Nasogastric tube insertion

Preparation

1. Obtain informed consent^{3, 7}
2. Gather equipment^{3, 7}
3. Perform hand hygiene^{3, 7}
4. Open and prepare required equipment^{3, 7}
   1. Note: Nasogastric tube may be placed on ice or in the freezer to aid insertion
5. Position the patient

• Adults and older children:
  • Conscious patient: Upright^{3, 7}
  • Unconscious patient: On their side^{3, 7}
• Infants: Supine with head elevated 30-40° ¹⁰

6. Assess nostrils for obstructions^{3, 7}
7. Perform hand hygiene^{3, 7}
8. Don personal protective equipment^{3, 7}

Procedure

1. Determine length to insert: Measure distance from the tip of the patient’s nose to the tip of their earlobe, then to the xiphisternum^{3, 10}
   1. Paediatric: Measure from tip of nose to earlobe, then to halfway between the xiphoid process and the umbilicus
2. +/- Spray local anaesthetic into desired nasal cavity and wait for anaesthetic to take affect^{3, 10}
3. Lubricate nasogastric tube or dip in water if pre-lubricated^{3, 10}
4. Extend the patient’s head^{3, 10}
5. Insert the nasogastric tube through the nose into the nasopharynx^{3, 10}
6. Once in the oropharynx, flex the patient’s head^{3, 10}
7. Ask the patient to swallow, advancing the nasogastric tube with each swallow^{3, 10}

1. Sips of water may be given if not contraindicated (e.g. impaired swallowing)
2. Sucrose may be given to infants if not contraindicated

8. Stop advancing the nasogastric tube once the measured length is reach^{3, 10}
9. Remove stylet if applicable^{3, 10}
10. Secure the tube to the patient’s nose and check with occlusive tape^{3, 10}
11. Doff personal protective equipment^{3, 10}
12. Perform hand hygiene^{3, 10}

Confirming Positioning

The position of the nasogastric tube must be confirmed following its placement^{2, 5, 6}.

Methods:

• Chest X-Ray (CXR):
  • The gold standard method^{3, 4}
  • Required post-procedure before administering anything via the nasogastric tube^{3, 4}
  • Criteria for correct placement:
    • Descend in the midline, following oesophagus^{5, 6}
    • Bisect carina or bronchi^{5, 6}
    • Cross diaphragm in midline^{5, 6}
    • Tip visible below left hemidiaphragm, preferably >10cm beyond gastroesophageal junction^{5, 6}

• Bedside methods:
  • Mostly utilised prior to each use of the nasogastric tube
  • Gastric aspirate: Test the fluid aspirated via the nasogastric tube indicates stomach placement with a pH <5⁴
    • Note: Cannot be used for fine bore nasogastric tubes as they collapse on suctioning
  • Whoosh test: Auscultate the epigastrium whilst injecting air via the nasogastric tube using a 50mL syringe³
  • Bubbling: Place nasogastric tube in water. Respiratory tree placement is indicated by bubbling on expiration

Examples of misplacement:

• Intracranial
• Oesophagus
• Coiled in upper airway (e.g. Nasopharynx)
• Bronchus
• Lung
• Kinked nasogastric tube