube position were compared with thoracic radiographic findings. Complications during placement and use were recorded. Ninety-seven animals (82 dogs and 15 cats) were studied. The tube was misplaced into the respiratory tract in three (3.1%) cases. No technique for checking placement was completely concordant with radiography but the presence of negative pressure at the thoracic inlet during placement was consistent with the presence of the tube in the oesophagus in 86.2% cases, while capnography can be considered to confirm tracheal placement. The overall rate of complications during tube placement was 25.8%, with mostly minor clinical complications reported. There was no significant difference in the new-onset regurgitation/vomiting rate, or complications while the tube was insitu between the nasoesophageal and nasogastric groups. Misplacement of nasoenteric tubes is uncommon but a consistent alternative test to radiography for checking correct nasoenteric tube placement was not demonstrated. The choice of placement of either a nasoesophageal or nasogastric tube should be guided by clinician preference, and clients should be warned about possible complications during placement and while the nasoenteric tube is insitu.

Evaluation of a novel platform for placement confirmation of enteral feeding tubes in adults

ObjectiveThe aim of this study was to validate the ability of a novel, impedance-based platform for nasogastric feeding tube (FT) insertion to correctly predict intragastric FT placement in healthy individuals with and without acid suppression medication. MethodsTen patients underwent successive placement of 8, 10, and 12 French FTs with the final intragastric position predicted using an impedance-based algorithm and verified with an abdominal x-ray. Study procedures were repeated after patients received a proton pump inhibitor (PPI) for 3 d. ResultsNasogastric FTs with embedded electrodes spaced along the distal 31 cm of the tubes were placed with the final insertion depth determined by an algorithm integrating impedance and other physiologic parameters. Sixty FT (30 pre-PPI and 30 post-PPI) insertions were performed. The algorithm-predicted location was confirmed as intragastric in all insertions by post-placement abdominal x-ray. For all tube sizes and those with and without PPIs, the impedance at electrodes within the esophagus was significantly higher than at electrodes in the stomach (P < 0.01). As a secondary objective to assess the use of gastric aspirate pH to determine location, gastric aspirate could only be obtained in 30% of insertions. The mean gastric pH was 6.9 (SD 0.6) in patients taking PPIs. ConclusionsA novel platform for real-time assistance with nasogastric FT placement confirmation correctly determined intragastric FT location as confirmed by abdominal x-ray (standard of care) in all 60 insertions. Gastric pH measurements were difficult to obtain and unreliable for intragastric FT placement confirmation in patients taking acid suppression medication.

Confirmation of Safe Nasogastric Tube Placement: The Radiology Department’s Duties Closed Cycle Audit

The NPSA issued a patient safety alert (NPSA/2011/ PSA002) and new guidelines regarding the confirmation of safe nasogastric feeding tube placement. Between September 2005 and March 2010. There were 21 deaths and 79 cases of harm attributed to the incorrect placement of nasogastric tubes in the UK. In the NPSA report chest radiograph misinterpretation was attributed to 12 of the 21 deaths and 45 of 100 incidents. • Feeding through misplaced nasogastric tube (NGT) is a ‘Never Event’. • Associated complications: pneumonia, empyema, pneumothorax, vascular injury Aim: To evaluate the radiology department’s adherence to the national Patient Safety Agency NPSA guidelines published in 2011. We aim at 100% compliance.

Tracheal and Gastric pH study: Is pH testing for NGT confirmation in the critically ill still safe?

Delivering enteral feed or medications through a naso-gastric feeding tube (NGT) placed into the lung causes major morbidity.1 To prevent this from occurring an accurate means of assessing NGT placement is essential. In the UK, the National guidelines for assessment the of NGT position includes the measurement of gastric aspirate pH (<5.5) and assessment of tube placement using x-ray if indeterminate.1 However there is little evidence to support this as a safe approach in critically ill patients.

Placement of Nasogastric Feeding Tube and Postinsertion Care Review

Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.

Critical Illness and the Gastrointestinal System.

