Nasogastric intubation

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Nasogastric intubation
Kendall stomach tube Fr18.jpg
Stomach tube (Levin type), 18 Fr × 48 in (121 cm)
ICD-9-CM 96.07, 96.6

Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the esophagus, and down into the stomach. Orogastric intubation is a similar process involving the insertion of a plastic tube (orogastric tube) through the mouth. [1] Abraham Louis Levin invented the NG tube. Nasogastric tube is also known as Ryle's tube in Commonwealth countries, after John Alfred Ryle.

Contents

Uses

A nasogastric tube is used for feeding and administering drugs and other oral agents such as activated charcoal. For drugs and for minimal quantities of liquid, a syringe is used for injection into the tube. For continuous feeding, a gravity based system is employed, with the solution placed higher than the patient's stomach. If accrued supervision is required for the feeding, the tube is often connected to an electronic pump which can control and measure the patient's intake and signal any interruption in the feeding. Nasogastric tubes may also be used as an aid in the treatment of life-threatening eating disorders, especially if the patient is not compliant with eating. In such cases, a nasogastric tube may be inserted by force for feeding against the patient's will under restraint. [2] Such a practice may be highly distressing for both patients and healthcare staff. [2]

Nasogastric aspiration (suction) is the process of draining the stomach's contents via the tube. Nasogastric aspiration is mainly used to remove gastrointestinal secretions and swallowed air in patients with gastrointestinal obstructions. Nasogastric aspiration can also be used in poisoning situations when a potentially toxic liquid has been ingested, for preparation before surgery under anesthesia, and to extract samples of gastric liquid for analysis. [3]

If the tube is to be used for continuous drainage, it is usually appended to a collector bag placed below the level of the patient's stomach; gravity empties the stomach's contents. It can also be appended to a suction system, however this method is often restricted to emergency situations, as the constant suction can easily damage the stomach's lining. In non-emergency situations, intermittent suction is often applied giving the benefits of suction without the untoward effects of damage to the stomach lining. [4]

Suction drainage is also used for patients who have undergone a pneumonectomy in order to prevent anesthesia-related vomiting and possible aspiration of any stomach contents. Such aspiration would represent a serious risk of complications to patients recovering from this surgery.

Types

Polyurethane NG tube (Viasys Corflo), 8 Fr x 36 in (91 cm). This fine bore tube is appropriate for longer use (up to 4 weeks). Viasys corflo ng tube Fr8.JPG
Polyurethane NG tube (Viasys Corflo), 8 Fr × 36 in (91 cm). This fine bore tube is appropriate for longer use (up to 4 weeks).

Types of nasogastric tubes include:

Materials

Nasogastric tubes are available in a variety of different materials, each with their own unique properties.

Technique

An endotracheal tube and nasogastric tube as seen on CXR. Both in good position. ETTubeandNGtubeMarked.png
An endotracheal tube and nasogastric tube as seen on CXR. Both in good position.

Before an NG tube is inserted, it must be measured from the tip of the patient's nose, loop around their ear and then down to roughly 3–5 cm (1–2 in) below the xiphoid process. The tube is then marked at this level to ensure that the tube has been inserted far enough into the patient's stomach. Many commercially available stomach and duodenal tubes have several standard depth markings, for example 46 cm (18 in), 56 cm (22 in), 66 cm (26 in) and 76 cm (30 in) from distal end; infant feeding tubes often come with 1 cm depth markings. The end of a plastic tube is lubricated (local anesthetic, such as 2% xylocaine gel, may be used; in addition, nasal vasoconstrictor and/or anesthetic spray may be applied before the insertion) and inserted into one of the patient's anterior nares. Treatment with 2.0 mg of IV midazolam greatly reduces patient stress. [7] The tube should be directed straight towards the back of the patient as it moves through the nasal cavity and down into the throat. When the tube enters the oropharynx and glides down the posterior pharyngeal wall, the patient may gag; in this situation the patient, if awake and alert, is asked to mimic swallowing or is given some water to sip through a straw, and the tube continues to be inserted as the patient swallows. Once the tube is past the pharynx and enters the esophagus, it is easily inserted down into the stomach. The tube must then be secured in place to prevent it from moving. There are several ways to secure an NG placement. One method and the least invasive is tape. Tape is positioned and wrapped around the NG tube onto the patients nose to prevent dislodgement. [4]

