Can a nasogastric tube cause persistent coughing?

Can a Nasogastric Tube Cause Persistent Coughing?

Yes, a nasogastric tube can directly cause persistent coughing through multiple mechanisms, including mechanical irritation of the upper airway, increased aspiration risk, and impairment of normal protective reflexes.

Primary Mechanisms of NGT-Related Cough

Direct Mechanical Irritation

• The presence of an NGT causes loss of anatomical integrity of both the upper and lower esophageal sphincters, which can trigger cough reflexes 1
• NGT placement increases the frequency of transient lower esophageal sphincter relaxations, potentially stimulating the esophageal-bronchial cough reflex 2, 1
• The tube causes desensitization of the pharyngoglottal adduction reflex, which normally protects against aspiration 1

Aspiration-Related Cough

• NGTs are a well-established risk factor for aspiration and aspiration pneumonia, with accumulation of secretions in the pharynx and reflux of gastric contents being the primary mechanisms 1
• The tube allows colonization and aspiration of pharyngeal secretions and gastric contents, leading to high incidence of Gram-negative pneumonia in enterally fed patients 1
• Gastric bacteria can migrate upward along the tube and colonize the pharynx, creating a continuous source of irritation and potential aspiration 1

Upper Airway Complications

• NGT insertion can cause laryngeal irritation and even laryngospasm, particularly when misplaced into the tracheobronchial tree 3
• Misplacement complications, though uncommon, can include perforation of the nasopharynx with mediastinal passage, leading to serious respiratory complications including empyema and pneumothorax 4

Clinical Context and Differential Diagnosis

When evaluating persistent cough in a patient with an NGT, you must systematically rule out other common causes while recognizing the tube's contribution:

• GERD is frequently exacerbated by NGT presence due to sphincter incompetence, and GERD itself causes chronic cough in 5-41% of cases through esophageal-bronchial reflex mechanisms 2
• Upper airway cough syndrome (UACS) and asthma remain common causes of chronic cough that may coexist with NGT-related mechanisms 5
• The relationship between NGT and cough may be bidirectional—coughing itself can worsen reflux and aspiration risk 2

Critical Evaluation Steps

Immediate Assessment

• Verify correct NGT position with chest radiograph, as misplacement occurs more frequently than recognized and can cause serious complications 6, 4, 7
• The traditional nose-earlobe-xiphoid measurement method is too short; use evidence-based insertion length methods 6
• Do not rely on auscultation ("whooshing sound") alone for position verification—this method is unreliable and no longer recommended 7

Look for Red Flags

• New onset dyspnea, hemoptysis, or chest pain after NGT insertion suggests serious misplacement complications 4, 7
• Gastrointestinal bleeding or abnormal drainage fluid character may indicate mucosal injury 7
• Signs of aspiration pneumonia (fever, infiltrates on imaging, increased respiratory secretions) warrant immediate evaluation 1

Management Approach

If Cough Develops After NGT Placement

• Confirm tube position radiographically if not recently done 6, 4
• Elevate head of bed at least 30 degrees at all times to reduce gastric material migration to the trachea 2
• Consider empiric GERD treatment, as the NGT-induced sphincter incompetence makes reflux highly likely 2, 1

If Cough Persists Despite Confirmed Position

• Evaluate for aspiration with clinical assessment and imaging 1
• Consider whether the tube is truly necessary—removal may be the definitive solution if alternative feeding routes are feasible 1
• Treat coexisting causes systematically (UACS, asthma, GERD) as multiple etiologies commonly coexist 5

Important Caveats

The evidence directly linking NGTs to persistent cough is primarily observational, focusing on aspiration risk rather than cough as a primary outcome. However, the mechanistic pathways are well-established through studies on esophageal sphincter function and aspiration physiology 1. In clinical practice, if persistent cough develops or worsens after NGT placement and other causes have been addressed, strongly consider the tube itself as the culprit and evaluate whether continued use is justified against the risk of ongoing respiratory complications.