Critical illness can sometimes develop within the gastrointestinal (GI) system. This symposium series describes GI illnesses and phenomena seen within the organs of the GI system in hospitalized adults, particularly those who require critical care. The articles present state-of-the-science information for critical care and advanced practice nurses in the area of GI illnesses and their management, including providing nutrition to the critically ill. These topics are covered with a focus on pathophysiology, advanced assessment and evidence-based interventions, and cutting-edge therapies to allow nurses to innovate and strategize the care of patients with these difficult conditions.Patients of all ages can develop liver disease as a result of various illnesses; this liver disease can take the form of acute liver disease, end-stage liver disease (ESLD), or hepatocellular carcinoma. All of these disorders have significant and life-threatening aspects that require advanced knowledge of the disease processes and the application of interventions to thwart progression of the disease. Pryzbyl et al provide a timely update on the newest therapies to treat and, in some cases cure, the chronic form of liver disease and also analyze cutting-edge strategies to manage acute and acute-on-chronic hepatic failure. They review medical management, including when medical management fails and patients with life-threatening ESLD or acute liver failure undergo liver transplantation. Finally, they describe the most up-to-date preoperative and postoperative management strategies and therapies for transplant patients and examine the evidence on trends in liver transplantation, including methods to expand the donor pool as well as guidance and updates on recipient (candidate) selection.1Bloom and Seckel provide an update on the often-controversial topic of feeding tube insertion and care. They present detailed evidence about methods of insertion and recommendations on how to ensure that tubes are correctly placed and safely maintained. This is important information for acute and critical care nurses, as studies have shown a lack of standardization of clinical practice in feeding tube placement verification,2 checking gastric residuals, holding feedings, and other practices related to enteral nutrition management. Bloom and Seckel discuss best practices for enteral nasogastric feeding tube placement and care, with a focus on preventing the complications associated with this intervention.Finally, in the third article of the series, I describe the physiologic response to the infectious and inflammatory conditions of severe acute pancreatitis and fulminant colitis caused by Clostridium difficile. Patients hospitalized in acute care settings carry risk factors for developing either of these conditions, presenting critical care and advanced practice nurses with significant challenges to their identification and treatment. Severe sequelae of these diseases, including sepsis and systemic inflammatory response syndrome, correlate with the onset of organ failure and poor outcomes.3 The few interventions available to treat severe acute pancreatitis and fulminant colitis caused by C difficile are, for the most part, supportive in nature, but there are some evidence-based strategies described that may improve outcomes in patients experiencing the most severe form of these diseases and for whom there are few effective solutions. Although some of these strategies are still under investigation, they may prove valuable in improving the care available for these patients.Diseases of the GI tract and of the auxiliary organs of the GI system are highly prevalent, and patients with these diseases are seen in adult acute and critical care units. Despite their prevalence, GI system illnesses are often challenging to recognize. These diseases may be chronic in nature, such as with ESLD or acute-on-chronic liver disease, or may develop rapidly, as with acute liver failure or acute infectious/inflammatory conditions of organs of the GI tract. Critical care and advanced practice nurses are at the forefront in identifying and managing these complex disorders with the most state-of-the science strategies available, many of which are presented in this symposium. In addition, there is a clear need for knowledge and experience in nutrition in critical care and in the safe insertion of feeding tubes and their management. This is another area in which advanced practice nurses can be instrumental in forging needed change and updated standards.

Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children – A follow-up study

BackgroundNasogastric (NG) feeding tubes are used to deliver nutrition, hydration, and medications to hospitalized infants and children but the ongoing use of non-evidence-based practice (EBP) methods to confirm NG tube (NGT) placement has been associated with adverse patient events. MethodsA study was undertaken to ascertain if practice changes have occurred since findings from a previous study were published by the New Opportunities for Verification of Enteral tube Location (NOVEL) project. The NOVEL project was an initiative of the American Society of Parenteral and Enteral Nutrition (ASPEN). A survey was distributed to member organizations participating in the NOVEL project. Respondents were also asked if and when a change in practice occurred in the policy for NGT placement verification, if there was variation within the institutional units and if there were barriers to practice change. FindingsRespondents were primarily nurses (205/245) from 166 institutions that provided care to combined adult/pediatric/neonatal (122/166) patients. Respondents indicated a radiograph (64%) or pH measurement (24%) were best practice but in actual practice 42% use pH measurement and 23% use a radiograph to verify NGT placement. There was variability within institutions, with the Neonatal Intensive Care Unit (NICU) most often using aspiration and direct eye visualization to verify placement and the other units within the institutions using EBP method(s). DiscussionComparing these results to previous work by the NOVEL project shows an increase toward the use of EBP method(s) to verify NGT placement verification. Application to practiceThis study demonstrates variation within units at the same facility using methods unsupported by the literature, demonstrating that many centers still rely on non-EBP methods of NG placement confirmation, despite cautions issued by many major healthcare organizations.

