Nasogastric/Orogastric Tube (NG Tube/OG Tube)

Indications

Administration of Medications/Oral Contrast/Enteral Nutrition (see Enteral Nutrition, [[Enteral Nutrition]])

Clinical Utility

  • Infusion of Medications/Oral Contrast/Enteral Tube Feeding
  • Measurement of Gastric Residual Volume
    • REGANE Trial (Intensive Care Med, 2010) [MEDLINE]
      • Gastric Residual Volumes Up to 500 ml Could be Safely Tolerated
    • NUTRIREA 1 Trial (JAMA, 2013) [MEDLINE]
      • Not Monitoring Gastric Residual Volume Did Not Increase the Incidence of Aspiration or Related Complications
    • Recommendations (Society of Critical Care Medicine, SCCM, and American Society for Parenteral and Enteral Nutrition, ASPEN, 2016 Guidelines) [MEDLINE]
      • Gastric Residual Volume Should Not Be Used to Monitor Enteral Nutrition (Quality of Evidence: Low): if used, cutoff for residual volume should be >500 mL

Diagnosis of Upper Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage, [[Gastrointestinal Hemorrhage]])

General Comments

  • Generally Performed via a Salem Sump

Clinical Efficacy

  • Aspiration of Gastric Contents Has a Low Sensitivity to Detect an Upper GI Bleeding Source

Gastric Lavage

General Comments

  • Generally Performed via a Salem Sump or Larger Tube

Clinical Utility

  • Removal of Blood or Blood Clots to Facilitate Esophagogastroduodenoscopy (EGD) (see Esophagogastroduodenoscopy, [[Esophagogastroduodenoscopy]])
  • Removal of Ingested Agents in the Setting of Overdose/Intoxication
    • XXX Intoxication

Post-Abdominal/Gastrointestinal Surgery

General Comments

  • Generally Performed via a Salem Sump

Clinical Efficacy

  • Systematic Review of Prophylactic Nasogastric Tube Placement After Abdominal; Surgery (Br J Surg, 2005) [MEDLINE]
    • Patients without Routine Nasogastric Tubes Had Earlier Return of Bowel Function, Marginal Decrease in Pulmonary Complications, Marginal Increase in Wound Infections, and Marginal Increase in Ventral Hernia
    • Routine Nasogastric Tube Use Had No Impact on the Incidence of Anastomotic Leak
  • Systematic Review of Prophylactic Nasogastric Tubes Placed After Abdominal Surgery (Cochrane Database Syst Rev, 2007) [MEDLINE]
    • Patients without Routine Nasogastric Tubes Had Earlier Return of Bowel Function and a Decrease in Pulmonary Complications
    • Patients without Routine Nasogastric Tubes Had a Trend Toward an Increase in the Risk of Wound Infection and Ventral Hernia
    • Routine Nasogastric Tube Use Had No Impact on the Incidence of Anastomotic Leak
    • Routine Nasogastric Tube Use Decreased Vomiting, But Increased Patient Discomfort

Treatment of Bowel Obstruction

General Comments

  • Generally Performed via a Salem Sump

Types of Bowel Obstruction

Treatment of Ileus (see Ileus, [[Ileus]])

General Comments

  • Generally Performed via a Salem Sump

Contraindications

  • Basilar Skull Fracture (see Basilar Skull Fracture, [[Basilar Skull Fracture]]): due to the risk of intracranial incursion
  • Coagulopathy (see Coagulopathy, [[Coagulopathy]]): due to the risk of epistaxis
  • Esophageal Stricture (see Esophageal Stricture, [[Esophageal Stricture]]): due to risk of esophageal perforation
  • Esophageal Varices (see Esophageal Varices, [[Esophageal Varices]]): due to the risk of inducing variceal hemorrhage
  • Facial Fracture (see xxxx, [[xxxx]]): due to the risk of intracranial incursion
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]]): due to the risk of epistaxis

