Under what conditions should a gastric tube be reinserted orally rather than nasally?

Conditions for Oral Gastric Tube Insertion Rather Than Nasal Insertion

Gastric tubes should be inserted orally rather than nasally in patients with suspected or confirmed basal skull fractures, as nasal insertion carries risk of intracranial placement which has been associated with patient mortality. 1

Primary Indications for Oral Gastric Tube Insertion

• Suspected or confirmed basal skull fractures: Orogastric tubes are recommended instead of nasogastric tubes in trauma patients with basal skull fractures to avoid potential intracranial placement 1
• Maxillofacial trauma: Patients with facial injuries, particularly those involving the nasal passages or midface fractures should receive oral rather than nasal gastric tubes 2
• Nasal obstruction or deformity: When nasal passages are obstructed or anatomically unsuitable for tube passage 3
• Coagulopathy: Patients with bleeding disorders where nasal insertion may cause significant epistaxis 2
• Recent nasal surgery: To avoid disruption of surgical repairs 3
• Rapid sequence intubation with high aspiration risk: In critically ill patients requiring urgent gastric decompression during airway management 2

Technical Considerations for Orogastric Tube Insertion

• Orogastric tubes have higher first-pass success rates (85%) compared to nasogastric tubes (68%) in intubated patients 4
• Using an Orogastric Tube Guide as a rigid conduit significantly improves success rates (97% vs 76%) and reduces insertion time compared to conventional "blind" insertion techniques 5
• Orogastric tubes typically enter the hypopharynx just lateral to the arytenoid cartilages 4
• When resistance is encountered, applying lateral neck pressure over the lateral thyrohyoid membrane can facilitate passage in 85% of cases by compressing the piriform sinuses and moving the arytenoid cartilages medially 4

Verification of Placement

• Radiographic confirmation is required before initiating feeding to confirm proper gastric tube position regardless of insertion route 2
• Alternative verification methods include aspiration of gastric contents and measurement of gastric pH 2
• Auscultation alone is not reliable for confirming proper placement 2

Duration Considerations

• Both nasogastric and orogastric tubes are suitable for short-term enteral access (typically <4 weeks) 6, 3
• For longer-term feeding needs (>4 weeks), percutaneous gastrostomy tubes are generally preferred 6
• In patients with dysphagia, particularly stroke patients, if a nasogastric tube is poorly tolerated or frequently dislodged, consider early PEG placement rather than switching to orogastric route 6

Special Considerations

• In intubated patients, the average distance to passage of the orogastric tube by the arytenoid cartilage is 13.2 cm (compared to 16.2 cm for nasogastric tubes) 4
• Secure fixation is essential as tube dislodgement can occur in 40-80% of gastric tubes without proper fixation 3
• Orogastric tubes may be more difficult to secure in conscious patients and may cause more discomfort than nasogastric tubes 2
• Nasogastric tubes do not necessarily impair swallowing therapy in stroke patients, which should start as early as possible regardless of tube placement 6

Potential Complications

• Common sites of impaction during insertion include the piriform sinuses (46%), arytenoid cartilages (25%), and trachea (21%) 4
• Mercury tips of older-style tubes can become lodged within the nasal cavity during removal, requiring specialist extraction 7
• Proper technique and equipment selection can minimize complications regardless of insertion route 8