Should an X-ray be done after changing a Nasogastric (NG) tube to confirm correct placement?

X-Ray Confirmation is Required After NG Tube Change

X-ray confirmation should always be performed after changing a nasogastric (NG) tube to verify correct placement before initiating feeding or medication administration. 1

Rationale for X-ray Confirmation

The need for radiographic confirmation after NG tube placement or change is supported by multiple high-quality guidelines:

• The Society of Interventional Radiology and American Gastroenterological Association (2011) explicitly state that "every patient should undergo radiography to confirm proper position of an NG or OG tube before feeding is initiated" 1
• The American College of Radiology (2021) identifies radiographs as "the gold standard for nasogastric tube placement confirmation" 1
• The American Gastroenterological Association's 2025 clinical practice update confirms that "radiographic confirmation of tube placement should be performed for all blind enteric placements" 1

Risks of Misplaced NG Tubes

Failure to confirm proper placement can lead to serious complications:

• Misplaced tubes can enter the lungs, pleural cavity, or become coiled in the esophagus 1
• 2.2% of tubes are reported to be in the lung when checked by X-ray, with a median depth of 18 cm beyond the carina 2
• Misplaced tubes can cause pneumothorax, pneumonia, and even death if feeding is initiated through an improperly positioned tube 2, 3

Limitations of Non-Radiographic Confirmation Methods

Alternative methods for confirming NG tube placement are unreliable:

• Bedside auscultation techniques can be misleading, as sounds may be misinterpreted even when tubes are in improper positions 1
• pH testing alone is not always possible (unavailable in 44% of cases in one study) 4
• Even direct intra-abdominal palpation of an NG tube during surgery has been shown to be unreliable 5

Modern Alternatives to X-ray

While X-ray remains the gold standard, newer technologies are emerging:

• Electromagnetic tracking devices show promise with high sensitivity (98%) and specificity (100%) compared to X-ray 6
• These devices can provide real-time feedback during insertion and may detect lung placement before damage occurs 4
• However, these technologies are not yet universally available or adopted in clinical practice

Clinical Algorithm for NG Tube Placement Verification

1. After NG tube placement or change:

   • Obtain a chest/abdominal X-ray to confirm proper positioning
   • Ensure the tube tip is visible in the stomach (not in the esophagus or respiratory tract)
   • Do not initiate feeding or medication until proper position is confirmed

2. If X-ray confirms proper placement:

   • Document the confirmation
   • Begin prescribed feeding or medication administration

3. If X-ray shows improper placement:

   • Remove or reposition the tube immediately
   • Obtain a repeat X-ray to confirm correct placement before use

Special Considerations

• In ICU settings, portable radiography is considered "usually appropriate" for patients following support device placement 1
• For long-term NG tubes, guidelines recommend changing them every 4-6 weeks, alternating nostrils 1
• For patients requiring frequent tube changes, consider more permanent access options (gastrostomy) if enteral feeding is anticipated for more than 4-6 weeks 1

X-ray confirmation after NG tube change is not merely a precaution but an essential safety measure to prevent potentially life-threatening complications from misplaced tubes.