Another securement device is a nasal bridle, or a device that enters one nare, around the nasal septum, and then to the other nare where it is secured in place around the nasogastric tube. There are two ways a bridle is put into place. One method, according to the Australian Journal of Otolaryngology, is performed by a physician to pull a material through the nares and then tied with the ends shortened to prevent removal of the tube. [8] The other method is a device called the Applied Medical Technology, or AMT, bridle. This device uses a magnet inserted into both nares that connects at the nasal septum and then pulled through to one side and tied. This technology allows nurses to safely apply bridles. [8] Several studies have proven the use of a nasal bridle prevents the loss of the NG placement that provides necessary nutrients or suctioning. A study conducted in the UK from 2014 through 2017, determined that 50% of feeding tubes secured with tape were lost inadvertently. [9] The use of bridle securement decreased the percentage of NGs lost from 53% to 9%. [9]

Great care must be taken to ensure that the tube has not passed through the larynx into the trachea and down into the bronchi. The reliable method is to aspirate some fluid from the tube with a syringe. This fluid is then tested with pH paper (note not litmus paper) to determine the acidity of the fluid. If the pH is 4 or below then the tube is in the correct position. If this is not possible then correct verification of tube position is obtained with an X-ray of the chest/abdomen. This is the most reliable means of ensuring proper placement of an NG tube. [10] The use of a chest x-ray to confirm position is the expected standard in the UK, with Dr/ physician review and confirmation. Future techniques may include measuring the concentration of enzymes such as trypsin, pepsin, and bilirubin to confirm the correct placement of the NG tube. As enzyme testing becomes more practical, allowing measurements to be taken quickly and cheaply at the bedside, this technique may be used in combination with pH testing as an effective, less harmful replacement of X-ray confirmation. [11] If the tube is to remain in place then a tube position check is recommended before each feed and at least once per day.

Only smaller diameter (12 Fr or less in adults) nasogastric tubes are appropriate for long-term feeding, so as to avoid irritation and erosion of the nasal mucosa. These tubes often have guidewires to facilitate insertion. If feeding is required for a longer period of time, other options, such as placement of a PEG tube, should be considered.[ citation needed ]

Function of an NG tube properly placed and used for suction is maintained by flushing. This may be done by flushing small amounts of saline and air using a syringe [12] or by flushing larger amounts of saline or water, and air, and then assessing for the air to circulate through one lumen of the tube, into the stomach, and out the other lumen. When these two techniques of flushing were compared, the latter was more effective. [13]

Contraindications

The use of nasogastric intubation is contraindicated in patients with moderate-to-severe neck and facial fractures due to the increased risk of airway obstruction or improper tube placement. Special attention is necessary during insertion under these circumstances in order to avoid undue trauma to the esophagus. There is also a greater risk to patients with bleeding disorders, particularly those resulting from the distended sub-mucosal veins in the lower third of the esophagus known as esophageal varices which may be easily ruptured due to their friability and also in GERD(Gastro Esophageal Reflux Disease). [4]

Alternative measures, such as an orogastric intubation, should be considered under these circumstances, or if the patient will be incapable of meeting their nutritional and caloric needs for an extended time period (usually >24 hours).[ citation needed ]

Complications

Complications with nasogastric intubation can occur due to incorrect initial placement of the nasogastric tube or due to changes in tube position that go unrecognized. Nasogastric tubes mistakenly placed in the trachea or lungs can lead to aspiration of enteral feeds or medications administered through the NG tube. This can also lead to pneumothorax or pleural effusion, which often requires a chest tube to drain. [14] [4] Nasogastric tubes can also be mistakenly placed within the intracranial space; this is more likely to occur in patient who already have specific types of skull fractures. [4]

Other complications include clogged or nonfunctional tubes, premature removal of the tube, erosion of the nasal mucosa, esophageal perforation esophageal reflux, nose bleeds, sinusitis, sore throat and gagging. [14] [4]

Fox News Digital reported about a voluntary field correction notice dated March 21, 2022, referenced 60 injuries and 23 deaths related to misplacement of a nasogastric tube. [15] Avanos Medical's Cortrak2 EAS recall, has been classified as a Class I recall by the FDA, following these reports. [16]

See also

Related Research Articles

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Esophageal atresia</span> Congenital discontinuity of the oesophagus

Esophageal atresia is a congenital medical condition that affects the alimentary tract. It causes the esophagus to end in a blind-ended pouch rather than connecting normally to the stomach. It comprises a variety of congenital anatomic defects that are caused by an abnormal embryological development of the esophagus. It is characterized anatomically by a congenital obstruction of the esophagus with interruption of the continuity of the esophageal wall.

<span class="mw-page-title-main">Dysphagia</span> Difficulty in swallowing

Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right.

<span class="mw-page-title-main">Esophageal motility study</span> Medical test

An esophageal motility study (EMS) or esophageal manometry is a test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).

<span class="mw-page-title-main">Pulmonary aspiration</span> Entry of materials into the larynx (voice box) and lower respiratory tract

Pulmonary aspiration is the entry of material such as pharyngeal secretions, food or drink, or stomach contents from the oropharynx or gastrointestinal tract, into the larynx and lower respiratory tract, the portions of the respiratory system from the trachea (windpipe) to the lungs. A person may inhale the material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.

