When should a Ryle's (nasogastric) tube be removed?

From the Guidelines

A Ryle's tube should be removed as early as possible, with daily revaluation of the need for it, taking into account the risk of gastric stasis and aspiration related to gut dysfunction, as recommended by the ERAS society guidelines 1. When considering the removal of a Ryle's tube, several factors should be taken into account to ensure it is done safely and at the appropriate time. These factors include the patient's ability to tolerate oral intake, the return of normal bowel function, and the achievement of the specific purpose for which the tube was placed.

• The patient should demonstrate adequate swallowing function and have no vomiting.
• Signs of bowel recovery, such as passing flatus or stool, should be present.
• Gastric output should have decreased to less than 200-300 ml per day. Before removal, it is advisable to clamp the tube for a trial period, usually 24 hours, to ensure the patient can manage without it 1. The removal procedure itself involves several steps:
• Disconnecting the tube from any drainage system.
• Deflating any balloon if present.
• Removing any securing tape or device.
• Gently withdrawing the tube while the patient takes small sips of water and is positioned upright to prevent aspiration of any residual gastric contents. After removal, patients should be monitored for signs of respiratory distress, nausea, vomiting, or abdominal distension, which might indicate complications or the need to reinsert the tube. The ERAS society guidelines recommend a multifaceted approach to minimizing postoperative ileus, which includes the omission or early removal of nasogastric intubation 1. This approach, combined with other strategies such as minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, and laxative administration, can help reduce the duration and severity of postoperative ileus. By following these guidelines and considering the individual patient's needs and clinical status, the removal of a Ryle's tube can be managed effectively to promote recovery and minimize complications.

From the Research

Removal of Ryle's Tube

The decision to remove a Ryle's (nasogastric) tube depends on various factors, including the patient's condition, the reason for tube insertion, and the presence of complications.

• The study by 2 suggests that nasogastric tubes may not be necessary for patients with small bowel obstruction who do not have active emesis, and that their use may be associated with increased risk of pneumonia and respiratory failure.
• Another study by 3 found that routine nasogastric decompression after abdominal surgery does not accomplish its intended goals and may actually increase the risk of pulmonary complications and patient discomfort.
• A study by 4 found that early oral feeding after removal of the nasogastric tube is safe and can be started immediately after tube removal, provided that normal bowel sounds are present.
• The presence of a nasogastric feeding tube has been associated with an increased risk of aspiration and aspiration pneumonia, as reported by 5.
• In the context of hyperemesis gravidarum, nasogastric enteral feeding has been shown to be effective in relieving intractable nausea and vomiting and providing adequate nutritional support, as reported by 6.

Criteria for Removal

The criteria for removing a Ryle's tube may include:

• Resolution of the underlying condition for which the tube was inserted
• Return of normal bowel function and bowel sounds
• Ability to tolerate oral feeding
• Absence of complications such as pneumonia or respiratory failure
• Patient comfort and tolerance of the tube

Timing of Removal

The timing of removal of a Ryle's tube depends on the individual patient's condition and the specific circumstances of their care.

• In general, the tube can be removed when the patient is able to tolerate oral feeding and the underlying condition has resolved.
• The study by 4 suggests that early removal of the tube and initiation of oral feeding can be safe and effective in patients undergoing gastrointestinal operations.
• However, the decision to remove the tube should be made on a case-by-case basis, taking into account the patient's overall condition and the presence of any complications.