What are the proper procedures and precautions for Ryle (nasogastric) tube insertion?

Proper Procedures and Precautions for Ryle (Nasogastric) Tube Insertion

Nasogastric tube insertion requires careful adherence to proper technique and verification of placement to minimize complications and ensure patient safety. 1

Indications for Nasogastric Tube Insertion

• Enteral nutrition when oral intake is inadequate but gut function is preserved 1
• Gastric decompression for patients undergoing rapid sequence intubation with high aspiration risk 1
• Nutritional support in patients with dysphagia, particularly stroke patients 1
• Nutritional support in critically ill ventilated patients 1
• Support for patients with neurologic diseases affecting swallowing (stroke, motor neuron disease, multiple sclerosis, Parkinson's disease) 1

Contraindications

• Mechanical obstruction of the GI tract (unless for decompression) 1
• Active peritonitis 1
• Uncorrectable coagulopathy 1
• Bowel ischemia 1
• Abnormal nasal anatomy (relative contraindication) 1
• Recent facial trauma or oronasal surgery (relative contraindication) 1
• Recent GI bleeding (especially from peptic ulcer with visible vessel or esophageal varices - delay for 72 hours) 1

Pre-Insertion Assessment

• Evaluate for contraindications 1
• Consider oral gastric tube instead of nasogastric in cases of:
  • Maxillofacial trauma involving nasal passages 2
  • Nasal obstruction or deformity 2
  • Coagulopathy (to avoid significant epistaxis) 2
  • Recent nasal surgery 2

Equipment Required

• Appropriately sized nasogastric tube (typically 8F-12F for adults) 3
• pH testing strips 1
• Lubricating jelly 1
• Tape or securing device 1
• Clean gloves 1
• Cup of water with straw (if patient is alert) 1
• Stethoscope 1
• Syringe (10-60 ml) 1

Insertion Procedure

1. Preparation:

   • Explain procedure to patient and obtain consent 3
   • Position patient upright with head in neutral or slightly flexed position 1
   • Measure insertion distance using NEX method (Nose-Earlobe-Xiphoid) or alternative methods 4
   • Mark desired insertion length on tube 4

2. Insertion technique:

   • Apply water-soluble lubricant to tube tip 1
   • Insert tube through nostril, directing posteriorly and slightly downward 1
   • When tube reaches nasopharynx, gently advance while patient sips water (if able) to facilitate passage through esophagus 1
   • Continue advancing tube until predetermined mark is reached 4
   • If resistance is met, never force the tube; withdraw slightly and try again with slight rotation 1

Verification of Placement

• Radiographic confirmation is the gold standard before initiating feeding or medication administration 1
• Alternative verification methods include:
  • Aspiration of gastric contents and measurement of pH (pH <5.5 suggests gastric placement) 1
  • Do not rely solely on auscultation as this method is unreliable 1

Securing the Tube

• Apply hypoallergenic tape to secure tube to nose 1
• Consider nasal bridles for patients at high risk of dislodgement (reduces dislodgement rate from 36% to 10%) 1
• Document insertion length at exit point from nostril 4

Post-Insertion Care

• Flush tube with 40 ml of water after each medication administration or feeding 3
• Change dressing regularly and inspect insertion site for irritation 3
• Monitor for tube displacement by checking external tube length and pH of aspirate 1

Complications and Prevention

• Misplacement: Always verify placement radiographically before first use 1
• Dislodgement: Occurs in 40-80% of cases without proper securement 1
• Tube occlusion: Prevent by regular flushing with water 1
• Sinusitis: Consider alternative feeding routes for long-term use (>3-4 weeks) 1
• Aspiration pneumonia: Ensure proper placement and elevation of head during feeding 1
• Nasal irritation/erosion: Proper tube size selection and securement 1

Duration Considerations

• NGT is suitable for short-term use (<4 weeks) 1
• For longer-term feeding needs (>4 weeks), consider percutaneous gastrostomy tubes 1

Special Considerations

• In patients with high risk of aspiration, verify placement before each use 1
• Early NGT feeding may decrease mortality risk in stroke patients compared to delayed feeding 1
• NGT does not necessarily impair swallowing therapy in stroke patients 1