<span class="mw-page-title-main">Feeding tube</span> Medical device used to provide nutrition to people

A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral feeding or tube feeding. Placement may be temporary for the treatment of acute conditions or lifelong in the case of chronic disabilities. A variety of feeding tubes are used in medical practice. They are usually made of polyurethane or silicone. The diameter of a feeding tube is measured in French units. They are classified by the site of insertion and intended use.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Percutaneous endoscopic gastrostomy</span> Feeding tube going into the stomach through the abdominal wall

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. This provides enteral nutrition despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition. The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine by passing a jejunal extension tube through the PEG tube and into the jejunum via the pylorus.

<span class="mw-page-title-main">Capnography</span> Monitoring of the concentration of carbon dioxide in respiratory gases

Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO
2) in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care. It is usually presented as a graph of CO
2 (measured in kilopascals, "kPa" or millimeters of mercury, "mmHg") plotted against time, or, less commonly, but more usefully, expired volume (known as volumetric capnography). The plot may also show the inspired CO
2, which is of interest when rebreathing systems are being used. When the measurement is taken at the end of a breath (exhaling), it is called "end tidal" CO
2 (PETCO2).

<span class="mw-page-title-main">Peripherally inserted central catheter</span> Catheter intended for long periods of use

A peripherally inserted central catheter, less commonly called a percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period of time or for administration of substances that should not be done peripherally. It is a catheter that enters the body through the skin (percutaneously) at a peripheral site, extends to the superior vena cava, and stays in place for days, weeks or even months.

<span class="mw-page-title-main">Aspiration pneumonia</span> Medical condition

Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may include lung abscess, acute respiratory distress syndrome, empyema, and parapneumonic effusion. Some include chemical induced inflammation of the lungs as a subtype, which occurs from acidic but non-infectious stomach contents entering the lungs.

<span class="mw-page-title-main">Balloon tamponade</span>

Balloon tamponade usually refers to the use of balloons inserted into the esophagus, stomach or uterus, and inflated to alleviate or stop refractory bleeding.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

<span class="mw-page-title-main">Sengstaken–Blakemore tube</span> Medical device

A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices. The use of the tube was originally described in 1950, although similar approaches to bleeding varices were described by Westphal in 1930. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present.

<span class="mw-page-title-main">Combitube</span> Device used to provide an airway

The Combitube—also known as the esophageal tracheal airway or esophageal tracheal double-lumen airway—is a blind insertion airway device (BIAD) used in the pre-hospital and emergency setting. It is designed to provide an airway to facilitate the mechanical ventilation of a patient in respiratory distress.

<span class="mw-page-title-main">Subglottic stenosis</span> Medical condition

Subglottic stenosis is a congenital or acquired narrowing of the subglottic airway. It can be congenital, acquired, iatrogenic, or very rarely, idiopathic. It is defined as the narrowing of the portion of the airway that lies between the vocal cords and the lower part of the cricoid cartilage. In a normal infant, the subglottic airway is 4.5-5.5 millimeters wide, while in a premature infant, the normal width is 3.5 millimeters. Subglottic stenosis is defined as a diameter of under 4 millimeters in an infant. Acquired cases are more common than congenital cases due to prolonged intubation being introduced in the 1960s. It is most frequently caused by certain medical procedures or external trauma, although infections and systemic diseases can also cause it.

<span class="mw-page-title-main">Esophageal food bolus obstruction</span> Medical condition

An esophageal food bolus obstruction is a medical emergency caused by the obstruction of the esophagus by an ingested foreign body.

A tracheo-esophageal puncture is a surgically created hole between the trachea (windpipe) and the esophagus in a person who has had a total laryngectomy, a surgery where the larynx is removed. The purpose of the puncture is to restore a person’s ability to speak after the vocal cords have been removed. This involves creation of a fistula between trachea and oesophagus, puncturing the short segment of tissue or “common wall” that typically separates these two structures. A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for oesophageal speech.

An bronchial blocker is a device which can be inserted down a tracheal tube after tracheal intubation so as to block off the right or left main bronchus of the lungs in order to be able to achieve a controlled one sided ventilation of the lungs in thoracic surgery. The lung tissue distal to the obstruction will collapse, thus allowing the surgeon's view and access to relevant structures within the thoracic cavity.