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

Radiation therapy (RT) associated oral mucositis, xerostomia and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers (HNC). We sought to determine if reactive nasogastric tube (NGT) placement was an effective strategy for nutritional support in these patients and if invasive percutaneous endoscopic gastrostomy (PEG) tube insertion could be avoided.This is an IRB- approved study of patients treated for HNC using definitive or adjuvant RT with or without concurrent chemotherapy between June 2017 and December 2020. We evaluated the indications for NGT (Dobhoff) placement, time of placement during the course of RT, patient tolerance of NGT and median duration of NGT placement. In addition, we followed weight loss during treatment, treatment interruptions, and treatment related toxicities. Complications associated with having the NGT, if the NGT needed to be replaced during treatment, and if the patient had any hospitalization during the course of treatment was tracked. The indication for NGT placement is weight loss > 10% of baseline during the course of treatment, most often due to dysphagia and/or odynophagia unrelieved by pain medication. NGT placement is done in the radiation oncology outpatient clinic by the attending physician and/or nurse practitioner.Of the 441 patients treated during the time period of this study, 47 required reactive NGT placement for nutritional support. Patients included 40 with primary oropharynx, 3 oral cavity, 2 larynx, 1 nasopharyngeal, and 1 unknown. Chemotherapy was given concurrently with radiation in 87.2% (41/47) patients. The median time of NGT placement was during week 5.0 of the 6-7-week course of RT. The median percentage weight loss from baseline to the date of NGT placement was 12.9%. The median duration of NGT placement was 29 days (range, 5 to 151 days). There were no serious medical complications associated with having the NGT in place during treatment. 27.6% (13/47) of patients had the NGT dislodged or displaced and needed replacement. 4.3% (2/47) of patients had the NGT replaced due to clogging. 38.3% (18/47) of patients with an NGT had to be hospitalized during the course of RT, with the predominant symptoms being failure to thrive 22.2% (4/18) and nausea/vomiting 22.2% (4/18). 6.4% (3/47) of patients requested removal of the NGT due to local irritation. 76.6% (36/47) of patients did not require further nutritional support with the placement of a percutaneous endoscopic gastrostomy (PEG) tube.This study indicates clinic placement of an NGT 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 NGT placed. The placement procedure is well tolerated and there were no complications associated with having the NGT during treatment. PEG tube insertion was avoided in 76.6% of the patients.

Immediate chest radiograph interpretation by radiographers improves patient safety related to nasogastric feeding tube placement in children

BackgroundDespite the publication of a national patient safety alert in 2016, inadvertent feeding through misplaced nasogastric tubes continues to occur, either through failure to review the radiograph, misinterpretation of it, or failure to communicate the results.ObjectiveThe objectives were to determine whether training in a new pathway introduced to avoid these “never events” was followed and whether radiographer comments and prompt communication of results could reduce risk and improve patient safety in relation to nasogastric tube placement in children.Materials and methodsFollowing radiographer training in interpretation of nasogastric tube position and use of a commenting proforma and communication pathway, we reviewed all radiographs obtained to check nasogastric tubes performed over a 13-month period in children 0–16 years of age. Then we assessed accuracy of the radiographer comments, adherence to the pathway, and any practice change in children with misplaced nasogastric tubes.ResultsWe reviewed 282 nasogastric tube check radiographs. For 262 radiographs (92.9%) the pathway was followed correctly. Of the total 282 radiographs, 240 (85%) were immediately reported using the standardised commenting proforma, and 235 radiographer comments were affirmed by the radiologist (97% accuracy, confidence interval 0.95–0.99). Of the immediately reported radiographs, 213 (88.8%) nasogastric tubes were considered to be safe for use. Four (1.7%) of the immediately reported nasogastric tubes were misplaced in a bronchus, and the report communicated to the clinical team resulted in removal or re-siting of the tubes.ConclusionNasogastric tube check radiographs in children can be reported accurately by radiographers trained in their interpretation and the results promptly communicated to clinical staff, improving safety in relation to nasogastric tube placement in children.

