Nasogastric Tube Insertion in 5 Easy Steps
The insertion of a nasogastric (NG) tube should follow a standardized 5-step procedure to ensure correct placement and minimize complications. 1
Step 1: Preparation
- Explain the procedure to the patient
- Mark the tube at a distance equal to that from the xiphisternum to the nose via the earlobe (50-60 cm)
- Lubricate the tube externally with gel/water and internally with water if a guidewire is present
- Check the guidewire moves freely
- Check nasal patency by having the patient "sniff" with each nostril occluded in turn
- The clearer nostril can be sprayed with lidocaine to minimize discomfort
Step 2: Position the Patient
- Sit the patient upright with the head level
- Use a pillow with 5 cm height for optimal positioning 2
- For intubated patients or those with difficult insertions, head flexion with lateral neck pressure can increase success rates 3
Step 3: Initial Insertion
- Slide the tube gently backwards along the floor of the clearer nostril until visible at the back of the pharynx (10-15 cm)
- If there is difficulty passing the tube, ask the patient to tilt their head forwards or turn it to one side
Step 4: Advance the Tube
- If the patient is cooperative, ask them to take a mouthful of water
- Advance the tube 5-10 cm as they swallow
- Repeat the water swallow/advance until the preset mark on the tube reaches the nostril
- Withdraw the tube at any stage if the patient is distressed, coughing, or cyanosed
Step 5: Confirm Placement and Secure
- Once in place, remove any guidewire
- Check position of the tube before use (using appropriate verification methods)
- Secure the tube carefully to prevent displacement
- Document tube insertion in the patient's notes 1
Important Considerations
Tube Selection
- Use fine bore 5-8 French gauge NG tubes for feeding
- Larger bore tubes should only be used when gastric decompression or aspiration is necessary 1, 4
Verification of Placement
- Correct position must be verified before administering anything through the tube
- Methods include X-ray verification, aspiration of gastric content, or measurement of gastric pH 4
Complications to Watch For
- Insertion-related: nasal bleeding, gagging, vomiting, esophageal perforation, tracheal placement
- Usage-related: pharyngolaryngitis, respiratory infections, swallowing difficulties 4
Starting Feeding
- For uncomplicated cases, feeding can begin within 2-4 hours after tube placement
- For patients with nasogastric tubes, feeding can start immediately according to the established nutritional care plan once appropriate tube placement is confirmed 1