Can nurses place nasogastric (NG) tubes in patients after tracheostomy?

Can Nurses Place NG Tubes After Tracheostomy?

Yes, nurses can place nasogastric tubes in patients with tracheostomy, but radiographic confirmation is mandatory before use, and special attention must be paid to the risk of misplacement into the tracheobronchial tree.

Key Safety Considerations

The presence of a tracheostomy does not prohibit NG tube placement by nurses, but it creates specific risks that require heightened vigilance:

Critical Safety Points

• Radiographic confirmation is non-negotiable 1. While bedside auscultation (the "whoosh test") is commonly used, it is unreliable and can miss dangerous misplacements including placement in the lung, pleural cavity, or coiled in the esophagus 1. This is particularly dangerous in tracheostomy patients where the upper airway anatomy is altered.

• Tracheobronchial misplacement risk is real 2. A case report specifically documents that NG tubes can be misplaced even in awake patients with inflated cuffed tracheostomy tubes, despite acidic pH testing suggesting gastric placement 2. The inflated cuff does not guarantee protection against misplacement.

Placement Technique

Standard blind bedside placement can be performed 1:

• Use an 8-12F tube after lubrication
• Flex the head (if not contraindicated)
• Pass the tube through the naris
• Do not rely on auscultation alone for confirmation

Mandatory Confirmation Protocol

Before initiating any feeding or medication administration 1:

1. Obtain chest X-ray to confirm proper gastric position
2. Document the depth of insertion prominently
3. Do not use pH testing or auscultation as sole confirmation methods

This radiographic requirement applies universally but is especially critical in tracheostomy patients given the altered airway anatomy and documented cases of misplacement 2.

Timing Considerations

Optimal timing: Place the NG tube after the tracheostomy is established and ventilation is stable 3. The consensus airway guidelines specifically recommend passing an NG tube "after tracheal intubation is complete and ventilation established to minimise the need for later interventions" 3. This same principle applies to tracheostomy placement.

Common Pitfalls to Avoid

1. Never rely on auscultation alone - This method has been shown to miss dangerous misplacements 1
2. Don't assume the inflated tracheostomy cuff protects against misplacement - Case reports prove otherwise 2
3. Don't skip radiographic confirmation - Even in experienced hands, blind placement can result in tracheobronchial positioning 1
4. Avoid pH testing as sole confirmation - This has been documented to give false reassurance in tracheostomy patients 2

Scope of Practice Considerations

While the evidence confirms that bedside NG tube placement is commonly performed by nurses 1, 4, institutional policies and individual nurse competency must be verified. The procedure itself is within nursing scope when properly trained 4, 5, but the presence of a tracheostomy may trigger additional institutional requirements for physician involvement or specialized training.

If difficulty is encountered during placement, do not persist with multiple attempts. Consider endoscopic or fluoroscopic guidance, which achieves >90% success rates 1.