Efficacy of commercial nasal bridle use in reducing feeding tube dislodgements in pediatric patients following double stage laryngotracheoplasty

IntroductionMaintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements. MethodsMedical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements. ResultsA total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group. ConclusionThe commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach

ObjectivesThe existing British National Patient Safety Agency (NPSA) safety guideline recommends testing the pH of nasogastric (NG) tube aspirates. Feeding is considered safe if a pH of 5.5 or lower...

Nasogastric feeding tube placement in head and neck oncology patients

Nasogastric feeding tube placement in head and neck oncology patients

Real-time image-guided nasogastric feeding tube placement: A case series using Kangaroo with IRIS Technology in an ICU

ObjectivePulmonary misplacement during the blind insertion of enteral feeding tubes is frequent, particularly in ventilated and neurologically impaired patients. This is probably the first clinical study using the Kangaroo Feeding Tube with IRIS technology (IRIS) which incorporates a camera designed to provide anatomic landmark visualization during insertion. The study aim was to evaluate IRIS performance during bedside gastric placement. MethodsThis is the first prospective study to collect data on the use of IRIS. Twenty consecutive unconscious patients requiring enteral nutrition were recruited at a single center. IRIS placement was considered complete when a clear image of the gastric mucosa appeared. Correct placement was confirmed using a contrast-enhanced abdominal X-ray. To evaluate the device performance over time, the camera was activated every other day up to 17 d postplacement. ResultsIn 7 (35%) patients, the trachea was initially visualized, requiring a second placement attempt with the same tube. The IRIS camera allowed recognition of the gastric mucosa in 18 (90%) patients. The esophagogastric junction was identified in one patient, while in a second patient the quality of visualization was poor. Contrast-enhanced X-ray confirmed the gastric placement of IRIS in all patients. IRIS allowed identification of gastric mucosa in 14 (70%) patients 3 d after placement. Performance progressively declined with time (P = 0.006, chi-square for trend). ConclusionIRIS placement could have spared X-ray confirmation in almost all patients and prevented misplacement into the airway in about one third. Visualization quality needs to be improved, particularly after the first week.

Magnetic Resonance-Guided Nasogastric Feeding Tube Placement for Neonates: A Preclinical Study.

Establishing postnatal nutrition delivery is challenging in neonates with immature sucking and swallowing ability. Enteral feeding is the gold standard for such patients, but their small size and fragility present challenges in nasogastric (NG) feeding tube placement. Feeding tubes are typically placed with x-ray guidance, which provides minimal soft tissue contrast and exposes the baby to ionizing radiation. This research investigates magnetic resonance (MR) guidance of NG feeding tube placement in neonates to provide improved soft tissue visualization without ionizing radiation. A novel feeding tube incorporating 3 solenoid coils for real-time tracking and guidance in the MR environment was developed. The feeding tube was placed 5 times in a rabbit with conventional x-ray guidance to assess mechanical stability and function. After x-ray procedures, the rabbit was transferred to a neonatal MR system, and the tube was placed 5 more times. In procedures guided by x-ray and MR, the feeding tube provided sufficient mechanical strength and functionality to access the esophagus and stomach of the rabbit. MR imaging provided significantly improved soft tissue contrast versus x-ray, which aided in proper tube guidance. Moreover, MR guidance allowed for real-time placement of the tube without the use of ionizing radiation. The feasibility and benefits offered by an MR-guided approach to NG feeding tube placement were demonstrated. The ability to acquire high-quality MR images of soft tissue without ionizing radiation and a contrast agent, coupled with accurate 3-dimensional device tracking, promises to have a powerful impact on future neonatal feeding tube placements.

A malfunctioning nasogastric feeding tube.

A critical point of nasogastric feeding tube placement, potentially resulting in an unsafe and/or non-effective operation of the device, is the monitoring of its proper placement into the stomach. A properly obtained and interpreted radiograph is currently recommended to confirm placement. We reported the case of a 68-year-old demented woman referred for complicated dysphagia. A nasogastric tube was blindly inserted and its placement was confirmed by the radiologist. Enteral nutrition was initiated but the patient began to vomit immediately. After reviewing the radiograph it was understood that a gastric loop in the tube and its tip pointing upwards did not allow a safe infusion of the feeding formula. It is not enough having the radiologist reporting that a nasogastric feeding tube is placed in the stomach; the inclusion in the report of specific warnings on any potential cause of malfunctioning of the device should be considered. The presence of a gastric loop should be taken into account as a cause of potential malfunctioning.

