What are the indications for nasogastric tube (NGT) insertion?

Indications for Nasogastric Tube (NGT) Insertion

Nasogastric tube insertion is primarily indicated for gastric decompression in patients at high risk of regurgitation of gastric contents, particularly before rapid sequence intubation, and for enteral feeding in patients unable to maintain adequate oral intake.

Primary Indications

Gastric Decompression

• Patients undergoing rapid sequence intubation (RSI) with high risk of aspiration: NGT decompression is advised when the benefit outweighs the risk in patients who are at high risk of regurgitation of gastric contents during intubation 1
• Patients with gastric distention or full stomach: Clinical assessment and point-of-care ultrasound can help determine the need for NGT decompression 1
• Bowel obstruction: Essential for decompression of the stomach in critically ill patients with intestinal obstruction 2

Enteral Access for Nutrition

• Short-term enteral nutrition: When oral intake is inadequate but gut function is preserved 1
• Patients with dysphagia: Particularly in stroke patients with swallowing difficulties requiring nutritional support 1
• Mechanically ventilated patients: For providing nutritional support in critically ill ventilated patients 1

Medication Administration

• Alternative route for medication delivery: When oral administration is not possible 2
• Patients unable to swallow medications: Due to altered mental status or mechanical issues 2

Risk Assessment for NGT Insertion

High-Risk Factors for Regurgitation (Requiring Decompression)

• Presence of solid gastric contents: Identified through point-of-care ultrasound 1
• Estimated gastric fluid volume >1.5 mL/kg: With patient in right lateral decubitus position 1
• Presence of clear fluids: In both supine and lateral decubitus positions 1

Considerations for Tube Size Selection

• For feeding purposes: Small diameter tubes (8 French) should be used to minimize risk of internal pressure sores 1
• For gastric decompression: Larger diameter tubes may be required 1

Contraindications and Cautions

Potential Complications to Consider

• Nasal bleeding: Common complication during insertion 1, 3
• Gagging and vomiting: Can occur during insertion process 1
• Esophageal perforation: Rare but serious complication 1
• Tracheal placement: Can lead to respiratory distress if undetected 1, 3
• Airway compromise: Potential for aspiration of blood or secretions during insertion 3

Verification of Placement

• Radiographic confirmation: Required before initiating feeding to confirm proper position 1
• Aspiration of gastric contents: Can help verify placement 1
• Measurement of gastric pH: Alternative method to confirm position 1
• Auscultation alone is unreliable: Can lead to misinterpretation of tube position 1, 4

Special Considerations

Critically Ill Patients

• Before rapid sequence intubation: Consider NGT when risk of aspiration is high 1
• Risk-benefit assessment: Weigh benefits of decompression against risks of insertion complications 1

Stroke Patients

• Dysphagia management: NGT does not necessarily impair swallowing therapy, which should start as early as possible 1
• Tube position concerns: Misplacement with coiling in the pharynx can worsen dysphagia; consider reinsertion or endoscopic evaluation 1

Long-term Considerations

• For prolonged feeding needs: Consider more permanent options like PEG if enteral nutrition will be required >14 days 1
• Ventilated stroke patients: Early PEG (within 1 week) may be preferred over NGT for prolonged feeding due to lower rates of ventilator-associated pneumonia 1

Insertion Techniques

• Bedside placement: Most common method, with patient's head flexed and sips of water to assist passage 1
• Blind placement: Can be performed at bedside but requires confirmation of position 1
• Image-guided placement: Using fluoroscopy or ultrasound for difficult cases 1
• Endoscopic guidance: May be used in complex cases 1

Common Pitfalls and How to Avoid Them

• Relying solely on auscultation: Always confirm placement with radiography before initiating feeding 1, 4
• Inadequate insertion length: Can lead to tube tip in esophagus, increasing aspiration risk 4
• Excessive insertion length: May cause tube kinking, curling into esophagus, or duodenal entry 4
• Failure to recognize complications: Monitor for signs of bleeding, respiratory distress, or discomfort 3
• Inadequate securement: Can lead to dislodgement and need for reinsertion 1