What are the criteria for Nasogastric (NG) tube placement?

From the Guidelines

Nasogastric (NG) tubes are indicated for patients who require short-term enteral access for feeding, medication administration, or gastric decompression, particularly those with impaired nutrient intake due to neurologic disease, postcerebrovascular accident, motor neuron disease, multiple sclerosis, movement disorder, or unconscious patient/ventilated patient, as outlined in the AGA clinical practice update on endoscopic enteral access 1. The primary criteria for NG tube placement include inability to maintain adequate oral intake, risk of aspiration, need for gastric decompression following surgery or in bowel obstruction, and administration of medications that cannot be taken orally. Some key points to consider when deciding on NG tube placement include:

• Patients with altered consciousness, severe dysphagia, upper gastrointestinal obstruction, or those requiring mechanical ventilation often meet these criteria.
• Before insertion, assess for contraindications such as severe facial trauma, basilar skull fractures, recent nasal surgery, or esophageal varices.
• Once inserted, proper placement must be confirmed by radiographic verification (gold standard), pH testing of aspirate (pH < 5 indicates gastric placement), or a combination of methods.
• Never rely solely on auscultation over the epigastrium.
• Regular assessment for complications is essential, including skin breakdown at insertion site, sinusitis, aspiration pneumonia, and tube displacement.
• NG tubes are typically not suitable for long-term feeding (beyond 4-6 weeks), at which point more permanent enteral access should be considered, as percutaneous tube placement is typically reserved for individuals who are expected to require enteral access for 4 or more weeks 1. In terms of specific patient populations, the ESPEN guideline on clinical nutrition in neurology notes that early enteral nutrition in patients with swallowing difficulties after stroke may reduce mortality and improve outcomes, and that nasogastric tube feeding may be preferred over PEG tube feeding in the initial phase due to its less invasive nature and lower risk of complications 1. However, the choice between NG tube and PEG tube feeding should be individualized based on the patient's specific needs and circumstances, taking into account factors such as the anticipated duration of enteral access, the patient's ability to tolerate the tube, and the risk of complications 1. Ultimately, the decision to use an NG tube should be based on a careful assessment of the patient's needs and a consideration of the potential benefits and risks, with the goal of optimizing morbidity, mortality, and quality of life outcomes.

From the Research

Criteria for Nasogastric (NG) Tube Placement

The decision to place a nasogastric tube is typically based on a patient's inability to consume food orally, which can be due to various reasons such as difficulty swallowing, unconsciousness, or the need for enteral nutrition. The criteria for NG tube placement can be summarized as follows:

• Difficulty in swallowing, which was the main reason for beginning enteral nutrition in a study involving 64 patients 2
• Need for enteral nutrition, which is often required in hospitalized patients with problems related to oral nutrition 2
• Presence of conditions that require bypassing the oral route for nutrition, such as acute stroke, which was the most commonly reported reason for NGT insertion in a meta-summary of case reports 3

Complications Associated with NG Tube Placement

NG tube placement can lead to several complications, including:

• Tube dislodgement, which occurred in 48.5% of patients in a prospective and observational study 2
• Electrolytic alterations, which were observed in 45.5% of patients in the same study 2
• Hyperglycaemia, which occurred in 34.5% of patients 2
• Diarrhoea, constipation, vomiting, tube clogging, and lung aspiration, which were also reported in the study 2
• Nasogastric tube syndrome, a potentially life-threatening complication characterized by throat pain, vocal cord paralysis, and upper airway obstruction, which has been reported in several case reports and case series 3, 4

Patient Characteristics and Risk Factors

Certain patient characteristics and risk factors can increase the likelihood of complications associated with NG tube placement, including:

• Older age, with an average age of 76.2 years in a study involving 64 patients 2
• Presence of underlying conditions, such as diabetes mellitus and hypertension, which were reported in 37.04% and 33.33% of patients, respectively, in a meta-summary of case reports 3
• Immunosuppression, which was reported in 11.11% of patients in the same meta-summary 3