Ultra-thin caliber endoscopes in daily practice: uses for therapeutic application and beyond on the basis of review of 1028 procedures.

Background and study aims: Ultra-thin caliber endoscopes (UTCEs) are versatile and applicable in various conditions. However, only limited data exist on the actual daily clinical use of UTCEs. The aim of our study was to determine indications for UTCEs in a large patient cohort. In turn, our 2 main objectives were (1) to evaluate patient comfort and safety and (2) to determine benefits and potential advantages associated with the use of UTCEs in this same cohort. Patients and methods: We performed a retrospective analysis of our prospective database of 1028 procedures with UTCEs in 457 patients. All procedures were carried out in the Department of Gastroenterology and Hepatology, VU University Medical Center, in Amsterdam, the Netherlands, between May 2008 and May 2014. In these procedures, either the Fujinon (Tokyo, Japan) EG-530N UTCE or the Olympus (Tokyo, Japan) GIF N-180 UTCE was used. Results: Mean (standard deviation [SD]) age of patients was 64 (20) years, and most (60 %) of the patients were men. Most (61 %) of the underlying diseases, requiring endoscopic procedures, were found in the esophagus. Of the procedures performed, 91 % were successful, and 82 % were therapeutic. In comparison with regular endoscopes, the most important advantage of the UTCE was the ability to pass a stenosis (37 %), followed by nasogastric feeding tube placement (13 %). Newer and more innovative uses of the UTCE were percutaneous endoscopic gastrostomy (PEG)-jejunal extension placement with endoscope introduction through existing PEG tract, retrograde esophageal introduction through existing PEG tract, inspection of colonic neovagina stenosis, and direct inspection of the common bile duct. Conclusions: In everyday clinical practice, the UTCE has specific advantages over conventional endoscopes because of its small caliber. The 3 main advantages are (1) introduction of high-grade strictures; (2) introduction of fistulas, including PEG fistula; and (3) increased patient comfort. The endoscopist should appreciate these advantages and consider use of the UTCE accordingly.

A call to action: the development of enteral access safety teams.

Safety concerns regarding the verification of nasogastric feeding tube placement prompted the American Society for Parenteral and Enteral Nutrition to call for an interdisciplinary, interorganizational group to work on best practices and new technologies to address this issue in pediatric patients. This commentary calls for the development of specialized teams within hospitals to improve the quality of care provided to children and infants who require nasogastric feeding tubes. It is expands on the information presented in an article in the issue by Irving et al regarding the current status of nasogastric tube placement and verification methods.

Competence in confirming correct placement of nasogastric feeding tubes amongst FY1 doctors.

Foundation year one (FY1) doctors are required to confirm correct placement of nasogastric (NG) feeding tubes on chest radiography on a regular basis. Many FY1s do not receive formal training during medical school or during the FY1 year. Multiple incidents of harm to patients, including death, resulting from incorrect placement of an NG feeding tube have been reported to the National Patient Safety Agency (NPSA) since 2005. Our audit assessed the confidence and knowledge of FY1 doctors in correctly confirming NG placement using a qualitative questionnaire. The results showed that both confidence and knowledge on the topic were remarkably poor. Our intervention consisted of a teaching session to the FY1 cohort, which included information on NPSA guidelines for identifying correct NG placement. A post-teaching questionnaire was attained from the same group of FY1s. Confidence and knowledge of the criteria had significantly improved. We concluded that there is clearly a need for teaching on this subject at an undergraduate and post-graduate level. The interactive peer-led style of our teaching session was shown to be highly effective. The addition of handouts and posters in the clinical workplace acted as helpful reminders for junior doctors to use at the point of need. Our project has highlighted a gap in training which poses a serious potential risk to patient safety. We have created a simple solution which, if adopted on a local and national scale, will facilitate a reduction in avoidable harm to patients.

The Nasogastric Tube in the Thorax after Gastric Pull Up!

Although nasogastric tube (NGT) is a simple procedure, the blind placement of nasogastric feeding tubes is not without risks. Chest radiogram is done to confirm the correct position of the NGT. We report a case where radiography could not be confirmatory for the correct position of the tube in a specific group of patients.

Fluoroscopy-guided percutaneous gastrostomy and nasogastric feeding tube placement: comparison of the clinical effect

Fluoroscopy-guided percutaneous gastrostomy and nasogastric feeding tube placement: comparison of the clinical effect