What should I do if I meet resistance while inserting a nasogastric tube?
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Explain the procedure of nasogastric (NG) intubation, as well as its benefits, risks, complications, and alternatives, to the patient or the patient's representative. Show
Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backward (see the images below), and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect.  View Media Gallery View Media Gallery Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump NG tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube (see the image below). View Media Gallery Apart from the nose-to-ear-to-xiphisternum (NEX) method, several other methods for determining the length of the tube have been described. Among the various options, a formula based on gender, weight, and nose-to-umbilicus measurement while lying flat was found to be safer and more accurate in a study by Santos et al. [13] Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand, and put the straw in his or her mouth. Lubricate the distal tip of the NG tube (see the image below). View Media Gallery Gently insert the NG tube along the floor of the nose, and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow (see the image below). Continue to advance the NG tube until the distance of the previously estimated length is reached (see the video below). View Media Gallery Nasogastric tube insertion.View Media Gallery If, at any time, the patient experiences respiratory distress, is unable to speak, or has significant nasal hemorrhage, or if the tube meets significant resistance, stop advancing the tube and withdraw it completely. Fan et al described a no-swallow technique of NG tube intubation that relieved patient discomfort during the procedure. [14] In this technique, when the tube reached the pharynx, patients were required to take a deep breath and hold it, instead of swallowing as in the conventional technique. During breath-holding, the epiglottis covers the throat and the glottis closes, thereby reducing the likelihood of the tube entering the trachea. When the tube was inserted 15-20 cm, the patient was required to perform abdominal breathing to reduce discomfort and avoid failure of tube intubation (some patients can only hold their breath for a short time). This no-swallow technique was found to yield an increase in the success rate at first intubation, as well as reductions in the occurrence of nausea, tearing, mucosal injury, and changes in vital signs (heart rate, breath, systolic pressure), when compared with the technique used in the control group. [14] Verify proper placement of the NG tube by auscultating a rush of air over the stomach using the 60 mL Toomey syringe (see the first image below) or by aspirating gastric content. The authors recommend always obtaining a chest radiograph (see the second image below) in order to verify correct placement, especially if the NG tube is to be used for medication or food administration. Colorimetric capnography is another valid method for verifying NG tube positioning in mechanically ventilated patients. [15] View Media Gallery View Media Gallery In a retrospective descriptive analysis (N = 215) aimed at identifying factors associated with insufficient NG tube visibility on radiography, Torsy et al reported that in 14.9% of patients, the image quality was insufficient to determine the position of the tube. [16] The factors associated with poor visibility were high body mass index (BMI), male sex, and the absence of a guide wire inside the NG tube at the time of chest radiography. Although radiographic confirmation of NG tube position is conventionally considered the gold standard, it exposes the patients to ionizing radiation. Choi et al reported the use of a sonographic method to confirm the placement of nasogastric tube in pediatric patients. [17] They found that this method yielded good esophageal imaging; however, the gastric imaging was challenging, and it was improved by injecting an air bolus. Manometry is another safe and reliable method for differentiating airway placement of an NG tube from gastric placement. [18] A biphasic pressure change synchronous with airway pressure during mechanical ventilation indicates airway misplacement, and a pressure change during compression of the epigastric area indicates a gastric placement. Apply benzoin or another skin preparation solution to the nose bridge. Tape the NG tube to the nose to secure it in place (see the image below). If clinically indicated, attach the tube to wall suction after verification of correct placement. View Media Gallery PearlsDuring insertion, if concern exists that the NG tube is in the incorrect place, ask the patient to speak. If the patient is able to speak, then the tube has not passed through the vocal cords and/or lungs. The NG tube may coil in the nasopharynx or oropharynx. If this occurs, or if the tube is difficult to pass in general, try curling the distal end and partially freezing it in a cup of ice so it temporarily holds its curled shape better. Insert the lubricated tube tip through the nose with the curled end pointing downward. Once the distal tip passes into the hypopharynx, the curved tip faces anteriorly. Rotate the tube 180º so that the curved end points posteriorly toward the esophagus. Continue to insert in the usual manner by having the patient swallow water. Another option (applicable only in patients who are sedated and paralyzed) is to place two or three fingers through the patient’s mouth into the oropharynx. The fingers are used to guide the NG tube into the hypopharynx. Lifting the thyroid cartilage anterior and upward might open the esophagus and allow passage into the proximal esophagus. A method of freezing an NG tube with distilled water was shown to increase the success rate of insertion for