Nasogastric or Orogastric Tube Insertion

IndicationsTop

Gastric content retention, intestinal obstruction, suspected upper gastrointestinal bleeding, enteral feeding, medication administration, or gastric dilation (eg, following ventilation with a self-inflating bag and face mask).

ContraindicationsTop

Esophageal stricture, rupture, or recent esophageal variceal banding. Take special care or seek surgical consultation in patients with a recent gastric or esophageal surgery or procedure. Do not introduce a nasogastric tube in patients with limited nostril patency (most frequently due to septal deviation). In patients with severe facial trauma or basal skull fracture the decision to place the tube has to be made by appropriate surgical service.

Potential ComplicationsTop

Insertion of the nasogastric or orogastric tube into the trachea, pharyngeal irritation, gastritis. Additional complications of nasogastric tube insertion include nasal mucosa injury, epistaxis, and sinusitis.

Patient PreparationTop

Obtain informed consent. Place the patient in a supine or sitting position. Topical lidocaine spray or gel can be administered prior to procedure if available.

EquipmentTop

Nasogastric/orogastric tube (thin tubes are used for feeding only; thick tubes are used for gastric decompression, especially in patients with gastrointestinal bleeding or bowel obstruction or ileus but can also be used for administering drugs or enteral feeds). Longer small-bowel feeding tubes can be used for postpyloric feeding, which may reduce the risk of pneumonia in critically ill patients without impact upon other outcomes.Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias and imprecision. Alshamsi F, Utgikar R, Almenawer S, Alquraini M, Baw B, Alhazzani W. Postpyloric feeding in critically ill patients: updated systematic review, meta-analysis and trial sequential analysis of randomized trials. Saudi Crit Care J. 2017;1:6-23. Lubricant lidocaine gel, 60-mL slip-tip syringe, stethoscope, adhesive tape, nonsterile gloves.

ProcedureTop

Use topical anesthesia (lidocaine spray or jelly) if available to ensure maximal patient comfort during nasogastric tube insertion. Mark the distance from the tip of the nose (nasogastric tube) or from the mouth (orogastric tube) to the earlobe and distance from the ear to the stomach on the tube, so that the uppermost aspirating port is located at the level of the xiphoid process (in adults the cardia is usually located ~40 cm from the teeth). Coat the tip of the tube with lidocaine lubricant gel. For nasogastric tubes, gently insert the tube into the lowermost portion of the nostril perpendicular to the coronal plane. If this is unsuccessful, try to introduce the tube through the other nostril. For orogastric tubes, insert the tube backwards and downwards through the mouth and oropharynx. In conscious and cooperative patients ask them to flex the neck and swallow the tube. Insert the tube to the predetermined depth.

To assess placement, inject ~10 to 30 mL of air using a syringe and simultaneously auscultate the epigastrium. Gurgling sounds suggest correct tube positioning. Coughing, respiratory distress, hypoventilation, voice changes, or air outflow through the tube can all be signs of introducing the tube past the vocal cords. Secure the tube to the nose (nasogastric tube) or to the angle of the mouth (orogastric tube) using adhesive tape. If the tube is being used for feeding, confirm placement using radiography prior to administration of feeds or medications.

After The ProcedureTop

If the tube is used for feeding (enteral nutrition [EN]), we suggest to not monitor routinely for gastric residual volume (GRV) in patients with an endotracheal tube, as GRV measurements may lead to unnecessary withholding of EN due to perceived feeding intolerance.Evidence 2Weak recommendation (downsides likely outweigh benefits, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias and imprecision. Reignier J, Mercier E, Le Gouge A, et al; Clinical Research in Intensive Care and Sepsis (CRICS) Group. 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 Jan 16;309(3):249-56. doi: 10.1001/jama.2012.196377. PubMed PMID: 23321763. In patients at high risk of vomiting and aspiration, measurements of GRV could be considered especially at EN initiation and progression; EN should be delayed if GRV is >500 mL over 6 hours. Patients should be upright (head of the bed at ≥30 degrees) while nutrition is being administered. Flush and fill the tube regularly with clear water when not in use.