Correct Position for Ryles (Nasogastric) Tube Insertion
For proper nasogastric tube insertion, radiographic confirmation is mandatory before initiating feeding, with the tube tip ideally positioned in the body of the stomach, as blind placement methods alone are insufficient to ensure safe positioning. 1
Proper Insertion Technique
Insertion Procedure
- Use small diameter tubes (8 French) for feeding to minimize risk of internal pressure sores 2
- Larger diameter tubes should only be used when gastric decompression is required 2
- Placement should be performed by trained and technically experienced medical staff 2
Determining Insertion Length
- Traditional NEX (nose-ear-xiphoid) method is inadequate and often results in tubes that are too short 3
- XEN+10cm (xiphisternum to ear to nose plus 10cm) is more likely to reach the gastric body in most patients 3
- For optimal positioning, the tube should reach the body of the stomach (approximately 62cm from nares in adults) 4
Position Confirmation
Mandatory Confirmation Methods
- Radiographic confirmation is essential before initiating any feeding 2, 1
- The recommended study is a plain chest X-ray (anteroposterior view) that includes visualization of the upper abdomen 1
- X-ray should visualize the entire course of the tube from insertion through the esophagus into the stomach 1
Inadequate Confirmation Methods
- Bedside auscultation alone is unreliable and potentially dangerous 2
- pH testing alone is insufficient for initial placement confirmation 1
- External measurements cannot reliably predict correct positioning due to anatomical variations 3
Common Pitfalls and Complications
Positioning Errors
- Too short: tube tip in esophagus increases aspiration risk 4
- Too long: tube may kink in stomach, curl upwards into esophagus, or enter duodenum 4
- Misplacement into airways can lead to serious complications including pneumothorax and death 5
Tube Maintenance
- Daily reevaluation of the need for the tube is mandatory 1
- Reconfirmation of position is necessary after episodes of vomiting, retching, or coughing 1
- For patients with dysphagia, misplacement with coiling of the tube in the pharynx may worsen swallowing function 2
Advanced Techniques for Difficult Cases
- Water-soluble contrast can be administered through the NGT to help confirm position in uncertain cases 1
- Electromagnetic tracking systems show promise for real-time confirmation of tube position without radiation exposure 6
- Small-caliber endoscopy can be used for direct visualization during placement in difficult cases 2
By following these evidence-based guidelines for nasogastric tube insertion and confirmation, clinicians can minimize the risk of complications and ensure proper delivery of nutrition and medications to patients requiring this intervention.