From the Guidelines
To successfully insert a nasogastric (NG) tube, the most effective technique involves properly positioning the patient, lubricating the tube, and using a guided approach to minimize discomfort and ensure accurate placement. When inserting an NG tube, it is essential to prioritize the patient's comfort and safety. The procedure should begin with the patient sitting upright with their head level, and the tube should be lubricated externally with gel or water and internally with water if a guidewire is present 1.
Key Steps for NG Tube Insertion
- Explain the procedure to the patient and mark the tube at a distance equal to that from the xiphisternum to the nose via the earlobe (50–60 cm) 1.
- Check nasal patency by having the patient breathe through each nostril separately and choose the clearer nostril for insertion.
- Advance the tube gently backwards along the floor of the clearer nostril until visible at the back of the pharynx (10–15 cm), and then have the patient take a mouthful of water and swallow as the tube is advanced 5–10 cm 1.
- Repeat the water swallow/advance process until the preset mark on the tube reaches the nostril, and withdraw the tube if the patient shows signs of distress, coughing, or cyanosis.
Confirming Tube Placement
After insertion, it is crucial to confirm the proper placement of the NG tube before use. While bedside auscultation can be misleading, radiography is recommended to confirm the tube's position 1. Aspirating gastric contents and checking the pH (which should be ≤5.5) can also help verify correct placement.
Additional Considerations
For patients with difficult anatomy or when resistance is met during insertion, techniques such as rotating the tube gently, having the patient tilt their chin toward their chest, or using a cold tube that has been refrigerated to stiffen it slightly can be helpful 1. In some cases, using a laryngoscope for direct visualization or employing specific maneuvers like the SORT technique may be necessary. Always prioritize the patient's comfort and safety, and document the tube insertion in the patient's notes 1.
From the Research
Tricks for Nasogastric (NG) Tube Insertion
- The use of nebulized lidocaine before nasogastric tube insertion can significantly reduce patient discomfort, with a mean visual analog scale score reduction of 21.6 mm 2.
- Simple modifications in technique, such as using a ureteral guidewire as a stylet, a slit endotracheal tube as an introducer, or head flexion with lateral neck pressure, can improve the success rate of NG tube insertion 3.
- Video-assisted laryngoscopy (VAL) can be used to assist with NG tube insertion and prevent incorrect placement, such as into the lungs 4.
- Topical local anesthetic and vasoconstrictor nasal spray, such as lidocaine and phenylephrine, may not be effective in reducing distress related to NG tube insertion in young children 5.
- The application of lidocaine before NG tube insertion can alleviate pain and discomfort by 26% without increasing nasal bleeding or vomiting, according to a systematic review and meta-analysis 6.
Techniques for NG Tube Insertion
- Using a guidewire as a stylet to help guide the NG tube into place 3.
- Using a slit endotracheal tube as an introducer to help facilitate NG tube insertion 3.
- Head flexion with lateral neck pressure to help guide the NG tube into the esophagus 3.
- Video-assisted laryngoscopy (VAL) to directly visualize the NG tube insertion 4.
Anesthesia and Analgesia for NG Tube Insertion
- Nebulized lidocaine can be used to reduce patient discomfort during NG tube insertion 2.
- Topical local anesthetic and vasoconstrictor nasal spray, such as lidocaine and phenylephrine, may not be effective in reducing distress related to NG tube insertion in young children 5.
- Lidocaine can be applied before NG tube insertion to alleviate pain and discomfort 6.