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What is the most accurate method of assessing the location of the nasogastric tube?

Indications for nasogastric tube insertion, the procedure for inserting a nasogastric tube and how to check whether it is in the correct position

Abstract
Durai, R. et al [2009] Nasogastric tubes 1: insertion technique and confirming position. Nursing Times; 105: 16, early online publication.

This is the first in a two-part unit on nasogastric tube management. It discusses the indications, patient preparation, insertion technique and various methods of confirming the tubeâs position. According to the National Patient Safety Agency, 11 deaths and one case of serious harm occurred due to misplaced nasogastric feeding tubes over a two-year period [2003-2005]. It is therefore vital for staff inserting these tubes to know both the correct insertion methods and the procedure for verifying their correct intragastric positioning.

Keywords: Nasogastric tube, Insertion, Positioning, Patient safety
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Citation, DOI & article data

Citation:

Bickle I, Murphy A, Lukies M, et al. Nasogastric tube positioning. Reference article, Radiopaedia.org [Accessed on 19 Nov 2022] //doi.org/10.53347/rID-30966

Assessment of nasogastric [NG] tube positioning is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death.

Radiographic features

Plain radiograph

A correctly placed nasogastric tube should 10:

descend in the midline, following the path of the esophagus and avoiding the contours of the bronchi
clearly bisect the carina or bronchi
cross the diaphragm in the midline
have its tip visible below the left hemidiaphragm

Ideally, the tip should be at least 10 cm beyond the gastro-esophageal junction 1.

Malpositioning may include tip position:

remaining in the esophagus
traversing either bronchus or more distally into the lung
coiled in the upper airway
intracranial insertion, possible in both patients with and without skull base trauma or surgery 2
spinal canal insertion is very rare, occurring after skull base surgery in one case report 8,9

In some circumstances fluoroscopic nasojejunal tube insertion is necessary.

Ultrasound

Point-of-care ultrasonography may be used to guide the nasogastric tube in real-time with the probe placed sequentially in the following locations 7:

anterolateral neck
- cervical esophagus typically visualized to the left, posterolateral to the trachea
- an intraluminal curvilinear echogenic interface represents esophageal placement of the tube
epigastrium
- with a longitudinal view of the gastroesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualization
- oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement

Complications

Overall, complications occur in 1-3% of cases, with fatal sequelae in ~0.3% of cases. Complications include 1-6,8,9:

upper airway
- epistaxis from insertion trauma
lower airway
- aspiration pneumonia
- pneumothorax
- hemorrhage
- empyema
enteral
- GI perforation and mediastinitis or peritonitis
  - may further complicate with intravascular placement
- GI obstruction
- knotting/tangling of the tube
- intramural esophageal dissection
intracranial and spinal canal
- meningitis
- focal neurological deficits

Quiz questions

References

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Abstract

The purpose of this review was to [1] identify areas of agreement and disagreement in guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tube and [2] summarize factors that affect choices made by clinicians regarding which method[s] to use in specific situations. Systematic searches were conducted in the PubMed, Scopus, and CINAHL Plus databases using a combination of keywords and data-specific subject headings. Searches were limited to guidelines/recommendations from national level specialty groups and governmental sources published in the English language between January 1, 2015 and September 20, 2018. Fourteen guidelines that described methods to distinguish between gastric and pulmonary placement of nasogastric tubes were identified from a variety of geographic locations. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation.

Keywords

nasogastric tubes

enteral nutrition

tube placement determination

practice guidelines

intubation

gastrointestinal

Cited by [0]

What is the most accurate method to check for NG tube placement?

Auscultation is most often used at the bedside to check for appropriate placement of a nasogastric tube. Sound generated by air blown through the tube is used to determine tube placement in the gastrointestinal tract.

What is the most accurate method of determining that a NGT is in the stomach?

Ultrasound. The use of ultrasound at the neck can confirm NGT position in the esophagus and its use at the epigastrium can confirm a stomach placement.

Which method is best when confirming initial placement of an NG feeding tube?

Instead tube position should be initially confirmed via x-ray with clear documentation of NGT position marker. The medical team should document rationale for not obtaining gastric aspirate in the patient's progress note as well as an alternative plan to confirm NGT placement.

What is the best method for the nurse to verify correct nasogastric NG tube placement after insertion?

Chest radiography is the gold standard for confirming appropriate placement of a nasogastric tube. If the feeding tube is blindly inserted, radiographic confirmation of correct placement is recommended before administration of medication or feeding.