What are the guidelines for inserting a Ryles (nasogastric) tube in an adult or elderly patient with a compromised swallowing mechanism due to a history of stroke, traumatic brain injury, or other neurological disorders?

Nasogastric (Ryles) Tube Insertion in Neurological Patients

Immediate Pre-Insertion Assessment

Before inserting a nasogastric tube in stroke or neurological patients, you must first complete dysphagia screening and rule out absolute contraindications. 1, 2

Absolute Contraindications - Do NOT Insert Nasally:

• Basilar skull fractures or suspected cribriform plate injury (risk of intracranial placement) 2, 3
• Severe maxillofacial trauma involving nasal passages or midface fractures (use orogastric route instead) 2
• Recent nasal surgery 2
• Complete nasal obstruction or severe deformity 2
• Esophageal stricture, obstruction, or perforation 2

Relative Contraindications Requiring Careful Assessment:

• Active, uncorrected coagulopathy (high epistaxis risk) 2
• Recent variceal bleeding (avoid for 3 days, then use only fine-bore tubes) 4

Technical Insertion Protocol

Tube Selection:

Use small diameter tubes (8 French or less) to minimize pressure sores, improve tolerance, and reduce complications. 4, 5 Larger diameter tubes should only be used if gastric decompression is necessary. 4

Insertion Technique:

• Placement should be performed by trained and technically experienced medical or nursing staff 4, 6
• Stop after 2-3 failed attempts by experienced personnel - consider alternative routes rather than repeated trauma 2
• If repeated accidental removal occurs, consider a nasal loop/bridle to secure the tube 4, 1

Mandatory Position Confirmation:

Radiographic confirmation is absolutely mandatory before initiating any feeding. 4, 2, 5 Alternative methods:

• pH testing of aspirated gastric content (pH <5.5) must be checked prior to every use 4
• Auscultation alone is unreliable and should not be used 4

Post-Insertion Management

Feeding Initiation:

• Start feeding at low flow rates (10-20 ml/h) in acute stroke patients, as it may take 5-7 days to reach target nutritional intake 5
• Starter regimens using diluted feeds are unnecessary in patients with reasonable recent nutritional intake 4
• Position patients propped up by 30° or more during feeding and for 30 minutes after to minimize aspiration 4

Critical Monitoring:

• Check tube position before every feed using pH testing 4
• Monitor for pharyngeal coiling - the most common cause of feeding intolerance and vomiting 4, 5
• If dysphagia worsens with tube in place, perform endoscopic evaluation of pharyngeal tube position or reinsert the tube 4, 5
• Close monitoring of fluid, glucose, and electrolytes (sodium, potassium, magnesium, calcium, phosphate) is essential in first few days 4

Tube Maintenance:

• Long-term nasogastric tubes should be changed every 4-6 weeks, swapping to the other nostril 4
• Implement rigorous oral hygiene protocols to reduce aspiration pneumonia risk 1

When to Transition from Nasogastric to PEG

Consider PEG placement if enteral nutrition is anticipated for more than 4 weeks. 4 However, more recent evidence suggests earlier consideration:

• For mechanically ventilated stroke patients where prolonged feeding (>14 days) is probable, early PEG within 1 week is superior to nasogastric feeding due to lower ventilator-associated pneumonia rates 4, 2, 5
• If nasogastric tube is repeatedly dislodged despite adequate fixation, transition to PEG 4
• If dysphagia persists beyond 2-3 weeks, transition to PEG rather than continuing problematic nasogastric feeding 2

Concurrent Dysphagia Rehabilitation

Nasogastric tube feeding does not worsen dysphagia and should never prevent dysphagia therapy. 4, 1, 2 Key points:

• Dysphagia therapy should start as early as possible, even with tube in place 4, 1
• Recent studies demonstrate no negative impact of nasogastric tubes on swallowing function 4
• Worsening dysphagia is usually due to tube misplacement (pharyngeal coiling), not the tube itself 4, 5
• Encourage oral intake of safe textures as far as safely possible, even with tube feeding 4

Common Pitfalls to Avoid

• Do NOT assume nasogastric tube prevents aspiration - it does not 2
• Do NOT place tube without radiographic confirmation 4, 2, 5
• Do NOT use large-bore tubes (>8 French) unless gastric decompression needed 4, 2
• Do NOT continue nasogastric tube beyond 2-3 weeks if dysphagia persists - transition to PEG 2
• Do NOT delay dysphagia rehabilitation because tube is in place 4, 1, 2
• Do NOT insert nasally in patients with basilar skull fractures - risk of intracranial placement 2, 3

Expected Complications

Be aware that nasogastric tube complications are common: tube dislodgement occurs in 48-52% of patients, electrolyte alterations in 45%, hyperglycemia in 34%, diarrhea in 33%, vomiting in 20%, and aspiration pneumonia in 49% of stroke patients. 7, 8 Failed insertion occurs in 27% and malposition requiring reinsertion in 43% of cases. 7

Ethical Considerations

In patients with terminal dementia or palliative situations, tube feeding is not recommended - offer comfort feeding instead. 4 For patients with uncertain prognosis, a semi-invasive nasogastric approach may be more appropriate initially than PEG, with daily reassessment of indication. 4