Technique

Insertion Sites of Tubes

  • Oral
  • Nasal

Clinical Efficacy

  • xxx

Types of Tubes

  • General Comments
    • Nasogastric/Orogastric Tubes are Made of Polyvinyl Chloride (PVC), Polyurethane, or Silicone
  • Salem Sump: made of polyvinyl chloride (PVC)
    • Stiffer than Soft, Small-Bore Feeding Tubes
    • Typical Size Used in Adult Patient: 16 Fr
  • Soft, Small-Bore Feeding Tube (Corpak, Dobhoff, etc)
    • Softer than Salem Sump
    • Typical Size Used in Adult Patient: 3.5-12 Fr
    • Typical Length: 15-170 cm
    • May Be Weighted

Insertion Technique

  • Blind Insertion
    • Conventional Method of Placement is with the Head in Forward Position Tilted Toward the Chest
    • Trial of Methods for Nasogastric Tube Insertion in Intubated Patients (Indian J Anaesth, 2014) [MEDLINE]
      • Reverse Sellick’s Maneuver, Neck Flexion with Lateral Neck Pressure, and Guidewire-Assisted Techniques are All Better Alternatives to Conventional Method of Nasogastric Tube Insertion in Anesthetized, Intubated Adult Patients
    • Measurement for Optimal Required Length of Tube
      • Measure from Tip of Ear to Tip of Nose to Tip of Xiphoid: however, this method can both underestimate and overestimate the length of tube required
  • Endoscopic Placement (J Laryngol Otol, 1999) [MEDLINE]
    • May Be Required in Patients with Prior Gastric Bypass, Hiatal Hernia, etc
  • Interventional Radiology Placement Using Fluoroscopy
    • May Be Required in Patients with Prior Gastric Bypass, Hiatal Hernia, etc

Verification of Placement

Methods to Verify Nasogastric/Orogastric Tube Placement

  • Auscultation with Air Injection (with Catheter-Tipped Piston Toomey Syringe)
    • Commonly Performed
  • Colorimetric Capnography (see Capnography, [[Capnography]])
    • Technique
      • Advancement of the Tube to 30-35 cm and Measurement of Carbon Dioxide Aspirated from the Nasogastric/Orogastric Tube: detection of carbon dioxide confirms malplacement of the tube
    • Systematic Review of Diagnostic Accuracy of Methods to Verify Nasogastric Tube Placement in Mechanically Ventilated Patients (JBI Database System Rev Implement Rep, 2015) [MEDLINE]
      • Colorimetric Capnography Detected Nasogastric Tube Position with Very High Accuracy (Level 2b Evidence)
        • Sensitivity: 88-100%
        • Specificity: 99-100%
      • However, Further Research is Required to Determine the Best Implementation of this Technology: since colorimetric capnographs do not have manufactured NG tube adaptors, etc
  • Proprietary Cortrak System
    • Designed For Use with Corpak Soft Feeding Tubes
  • Radiographic Imaging (Chest X-Ray/KUB) (see Chest X-Ray, [[Chest X-Ray]] and Kidneys-Ureters-Bladder X-Ray, [[Kidneys-Ureters-Bladder X-Ray]])
    • Interim Imaging Following Advancement of the Tube to 30-35 cm
      • Advancement of the Tube to 30-35 cm with Imaging at that Preliminary Position (with the Tube at a Distance Unlikely to Penetrate the Lung Parenchyma and into the Pleural Space) is a Technique Which Could Be Utilized to Minimize the Risk of Pneumothorax in Cases Where the Tube is Inadvertently (Blindly) Placed into the Trachea
    • Imaging Following Final Tube Positioning: commonly used

