Can a swallow evaluation be performed with a Nasogastric Tube (NGT) in place?

Can a Swallow Evaluation Be Done with an NGT in Place?

Yes, swallow evaluations including videofluoroscopic swallow studies (VFSS) and clinical bedside assessments can and should be performed with a nasogastric tube in place, as the tube does not significantly impair swallowing function or prevent dysphagia therapy. 1

Evidence Supporting Swallow Evaluation with NGT In Situ

The most definitive guidance comes from the 2018 ESPEN neurology guidelines, which directly address this clinical question:

• Three recent studies, including two specifically in stroke patients, demonstrated that nasogastric tubes do not negatively impact swallowing function. 1

• Dysphagia therapy should start as early as possible in both tube-fed and non-tube-fed patients—the presence of an NGT should not delay assessment or treatment. 1

• The earlier assumption that NGTs impair swallowing has been contradicted by current evidence, making it unnecessary to remove the tube before evaluation. 1

When Worsening Occurs: A Critical Pitfall to Avoid

If dysphagia appears to worsen with an NGT in place, this is typically not due to the tube itself interfering with swallowing mechanics:

• The most common cause of worsening dysphagia with an NGT is tube misplacement with coiling in the pharynx. 1

• In this situation, perform endoscopic evaluation of the pharyngeal tube position or reinsert the tube—do not assume the tube is inherently causing the problem. 1

Clinical Implications for Practice

Timing of Swallow Assessment

• Perform swallow screening (such as a bedside water swallow test) before allowing oral intake in all stroke patients, regardless of NGT presence. 1

• A wet voice after swallowing, incomplete oral-labial closure, or high NIHSS score are independent predictors of aspiration risk that should prompt formal evaluation. 1

Instrumental Swallow Studies with NGT

• Videofluoroscopic swallow studies (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed to identify appropriate treatment strategies, even with an NGT in place. 1

• These instrumental evaluations are essential not just for diagnosis but to determine which therapeutic techniques will eliminate aspiration during oral eating and drinking. 1

Practical Considerations

• Use small diameter nasogastric tubes (8 French) in stroke patients to minimize the risk of internal pressure sores and reduce any potential mechanical interference. 1, 2

• Proper tube securement is essential—40-80% of NGTs become dislodged without appropriate securement, which can lead to pharyngeal coiling and actual swallowing problems. 1, 2

Conflicting Evidence: Pediatric vs. Adult Populations

Important caveat: While adult stroke literature strongly supports performing swallow evaluations with NGTs in place, pediatric studies show contradictory findings:

• One pediatric study found significantly higher aspiration rates (46% vs. 23.8%) during VFSS when NGTs were present. 3

• However, another pediatric study found no significant difference in swallowing events between studies with and without NGTs. 4

This guideline applies specifically to adult patients, particularly stroke patients, where the evidence is clear that NGTs do not impair swallowing assessment. 1

Clinical Algorithm

1. Do not remove the NGT before swallow evaluation unless pharyngeal coiling is suspected 1

2. Perform bedside swallow screening first (water swallow test) to identify high-risk patients 1

3. Proceed to instrumental evaluation (VFSS or FEES) if aspiration risk is identified, with the NGT remaining in place 1

4. If dysphagia worsens unexpectedly, check for pharyngeal tube coiling via endoscopy or reposition the tube 1

5. Begin dysphagia therapy immediately based on findings, without waiting for NGT removal 1