intubated patients. [19] Direct laryngoscopy or video laryngoscopy can aid in placing an NG tube in sedated patients by enabling visualization of the tip entering the esophagus. [20] A randomized crossover manikin trial conducted by Li et al introduced a newer technique of gastric tube placement via an 8.4-French deflection flexible ureteroscope, which served as a visual guidance system. [21] Placement time was substantially shorter and the incidence of procedure-related complications considerably lower than with the standard method. In a study by Lee et al that used a manikin simulator, the time required for NG tube placement was reduced significantly in both intubated and nonintubated patients if the procedure was done under visualization with a video-guided laryngoscope, as compared with manual and laryngoscope-assisted intubation. [22] Endotracheal tube assistance and video laryngoscopy can be used to facilitate NG tube insertion in anesthetized and intubated patients. The success rate is increased, and complications such as kinking of the tube are reduced. [23] Although pH, enzyme, bilirubin, and carbon dioxide testing have been used to distinguish respiratory from gastrointestinal placement of NG tubes, none of these methods has enabled detection of tube placement in the esophagus or gastroesophageal junction. [24] Therefore, the authors recommend the routine use of x-ray verification. A survey of critical care nurses around the United States showed that recommendations from multiple national-level organizations to obtain radiographic confirmation that each blindly inserted feeding tube is correctly positioned before the first use of the tube are not adequately implemented. [25] Auscultation is widely used despite recommendations to the contrary. In a randomized, controlled study that included 200 anesthetized patients, Appukutty et al found that three techniques can increase the success rate of NG tube placement. [26] The use of a ureteral guide wire as stylet or a slit endotracheal tube as an introducer increased the success rate in comparison with control subjects, though the latter technique significantly lengthened the time for insertion. However, head flexion with lateral neck pressure proved to be the easiest technique, with a high success rate and the lowest complication rate. Sharma et al described the use of a bubble technique for NG tube insertion, which they found to have higher confirmation rate than the conventional technique (76.8% vs 59.7%). [27] In this technique, 2% lidocaine jelly was added to the proximal end to form a single bubble, and tube placement was later confirmed by means of fluoroscopy. Next: ComplicationsSome degree of patient discomfort is common. Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s level of discomfort. Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges) prior to the procedure. Epistaxis may be prevented by generously lubricating the tube tip and using a gentle technique. Other complications that may occur are respiratory tree intubation and esophageal perforation. The NG tube safety pack developed by Leeds Medical School in the United Kingdom is an innovative approach to reducing complications that makes guideline recommendations accessible and easy to follow by incorporating them into the pack design. [28] Innovations such as this can help anticipate and mitigate errors in the placement of an NG tube. A rare complication, an NG tube knotting around an endotracheal tube, can happen when a nasal endotracheal tube is used along with the NG tube. [29] In an integrative review of 69 primary studies focusing on adverse events following NG tube placement, Motta et al reported that such events are relatively common and that the majority of them are respiratory which increase rates of hospitalization, death, or both. [30] Previous Questions
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of 10 Tables Back to List Contributor Information and Disclosures Author Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC Coauthor(s) Nirav R Shah, MD, MPH Senior Scholar, Stanford University School of Medicine Specialty Editor Board Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center Chief Editor Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India Additional Contributors Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center Acknowledgements The Chief Editor would like to acknowledge the assistance of Dr Mohsina Subair, former Senior Resident, Department of Surgery; Dr Archana Elangovan, former Senior Resident, Department of Surgery; Dr Gurushankari Balakrishnan, Senior Resident, Department of Surgery; and Dr Evangeline Mary Kiruba Samuel, Junior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, in updating the review of this article. What should be done if resistance is encountered during the initial attempt to insert an NG tube?11. If resistance is encountered, withdraw the NG tube slightly and advance it again. Never push the NG tube against resistance.
What complication may occur if an NG tube is not placed correctly?The most serious harm from NG tube placement arises from misplaced NG tubes, when the tip is lying in the lungs or the pleural space, leading to pneumothorax, pneumonia and feed empyema, which can be fatal if not recognised early.
What are the special considerations before inserting NGT?Special Considerations with NG Tubes:
Always assess correct placement of the NG tube prior to infusing any fluids or tube feeds as per agency policy. Check external length, color and pH of the fluid aspirated from the tube. Routine evaluation of tube placement will promote patient safety by reducing risk of aspiration.
What tips can you provide the patient to ease the insertion of an NG tube?Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort. then the stomach.
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