Nasogastric Tube: Uses and Purpose

• A nasogastric (NG) tube is a flexible tube inserted through the nose into the stomach
• NG tubes are used for feeding, medication delivery, draining fluids, and removing air from the stomach

Purpose and Uses of NG Tubes

• Feeding delivers liquid nutrition directly into the stomach, bypassing the mouth and digestive tract
• Individuals receive liquid nutrition formulas containing carbohydrates, proteins, fats, vitamins, and minerals
• Tube feeding is needed when someone cannot eat/absorb enough nutrients or has difficulty swallowing
• Blenderized tube feeding allows some people to receive blended, homemade meals through the tube
• Formula selection should be determined by a healthcare professional based on individual needs
• When preparing blended foods, follow proper food safety guidelines, especially for compromised immune systems
• Be aware that foods, like string beans or flaxseeds, may have a higher risk of clogging the tube
• Consult with a healthcare professional before starting or changing a tube feeding regimen
• Medication delivery allows administering medications difficult to take orally
• Stomach drainage helps by removing fluids, air, or blood from the stomach
• Decompression helps relieve pressure and distention in the stomach, from obstruction or ileus
• NG tubes are typically used for short-term periods, such as during recovery from surgery or illness

How NG Tubes Work

• A healthcare professional inserts the tube through a nostril into the stomach and secures it to prevent it from moving
• It can be used to deliver nutrients or medicines or to drain fluids from the stomach

Considerations

• Insertion can be uncomfortable, causing pain or nausea in some patients
• Prolonged use can cause irritation or discomfort in the nasal passages
• There is a risk of aspiration if the tube is not properly placed or managed

Alternative Options

• Gastrostomy tubes (G-tubes) or jejunostomy tubes (J-tubes) for long-term nutritional support

Proper Insertion

• The patient should be seated upright with the neck slightly flexed and the head of the bed elevated at least 30 degrees during and after feeding to minimize aspiration risk

Insertion Details

• Patient Position: The patient should be sitting upright in the "sniffing position" with their neck slightly flexed
• Head Support: Pillows can be used for comfort
• Insertion of NG tube should be along the floor of the nose, straight towards the nasopharynx
• Swallowing: Once the tube reaches the back of the throat, have the patient take small sips of water to guide it down the esophagus
• Monitoring is essential, the tube must be stopped and withdrawn if the patient gags, coughs, or shows distress
• After insertion, confirmation must be made to check the placement with X-ray or other methods

Elevation During Feeding

• Elevate the head of the bed to at least 30 degrees during and after feeding
• If patient cannot sit upright, elevate the head of the bed to 30-45 degrees during feeding and for at least 30mins after

Aspiration Risks and Monitoring

• Lying prone or supine during feeding increases the risk of aspiration
• The patient must be monitored for any signs of aspiration, such as coughing, choking, or difficulty breathing

Types of Nasogastric Tubes

• Single Lumen Tubes: These have a single, narrow channel for delivering medications and nutrition; Levin and Dobhoff are examples
• Double Lumen Tubes: These are designed for suctioning, with a wider channel for suction and a narrower one for air; Salem Sump is a model

Procedure Details

• A trained healthcare provider will explain the procedure and ask for signed consent

Insertion Steps

• Position the patient upright, apply medical gloves, and lubricate the tube with sterile gel
• Numb the sinus cavity and throat with an anesthetic, such as lidocaine
• Measure the correct length of tube and mark it in advance

Measuring Length

Healthcare providers use techniques to estimate the insertion length.

• This length is proportional to body size
• Some providers use general measurements such as 55 cm for adults

Calculating Length

• NEX (Nose-Earlobe-Xiphoid) Method: Measure from nose tip to earlobe to xiphoid process (tip of sternum) and mark the tube
• (Alternative): Some prefer measuring from the xiphoid process, to the earlobe, to the nose (XEN)
• Mark the tube clearly at the measured point

Post Insertion

• Aspiration: After insertion, always aspirate gastric contents to confirm correct placement or check pH
• Confirmation: Chest radiography is the gold standard for confirming NGT placement

Patient Safety

• Always follow proper protocols for NGT insertion and management to minimize the risk of complications
• NEX + 10cm: Add 10cm to the NEX measurement for the tube tip to go a bit further
• CoNEX Method: Corrected NEX (CoNEX) method has been developed to improve accuracy, using a formula (NEX × 0.38696) + 30.37 + 6 cm
• NEMU Method: Measure from the nose to the earlobe to a point midway between the xiphisternum and the umbilicus (NEMU). (Children)

Aspirate Gastric Content

• Normal gastric content includes juices that are colorless or slightly cloudy and off-white
• Green, yellow, or brown sometimes appears due to bile, blood, or other factors
• Withdraw gastric contents (2–5 ml) using the syringe attached to the nasogastric tube and test with litmus paper

Provider Steps

• Aim the tube towards the back of the throat to avoid pressure on the sinus cavity
• Gently aim it down into the esophagus as it reaches the back of the throat
• Give the patient water with a straw to sip, and ask the patient to swallow to pull the tube down or take a deep breath
• If the patient gasps, coughs, or shows distress, stop and withdraw the tube
• Keep advancing the tube until it reaches the mark that indicates the length. Check to ensure the tube is in the correct place

NG tube Size

• Ranging from 8 Fr to 18 Fr measured in French (Fr) units
• Smaller sizes (8-12 Fr) are for feeding, larger sizes (12-18 Fr) is for suctioning

Tube Types

• Levin Catheter: single lumen, small-bore
• Salem Sump Catheter: A large-bore tube with a double lumen, often used for continuous suction
• Dobhoff Tube: A small-bore tube with a weight at the end for gravity

Other considerations

• Stiff tubes are easier to insert; Fine-bore often have a guide wire
• Smaller French number = smaller size, so a smaller diameter on tube
• A "whoosh" or "gurgling" sound over the epigastrium (upper abdomen) during air insufflation indicates the tube is in the stomach
• Air insufflation also can mean the tube is in the lungs, esophagus, or other areas- not conclusive

Auscultation

• This is quick/ easy, but not specific, and not ideal
• A misplaced tube can still produce those sounds

Better Confirmation Options

• Aspirate Gastric Contents: If acidic fluid/ 1.5-3.5 (PH <5.5), the tube is in the stomach
• X-ray: abdominal x-ray, is still considered the gold standard for confirming NGT placement

Checking Placement

• Must check the correct placement to prevent harm

Confirmation Methods

• Chest X-ray is most accurate and is recommended, but radiation will occur if this is the action, so if you will be doing the test often, use pH, and perform at home
• Aspirate pH test- It has been placed right id there is acid

Pain

• May be uncomfortable, hopefully not very painful

Actions that a Doctor should take

• Give antathetic lozenges, or apply to nasal area, secure with tape, and switch Nostril if a concern

Long Term

• Six weeks only or if not gastrostomy, or gastrojejunostomy

NGT REPLACEMENT

• The general range is around every 2 to 4 weeks
• PVC tubes- every 4 weeks, and polyurethane tubes- 8 weeks

Tube removal action

• Only do this if properly trained or there is a chance of lungs, or get help