Should a nasogastric (NG) tube be inserted with the patient lying down flat or at a 45-degree angle?

Nasogastric Tube Insertion Position: Upright at 45-Degree Angle

Nasogastric tubes should be inserted with the patient positioned upright at a 45-degree angle rather than lying flat to reduce the risk of aspiration and facilitate proper tube placement. 1, 2

Proper Positioning Technique for NG Tube Insertion

Patient Position

• Position the patient upright with head elevated at 45 degrees when possible 2
• This position helps to:
  • Reduce the risk of aspiration during insertion
  • Facilitate proper passage of the tube into the esophagus
  • Decrease the likelihood of tube coiling or entering the airway

Special Circumstances

• For unconscious patients who must be nursed flat, consider:
  • Using nasojejunal tubes instead of nasogastric tubes 1
  • Having suction equipment readily available
  • Ensuring proper verification of tube placement before initiating feeds

Evidence-Based Insertion Protocol

1. Explain the procedure to the patient and obtain consent when possible
2. Position the patient upright with the head at a 45-degree angle 2
3. Mark the tube at a distance equal to that from the xiphisternum to the nose via the earlobe (50-60 cm) 1
4. Lubricate the tube externally with gel/water
5. Check nasal patency by having the patient sniff with each nostril occluded in turn
6. Insert the tube gently along the floor of the clearer nostril
7. Advance the tube as the patient swallows small sips of water (if conscious and able)
8. Verify placement before use (typically via X-ray for initial placement) 2

Verification of Tube Placement

• X-ray confirmation is necessary after initial blind placement before feeding is initiated 2
• The radiographic study should include visualization of the upper abdomen to ensure proper placement 2
• Daily reevaluation of tube position is necessary, especially after episodes of vomiting, retching, or coughing 2

Common Pitfalls and Complications

• Incorrect positioning technique: Lying flat increases risk of aspiration and tube misplacement
• Inadequate verification: Failure to confirm proper placement can lead to serious complications
• Tube misplacement: Can result in aspiration pneumonia if feeding is initiated with the tube in the airway
• Coiling in the pharynx: May occur with improper insertion technique, causing worsening of dysphagia 1

Special Considerations

• For patients with stroke or decreased level of consciousness, small diameter tubes (8 French) should be used to minimize the risk of internal pressure sores 1, 2
• In intubated patients, a 5 cm height pillow has been shown to improve successful insertion 3
• For patients at high risk of aspiration, elevate the head of the bed 30-45 degrees continuously after placement 2

The 45-degree upright position represents the optimal balance between patient comfort, insertion success, and safety by reducing the risk of aspiration and facilitating proper anatomical alignment for tube passage.