What is the proper procedure for inserting a Nasogastric (NG) tube?

Nasogastric (NG) Tube Insertion Procedure

The proper procedure for inserting a nasogastric (NG) tube involves using a fine bore 5-8 French gauge tube, ensuring proper patient positioning, adequate lubrication, and verification of correct tube placement before use to minimize complications and maximize patient safety. 1

Indications for NG Tube Placement

• NG tubes are indicated for short-term enteral access (typically <4-6 weeks) for patients with impaired nutrient intake due to neurologic disease, unconsciousness, upper GI obstruction, or head and neck cancer 1
• For longer-term feeding needs (>4-6 weeks), percutaneous gastrostomy tubes are generally preferred 1

Equipment Selection

• Use fine bore 5-8 French gauge NG tubes for most feeding applications 1
• Large bore PVC tubes should be avoided as they irritate the nose and esophagus, increasing risks of gastric reflux and aspiration 1
• Select appropriate tube size based on intended use (feeding vs. aspiration) 1

Pre-Procedure Preparation

• Obtain informed consent from the patient or legally authorized representative 1
• Explain the procedure to the patient to reduce anxiety 2
• Gather all necessary equipment (tube, lubricant, pH testing strips, tape/securing device) 2
• Position the patient upright with neck in neutral or slightly flexed position 3

Step-by-Step Insertion Procedure

1. Measure insertion length using a safer method than the traditional nose-earlobe-xiphoid (NEX) method, which often results in tubes that are too short 2

2. Prepare the tube:

   • Apply generous water-soluble lubricant to the tip of the tube 4
   • Consider chilling the tube to increase rigidity if needed 4

3. Insert the tube:

   • Gently insert the tube into the more patent nostril 1
   • Direct the tube posteriorly along the floor of the nasal cavity 4
   • When resistance is felt at the nasopharynx, ask the patient to swallow (if conscious) or flex the neck slightly forward 3
   • Advance the tube during swallowing or neck flexion 3
   • If difficulty is encountered, try applying lateral neck pressure or using head flexion to facilitate passage 3

4. Troubleshooting difficult insertions:

   • If resistance is met, never force the tube 4
   • Consider using a guidewire as a stylet to increase success rate 3
   • For intubated patients, consider direct visualization techniques 4
   • If the patient has difficulty passing the tube, ask them to tilt their head forward or turn it to one side 1

5. Verify tube position before use:

   • Check position of the tube before administering anything through it 1
   • Verification methods include:
     • Aspiration of gastric contents and pH testing 1
     • X-ray confirmation for high-risk patients 2

6. Secure the tube:

   • Once proper placement is confirmed, remove any guidewire 1
   • Secure the tube carefully to prevent dislodgement 1
   • Consider nasal bridles for confused patients or those at high risk of tube removal 1

Post-Insertion Care

• Document tube insertion in the patient's medical record 1
• For feeding tubes, adults with uncomplicated gastrostomy tube placement can commence enteral nutrition within 2-4 hours after the procedure 1
• For nasogastric tubes, feeding can start immediately according to the established nutritional care plan once appropriate tube placement is confirmed 1

Common Complications and Prevention

• Misplacement: The most serious complication is inadvertent placement into the trachea or lungs; always verify position before use 2
• Mucosal trauma: Use adequate lubrication and gentle technique to minimize bleeding and trauma 4
• Tube dislodgement: Secure properly; 40-80% of NG tubes become dislodged without proper fixation 1
• Coiling/kinking: Avoid excessive tube length; kinking is one of the most common complications 3

Special Considerations

• For unconscious or intubated patients, insertion may be more challenging and may require additional techniques 4
• For patients with facial trauma or skull fractures, use extreme caution and consider alternative routes 4
• For patients requiring jejunal feeding, a graduated program of commencement should be followed 1

By following this systematic approach to NG tube insertion, healthcare providers can maximize success rates while minimizing complications and ensuring patient safety.