What is the proper procedure for inserting an Orogastric Tube (OGT) in a 1-year-old male patient?

Orogastric Tube Insertion in a 1-Year-Old Male

In a 1-year-old patient, insert a well-lubricated orogastric tube (OGT) through the mouth rather than the nose, measuring the insertion length from xiphisternum to earlobe to nose plus 10 cm, and verify proper gastric placement using pH testing of aspirated contents combined with clinical assessment. 1

Tube Selection and Preparation

• Use an orogastric tube (OGT) rather than a nasogastric tube (NGT) in this age group when possible, as OGTs cause less mucosal trauma and are easier to insert in young children 2
• Ensure the tube is well-lubricated before insertion to minimize esophageal and oral mucosal damage 2
• Have appropriately sized tubes available based on the child's weight and age 3

Measurement of Insertion Length

The most accurate method for determining proper tube length is measuring from the xiphisternum to the earlobe to the nose, then adding 10 cm. 1 This formula provides the best estimate for optimal gastric positioning with an average difference of only 1.8 cm from ideal placement.

Alternative measurement approaches include:

• The traditional nose-to-earlobe-to-xiphisternum (NEX) method, though this frequently leads to improper positioning 4, 1
• Formula-based calculations, though these are less accurate in pediatric patients 1

Insertion Technique

Positioning

• Position the child with slight neck extension using a small roll under the shoulders to facilitate passage 2
• Maintain this position during insertion to optimize the pathway through the oropharynx 2

Insertion Process

• Insert the tube through the mouth in a downward and inward arc 2
• The tube should enter the hypopharynx just lateral to the arytenoid cartilages for successful passage 5
• Advance the tube to the pre-measured depth 4, 1

Managing Resistance

If resistance is encountered during insertion:

• Apply lateral neck pressure over the ipsilateral thyrohyoid membrane, which compresses the piriform sinuses and moves the arytenoid cartilages medially 5
• This maneuver relieves 85% of tube impactions at the laryngeal level 5
• Common sites of resistance include the piriform sinuses (46% of cases) and arytenoid cartilages (25% of cases) 5

Verification of Proper Placement

Multiple methods should be used to confirm gastric placement: 4

Primary Verification Methods

• Aspirate gastric contents and test pH - gastric aspirate should have a pH < 5.5 4
• Visual inspection of aspirated contents for characteristic gastric fluid appearance 4
• Auscultation over the stomach while insufflating air, though this should not be used as the sole verification method 4

Additional Confirmation

• Assess for absence of respiratory distress or coughing during insertion 4
• If any doubt exists about placement, obtain a chest X-ray to confirm position, as this remains the gold standard 4
• The tube tip should be visualized in the stomach, well below the gastroesophageal junction 4

Critical Safety Considerations

Contraindications and Cautions

• Avoid OGT placement in children with epidermolysis bullosa due to increased risk of oral and esophageal mucosal trauma; NGTs are preferred in these patients despite their drawbacks 2
• In children with fragile mucosa, ensure an experienced staff member performs the insertion 2
• Consider delaying non-urgent OGT placement in infants with pyloric stenosis, as early placement is associated with prolonged time to electrolyte correction and longer hospital stays 6

Securing the Tube

• Once proper placement is confirmed, secure the tube to prevent displacement 2
• In children with fragile skin, use a low-adherent film contact layer first, then apply adhesive tape to the film rather than directly to skin 2
• Reposition the child to neutral head position after securing, as neck flexion can advance the tube further while extension can pull it out 3

Common Pitfalls to Avoid

• Do not rely solely on auscultation for placement verification, as this method has high false-positive rates 4
• Avoid forcing the tube if significant resistance is met; instead, apply lateral neck pressure or withdraw and reposition 5
• Do not use the traditional NEX measurement as the sole guide, as it frequently results in malposition 4, 1
• Never assume proper placement without verification, as blind placement can result in misplacement in 4.7% to 69% of cases 4