References

  1. ↑ "Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition". NICE. August 2017. Retrieved 30 January 2018.
  2. 1 2 Kodua, Michael; Mackenzie, Jay-Marie; Smyth, Nina (2020). "Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa". International Journal of Mental Health Nursing. 29 (6): 1181–1191. doi:10.1111/inm.12758. ISSN   1447-0349. PMID   32578949. S2CID   220046454.
  3. ↑ Mulholland, Michael W., Lillemoe, Keith D., Doherty, Gerard M., Upchurch, Gilbert R., Alam, Hasan B., Pawlik, Timothy M. eds. Greenfield's Surgery: Scientific Principles and Practice. 6th Edition. Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103:Lippincott Williams & Wilkins; 2017.
  4. 1 2 3 4 5 6 7 8 9 10 Roberts, James R.; Custalow, Catherine B.; Thomsen, Todd W., eds. (2019). Roberts and Hedges' clinical procedures in emergency medicine (Seventh ed.). Philadelphia: Elsevier. ISBN   978-0-323-35478-3.
  5. 1 2 Nasogastric Tube. Last authored: Dec 2009, David LaPierre
  6. ↑ Section 82, Ensure Appropriate Position of the Dubhoff Tube Prior To Feeding. Betsy H. Allbee; Lisa Marcucci; Jeannie S. Garber; Monty Gross; Sheila Lambert; Ricky J. McCraw; Anthony D. Slonim; Teresa A. Slonim (28 March 2012). Avoiding Common Nursing Errors. Lippincott Williams & Wilkins. ISBN   978-1-4511-5324-8.
  7. ↑ Manning, Chelsea Taylor; Buinewicz, Jacob Dillon; Sewatsky, Thomas Patrick; Zgonis, Evangelia; Gutierrez, Kathy; O'Keefe, Michael F.; Freeman, Kalev; Bird, Steven B. (July 2016). "Does Routine Midazolam Administration Prior to Nasogastric Tube Insertion in the Emergency Department Decrease Patients' Pain? (A Pilot Study)". Academic Emergency Medicine. 23 (7): 766–771. doi: 10.1111/acem.12961 . PMID   26990304.
  8. 1 2 Lynch, Angelica; Tang, Cheryl S.; Jeganathan, Luxmana S.; Rockey, Jason G. (2018-01-30). "A systematic review of the effectiveness and complications of using nasal bridles to secure nasoenteral feeding tubes". Australian Journal of Otolaryngology. 1 (1): 8. doi: 10.21037/ajo.2018.01.01 .
  9. 1 2 Taylor, Stephen J; Allan, Kaylee; Clemente, Rowan; Marsh, Aidan; Toher, Deirdre (2018-10-04). "Feeding tube securement in critical illness: implications for safety" (PDF). British Journal of Nursing. 27 (18): 1036–1041. doi:10.12968/bjon.2018.27.18.1036. ISSN   0966-0461. PMID   30281347. S2CID   52917586.
  10. ↑ Thomas, Bruce; Cummin, David; Falcone, Robert E. (24 October 1996). "Accidental Pneumothorax from a Nasogastric Tube". New England Journal of Medicine. 335 (17): 1325–1326. doi: 10.1056/NEJM199610243351717 . PMID   8992337.
  11. ↑ "Confirmation of Nasogastric/Orogastric Tube (NGT/OGT) Placement". Cincinnati Children's Hospital Medical Center. August 22, 2011.
  12. ↑ Perry, AG; Potter, PA (2010). "Skill 34-4: Inserting and maintaining a nasogastric tube for gastric decompression". In Ostendorf, W (ed.). Clinical Nursing Skills & Techniques (7th ed.). Mosby Elsevier. pp. 914–920. ISBN   978-0-323-06805-5.
  13. ↑ Bani Hani, Murad; Ihim, Ikenna; Harps, Joyce; Cunningham, Steven C. (27 November 2015). "A breath of fresh air: a quality-improvement study comparing an air-circulating technique versus conventional technique to prevent nasogastric tube dysfunction". BMC Nursing. 14 (1): 63. doi: 10.1186/s12912-015-0111-9 . PMC   4661948 . PMID   26617465.
  14. 1 2 Motta, Ana Paula Gobbo; Rigobello, Mayara Carvalho Godinho; Silveira, Renata Cristina de Campos Pereira; Gimenes, Fernanda Raphael Escobar (2021). "Nasogastric/nasoenteric tube-related adverse events: an integrative review". Revista Latino-Americana de Enfermagem. 29: e3400. doi:10.1590/1518-8345.3355.3400. ISSN   1518-8345. PMC   7798396 . PMID   33439952.
  15. ↑ Aitken, Peter (29 April 2022). "Health tech company in talks with FDA about device that may have caused injury, death". foxnews.com. Retrieved 28 November 2022.
  16. ↑ "Avanos Medical Recalls Cortrak*2 Enteral Access System for Risk of Misplaced Enteral Tubes Could Cause Patient Harm". fda.gov. Retrieved 28 November 2022.
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