Where should a nasogastric (NG) tube be placed for regular feeding?

Nasogastric Tube Placement for Regular Feeding

For regular enteral feeding, a nasogastric (NG) tube should be placed with its tip in the body of the stomach, confirmed by X-ray before initiating feeding. 1, 2

Proper NG Tube Placement

Type of Tube

• Fine bore 5-8 French gauge NG tubes are recommended for regular feeding 1
• Large bore PVC tubes should be avoided as they:
  • Irritate the nose and esophagus
  • Increase risks of gastric reflux and aspiration 1

Insertion Depth

• Traditional methods like nose-earlobe-xiphoid (NEX) have been shown to be inadequate, often resulting in tubes that are too short 3
• The tube should be inserted deep enough to ensure the tip and all side openings are positioned in the body of the stomach 3
• If insertion length is too short, the tip may remain in the esophagus, increasing aspiration risk
• If insertion length is too long, the tube might kink in the stomach or enter the duodenum 3

Verification of Placement

Initial Verification

• X-ray confirmation is mandatory after initial blind placement before feeding is initiated 2
• The recommended radiographic study is a plain chest X-ray (anteroposterior view) that includes visualization of the upper abdomen 2
• This allows visualization of the entire course of the tube from insertion through the esophagus and into the stomach 2

Ongoing Verification

• Reconfirmation of position is necessary:
  • After episodes of vomiting, retching, or coughing
  • When there is clinical suspicion of tube displacement 2
  • Daily reevaluation of tube position is recommended 2

Considerations for Alternative Placement

When to Consider Post-pyloric (Nasojejunal) Placement

• Consider nasojejunal (NJ) tube placement instead of NG in cases of:
  • Gastric reflux problems
  • Delayed gastric emptying
  • Unconscious patients who must be nursed flat 1
  • High risk of aspiration 2

When to Consider Gastrostomy

• If enteral feeding is likely to be needed for more than 4-6 weeks, consider percutaneous gastrostomy 1, 4
• Gastrostomy allows feeding without the inconvenience, discomfort, and embarrassment of NG access 1
• Patients receive more of their prescribed feed with gastrostomy tubes as NG tubes "fall out" easily 1

Risk Minimization During Feeding

• Position patients with head elevated 30-45 degrees to reduce aspiration risk 2
• Monitor for feeding intolerance:
  • Check gastric residual volumes in high-risk patients
  • Assess for abdominal distension or discomfort 2

Common Pitfalls to Avoid

1. Inadequate verification: Relying on unreliable methods (air auscultation, pH testing) instead of X-ray confirmation can lead to serious complications 2

2. Improper tube securement: Between 40-80% of NG tubes become dislodged; proper securement is essential 1

3. Delayed transition to long-term access: Continuing with NG feeding beyond 4-6 weeks when gastrostomy would be more appropriate 1, 4

4. Insufficient monitoring: Failure to regularly reassess tube position, especially after events that might displace the tube 2

5. Inappropriate insertion length: Using outdated measurement techniques that result in tubes that are too short or too long 3