From the Guidelines
The best X-ray imaging to check nasogastric (NG) tube placement is a single anteroposterior (AP) chest X-ray that includes the upper abdomen, as it is the gold standard for confirming proper positioning of the NG tube in the stomach. This recommendation is based on the most recent evidence from the Journal of the American College of Radiology, which emphasizes the importance of radiographs in visualizing the course of the nasogastric tube 1. The X-ray should visualize the entire course of the tube from the nose or mouth, through the esophagus, and into the stomach, with the tip ideally positioned in the body of the stomach below the gastroesophageal junction. Key features to look for include:
- The tube crossing the midline to the left after passing through the lower esophagus
- The tip of the tube positioned in the stomach, below the gastroesophageal junction
- The absence of the tube in the trachea or pleural space
While a single AP view is typically adequate, in cases where positioning remains unclear, a lateral view may be added as a supplementary image to help distinguish between tracheal and esophageal placement. This approach is supported by the American College of Radiology's appropriateness criteria for intensive care unit patients, which highlights the importance of accurate NG tube placement confirmation to prevent complications 1. By using X-ray confirmation, healthcare providers can reduce the risk of complications from misplacement, such as aspiration pneumonia or inadvertent feeding into the lungs or pleural space.
From the Research
X-ray Imaging for NG Tube Placement
- The best X-ray imaging to check NG tube placement is not explicitly stated in the provided studies, but it is mentioned that chest radiographs (CXRs) are commonly used for this purpose 2, 3.
- The use of one or two views for NG tube placement is not specified in the studies, but it is noted that repeated X-rays are often required to confirm tube placement, with 33% of patients requiring more than three X-rays during their enteral episode 2.
Accuracy of X-ray Interpretation
- The accuracy of diagnostic radiographers' assessment of NGT position on CXRs is moderate, with 76% of image assessments being completely correct 3.
- However, there is a need for further training to achieve 100% accuracy, particularly in identifying poorly-visualised tube tips 3.
X-ray Technique
- There is variation in practice regarding the use of horizontal versus angled X-ray tubes for PA chest radiography, with no consistent rationale for either choice 4.
- Some radiographers use a horizontal tube, while others apply an angle, with some citing dose optimisation as the rationale for using an angled technique 4.
Clinical Guidelines
- Nurses are responsible for ensuring that NG tubes are placed correctly before use, and evidence-based methods for assessing tube placement are essential 5.
- However, the provided studies do not specify the best X-ray imaging technique or the number of views required for NG tube placement.