What are the precautions for a barium swallow using a Ryle's (nasogastric) tube?

Barium Swallow with Nasogastric Tube: Key Precautions

Barium swallow studies should generally be avoided in patients with nasogastric tubes in place, particularly when there is suspected upper tract dysfunction or complete esophageal obstruction, due to the high risk of aspiration. 1

Primary Contraindications and High-Risk Situations

Absolute Contraindications

• Complete esophageal obstruction with inability to swallow saliva - This dramatically increases aspiration risk during barium administration 1
• Suspected or confirmed upper tract swallowing dysfunction (pharyngeal dysphagia, brain stem stroke, cranial nerve palsies) - These patients have impaired protective reflexes and are at extreme risk for massive barium aspiration 2
• Active esophageal perforation - Barium can extend the defect and cause mediastinal contamination 1

High-Risk Clinical Scenarios Requiring Extreme Caution

• Patients with depressed consciousness or high NIHSS scores - These indicate severe neurological impairment with compromised airway protection 1
• Presence of dysphonia, wet voice after swallowing, or impaired voluntary cough - These are independent predictors of aspiration risk 1, 3
• Brain stem infarctions or multiple strokes - These patients have the highest aspiration risk during contrast studies 1, 2
• Incomplete oral-labial closure or absent gag reflex - Though preserved gag reflex doesn't guarantee safety, its absence increases risk 1

Critical Safety Protocols Before Proceeding

Mandatory Pre-Procedure Assessment

• Perform bedside water swallow test first - This screening tool identifies high-risk patients before exposing them to barium 1, 3
• Assess for wet voice quality after test swallows - This is a strong predictor of aspiration risk 1
• Verify NGT position radiographically - Ensure no pharyngeal coiling that could mechanically worsen dysphagia 3, 4
• Evaluate mental status and ability to follow commands - Cognitive deficits significantly reduce the safety of postural maneuvers during the study 5

Alternative Diagnostic Approaches

When upper tract dysfunction is suspected, videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed instead of standard barium swallow - these allow for controlled small-volume testing with immediate intervention capability 3, 6

Technical Modifications to Reduce Risk

If Barium Study Must Proceed

• Use small-volume boluses initially (1-3 mL) rather than continuous drinking 5
• Employ protective postural changes based on the specific swallowing abnormality:
  • Chin-down position for delayed pharyngeal swallow
  • Head rotation toward the weaker side for unilateral pharyngeal weakness
  • Head tilt away from the weaker side for unilateral oral weakness 5
• Have immediate suction available and personnel trained in airway management 2
• Consider performing study with anesthetic support and endotracheal intubation for airway protection in very high-risk patients 1

NGT-Specific Considerations

• Use small-diameter tubes (8 French) to minimize mechanical interference with swallowing 3, 4
• Ensure proper tube securement - 40-80% of NGTs become dislodged without appropriate fixation, leading to pharyngeal coiling that worsens aspiration risk 3
• Do not remove NGT before assessment unless pharyngeal coiling is confirmed - the tube itself does not significantly impair swallowing function 3

Common Pitfalls to Avoid

• Never assume the NGT prevents aspiration - it does not eliminate this risk and may actually increase it in some patients 4, 7
• Do not proceed with barium swallow as first-line investigation when dysphagia suggests upper tract dysfunction - refer to specialized dysphagia center first 2
• Avoid using barium in patients who cannot manage their secretions - this indicates severe dysphagia with very high aspiration risk 1
• Do not delay other investigations - contrast studies should not postpone endoscopy or other definitive management 1
• Never coat the esophagus with barium if endoscopic intervention may be needed, as this impairs visualization 1

Post-Procedure Monitoring

• Observe for fever, respiratory distress, or new oxygen requirements - these may indicate aspiration pneumonitis 1
• Monitor for signs of perforation (chest pain, subcutaneous emphysema, sepsis) if the study was performed despite relative contraindications 1
• Initiate appropriate aspiration precautions based on findings, including head elevation 30-45 degrees during and after feeding 7

When Barium Study Adds No Value

In stroke patients with clear clinical dysphagia, the decision to place feeding tubes (PEG or NGT) should be based on clinical grounds and severity of neurological deficits, not barium study results - research shows barium swallow findings do not significantly influence PEG placement decisions 8