Tube Fixation

  • Nasal Bridle
  • Adhesive Tape

Adverse Effects/Complications

Dermatologic Adverse Effects/Complications

  • Pressure Ulcer/Necrosis at Site of Tube Entry

Gastrointestinal Adverse Effects/Complications

  • General Comments
    • Nasogastric/Orogastric Tube Impairs Function of the Lower Esophageal Sphincter, Increasing the Risk of Reflux and Subsequent Esophagitis, Esophageal Stricture, Gastrointestinal Hemorrhage, or Pulmonary Aspiration
  • Esophageal Perforation (see Esophageal Perforation, [[Esophageal Perforation]])
    • Epidemiology: risk is increased with prior esophageal surgery
  • Esophagitis (see Esophagitis, [[Esophagitis]])
    • Epidemiology
      • Large-Bore Nasogastric Tubes are Associated with an Increased Risk of Esophagitis (J Clin Gastroenterol, 2000) [MEDLINE]
    • Physiology: due to either pressure on the esophageal mucosa or gastroesophageal reflux
  • Gastric Perforation (see Gastric Perforation, [[Gastric Perforation]])
    • Epidemiology: risk is increased with prior gastric surgery
  • Gastritis (see Gastritis, [[Gastritis]])
    • Physiology: due to pressure on the gastric mucosa
  • Gastroesophageal Reflux
    • Physiology: tube impairs function of the lower esophageal sphincter (potentially resulting in esophagitis, pulmonary aspiration, etc)
  • Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage, [[Gastrointestinal Hemorrhage]])
    • Physiology: chronic irritation/pressure on the mucosa due to mere presence of tube and/or suction
  • Intestinal Perforation (see Intestinal Perforation, [[Intestinal Perforation]])
  • Mechanical Complications (Including Tube Breakage, Tube Rupture, Tube Obstruction, Tube Malpositioning, Tube Coiling, and Tube Knotting)
    • Epidemiology: malpositioning is common
    • Clinical: may occur anywhere throughout the course of the tube (including in the pharynx, pyriform sinus, esophagus, stomach, and duodenum)
      • Gagging/Emesis May Indicate Coiling in the Pharynx or Piriform Sinus
    • Manegement of Knotted Tube: may require Interventional Radiology fluoroscopic or Gastroenterology endoscopic removal of the knot
  • Oropharyngeal Discomfort
    • Clinical: usually resolves in 24-48 hrs
    • Treatment: local topical anesthetics may be useful to decrease gagging and discomfort

Neurologic Adverse Effects/Complications

Inadvertent Placement of Nasogastric/Orogastric Tube into the Brain

  • Epidemiology
    • Risk is Increased in Patients with Head/Facial Trauma or Prior Transsphenoidal Surgery
  • Physiology
    • Tube May Traverse a Fractured Cribriform Plate or Fractured Ethmoid Lamina Cribrosa (at the Apex of the Nasal Cavity) to Enter the Brain
    • Tube May Traverse Prior Surgical Site from a Prior Transsphenoidal Pituitary Resection: even one that was performed years earlier (Am J Nurs, 2002) [MEDLINE]

Otolaryngologic Adverse Effects/Complications

Epistaxis (see Epistaxis, [[Epistaxis]])

  • Epidemiology: xxxxx

Nasogastric Tube Syndrome (see Nasogastric Tube Syndrome, [[Nasogastric Tube Syndrome]])

  • History
    • Nasogastric Tube Syndrome was First Reported in 1981
    • Highest Risk Group
      • Diabetic Renal Transplant Patients: probably due to prolonged gastroparesis and requirement for nasogastric tube drainage
  • Physiology
    • Believed to Be Due to Paresis of the Posterior Cricoarytenoid Muscles Secondary to Ulceration and Infection over the Posterior Lamina of the Cricoid
  • Diagnosis
    • Laryngoscopy/Esophagoscopy (see Laryngoscopy, [[Laryngoscopy]]): necessary for diagnosis
  • Clinical

Sinusitis (see Acute Rhinosinusitis, [[Acute Rhinosinusitis]])

  • Epidemiology
    • Risk is Increased with Nasal Placement
  • Physiology
    • XXXXX
  • Clinical

Pulmonary Adverse Effects/Complications

General Comments

  • Review of the Pulmonary Complication Rate for Blind Placement of Narrow-Bore of Nasogastric/Orogastric Tubes (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
    • Overall Pulmonary Complication Rate for Blind Placement of Narrow-Bore Nasoenteric Tubes: 1.9%
      • Of These, the Rate of Pneumothorax was 18.7% (5 of Which Resulted in Death)
      • Of These, Malpositioning Occurred in 13-32% of Subsequent Repositioning Attempts
      • Of These, 60.4% of the Patients were Mechanically Ventilated
  • Insertion Strategies May Mitigate the Risk for Nasogastric/Orogastric Tube Placement
    • Strategies
      • Use of Dedicated, Experienced Teams Which Place Nasogastric/Orogastric Tubes
      • Placement of Tube to 35 cm Followed by Radiography to Confirm Intraesophageal Placement Prior to Advancement into the Stomach
    • Clinical Efficacy
      • Utilization of a Specialized Feeding Tube Placement Team and Utilizing Feeding Tube Placement to 35 cm and Obtaining a Radiograph Before Full Advancement Significantly Decreased the Incidence of Procedure-Related Pneumothorax (0.09% vs 0.38%) ( J Am Coll Surg, 2004) [MEDLINE]: n = 4190 placements
      • Utilization of Mitigation Strategies for Small-Bore Nasogastric/Orogastric Tube Placement Decreases Adverse Events (JPEN J Parenter Enteral Nutr. 2006) [MEDLINE]

Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]])

  • Epidemiology
    • The Mere Presence of a Nasogastric/Orogastric Tube May Be a Risk Factor for Aspiration in Mechanically Ventilated Patients (Eur Resp J, 2006) [MEDLINE]
  • Physiology
    • Nasogastric/Orogastric Tube Impairs Function of the Lower Esophageal Sphincter, Increasing the Risk of Reflux and Subsequent Pulmonary Aspiration

Inadvertent Placement of Nasogastric/Orogastric Tube into the Tracheobronchial Tree

  • Epidemiology
    • Inadvertent Small-Bore Feeding Tube Placement into the Tracheobronchial Tree Occurred in Approximately 3.2% of Placements in a Major University Tertiary Referral Hospital (JPEN J Parenter Enteral Nutr, 2007) [MEDLINE]
      • Mandatory Radiographs (After Tube Placement) May Decrease the Risk of Subsequent Respiratory Administration, But Not the Risk of Misplacement Itself
    • Inadvertent Small-Bore Feeding Tube Placement Placement into the Tracheobronchial Tree Occurred in Approximately 1.9% of Placements (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
    • Nasogastric Tubes Can Be Inadvertently Placed into the Tracheobronchial Tree, Despite an Inflated Endotracheal Tube Cuff (J Chin Med Assoc, 2008) [MEDLINE]
  • Clinical
    • Atelectasis (see Atelectasis, [[Atelectasis]])
    • Cough (see Cough, [[Cough]])
    • Dyspnea (see Dyspnea, [[Dyspnea]])
    • Lost Volume on Ventilator (see Ventilator Mechanics, [[Ventilator Mechanics]])
      • On Mechanical Ventilation, the Lost Volume Can Be Quantified as the Difference Between Inspiratory Tidal Volume and Expiratory Tidal Volume (i.e. Expiratory Tidal Volume is Lower than Inspiratory Tidal Volume)
      • Lost Volume May Increase When Suction is Applied to the Nasogastric Tube
    • Lung Abscess (see Lung Abscess, [[Lung Abscess]])
    • Pneumonia (see Pneumonia, [[Pneumonia]])
    • Tracheal Perforation (see Tracheal Perforation, [[Tracheal Perforation]])

Inadvertent Placement of Nasogastric Tube Into the Pleural Space

  • Epidemiology
    • Inadvertent Small-Bore Feeding Tube Placement Placement into the Tracheobronchial Tree Occurred in Approximately 1.9% of Placements (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
  • Clinical
    • Pleural Effusion/Empyema (Due to Infusion into the Pleural Space) (see Pleural Effusion-Transudate, [[Pleural Effusion-Transudate]], Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]], and Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])
      • Pleural Effusion Will Have the Characteristics of the Infusate, So Pleural Effusion May Be Exudative or Transudative
      • Inadvertent Infusion into the Pleural Space May Result in Sepsis and Death (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]
    • Pneumothorax (see Pneumothorax, [[Pneumothorax]])
      • Risk of Major Complications (Pneumothorax, Hemopneumothorax) with Nasogastric Tube Placement is Approximately 0.7% (Similar to That of Central Venous Catheter Placement) (Crit Care, 1998) [MEDLINE]
      • In One Review, Pneumothorax was the Cause of Death in 5/8 Reported Mortalities (JPEN J Parenter Enteral Nutr, 2011) [MEDLINE]

Obstruction of Nasal Breathing

  • Epidemiology
    • While Obstruction of Nasal Breathing May Occur in Any Patient with Nasal Placement, this is Especially Prevalent in Neonates, as They are Obligate Nasal Breathers

Respiratory Failure (During or After Placement)

  • Epidemiology
    • XXXXX
  • Physiology
    • Due to Aspiration or Inadvertent Tracheobronchial Placement of the TUbe

Vascular Adverse Effects/Complications

  • Vascular Penetration
    • Inadvertent Tube Incursion into the Right Atrium
    • Inadvertent Tube Incursion into the Subclavian Artery

References

  • Fatal hydrothorax and empyema complicating a malpositioned nasogastric tube. Chest. 1981;79(2): 240-242

  • Inadvertent tracheobronchial placement of feeding tubes. Radiology. 1987;165(3):727-729

  • The nasogastric tube syndrome. Laryngoscope. 1990 Sep;100(9):962-8

  • A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2(1):25-28 [MEDLINE]

  • Duodeno-renal fistula due to a nasogastric tube in a neonate. Pediatr Surg Int. 1998;14(1-2):102 [MEDLINE]
  • Nasogastric tube knotting in open heart surgery. Acta Anaesthesiol Scand. 1999;43(7):790 [MEDLINE]
  • Nasendoscopically-assisted placement of a nasogastric feeding tube. J Laryngol Otol. 1999;113(9):839 [MEDLINE]
  • A unique complication of primary tracheoesophageal puncture: knotting of the nasogastric tube. Otolaryngol Head Neck Surg. 1999;120(4):528 [MEDLINE]
  • Inadvertent intracranial placement of a nasogastric tube in patients with head injuries. Surg Neurol. 1999;52(4):426 [MEDLINE]
  • Morbidity, mortality, and risk factors for esophagitis in hospital inpatients. J Clin Gastroenterol. 2000;30(3):264 [MEDLINE]

  • Intracranial placement of a nasogastric tube after severe craniofacial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(5):564 [MEDLINE]

  • Inadvertent intracranial nasogastric tube placement. Am J Nurs 2002; 102:25–27 [MEDLINE]

  • What is known about methods of correctly placing gastric tubes in adults and children. Gastroenterol Nurs. 2004;27(6):253 [MEDLINE]

  • Effect of institutional protocols on adverse events related to feeding tube placement in the critically ill. J Am Coll Surg. 2004;199:39-50 [MEDLINE]

  • Nasogastric tubes: hard to swallow. Ann Emerg Med. 2004;44(2):138 [MEDLINE]

  • Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92(6):673 [MEDLINE]
  • Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005;4(5):429-433 [MEDLINE]
  • Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract. 2006;21(1):40 [MEDLINE]

  • Nasogastric tube syndrome: a life-threatening laryngeal obstruction in a 72-year-old patient. Age Ageing (September 2006) 35 (5): 538-539

  • Nasogastric tube feeding is a cause of aspiration pneumonia in ventilated patients. Eur Resp J 2006; 27:436 – 437 [MEDLINE]

  • Enhancing patient safety during feeding- tube insertion: a review of more than 2000 insertions. JPEN J Parenter Enteral Nutr. 2006;30:440-445 [MEDLINE]

  • Clinical costs of feeding tube placement. JPEN J Parenter Enteral Nutr. 2007;31:269-273 [MEDLINE]

  • Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007 [MEDLINE]

  • Complications related to feeding tube placement. Curr Opin Gastroenterol. 2007;23(2):178 [MEDLINE]
  • Devices and techniques for bedside enteral feeding tube placement. Nutr Clin Pract. 2007 Aug;22(4):412-20 [MEDLINE]
  • Inadvertent tracheobronchial placement of feeding tube in a mechanically ventilated patient. J Chin Med Assoc. 2008;71(7):365 [MEDLINE]
  • Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement. J Parenter Enteral Nutr 2011;35(4):535-539 [MEDLINE]
  • Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5):625-9. doi: 10.1177/0148607111413898. Epub 2011 Jul 28 [MEDLINE]
  • NUTRIREA 1 Trial. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249 [MEDLINE]
  • Comparison of four techniques of nasogastric tube insertion in anaesthetised, intubated patients: A randomized controlled trial. Indian J Anaesth. 2014 Nov-Dec;58(6):714-8 [MEDLINE]
  • Diagnostic accuracy of methods used to verify nasogastric tube position in mechanically ventilated adult patients: a systematic review. JBI Database System Rev Implement Rep. 2015;13(1):188 [MEDLINE]
  • Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863 [MEDLINE]