1. Nasogastric feeding
Dr. M. A.Sofi MD; FRCP (London); FRCPEdin; FRCSEdin
Al Maarefa College of Science & Technology

2. Nasogastric Tube Insertion
Introduction Nasogastric tube (NGT) feeding is common practice and thousands of tubes are inserted daily without incident. However, there is a risk that the tube can become misplaced into the lungs during insertion, or move out of the stomach at a later stage.
Tubal insertion into the stomach is sometimes necessary in order to either diagnose or treat some existing digestive tract malfunctions. The usual tube inserted to have an access into the stomach is the Nasogastric Tube (NGT) commonly termed as Nasogastric Tube Insertion Procedure or simply put as NGT insertion. 

3. Nasogastric Tube Insertion
Is nasogastric tube feeding the right decision for this patient?
The details of the assessment must be recorded in the patient’s medical notes prior to commencement of feed.
The decision to insert a nasogastric tube must be made following careful assessment of the risks and benefits by at least two competent health care professionals including the senior doctor responsible for the patient’s care.
Is this the right time to place the nasogastric tube and is the appropriate equipment available?
Placement of nasogastric tubes should not occur at times when there is insufficient support available to accurately confirm placement (insufficient support may not be available at night or out of hours).

4. Nasogastric Tube Insertion Procedure
Nasogastric tubes used for the purpose of feeding must be radio-opaque throughout their length and have externally visible length markings. The tube length should be estimated before insertion using the NEX measurement (place exit port of tube at tip of nose. Extend tube to earlobe, and then to xiphisternum). Once inserted, the external tube length should be recorded and confirmed before each feed.
Is there sufficient knowledge/expertise available at this time to test for safe placement of the nasogastric tube? In the following circumstances, patients should NOT be fed correct tube placement has been confirmed by a competent person through x- ray and documented.

5. Nasogastric Tube Insertion
Diagnostic indications for NG intubation:
Evaluation of upper gastrointestinal (GI) bleeding (i.e., presence, volume)
Aspiration of gastric fluid content
Identification of the esophagus and stomach on a chest radiograph
Administration of radiographic contrast to the GI tract
Therapeutic indications for NGT intubaation:
Gastric decompression, including maintenance of a decompressed state after endotracheal intubation
Relief of symptoms and bowel rest in the setting of small-bowel obstruction
Aspiration of gastric content from recent ingestion of toxic material
Administration of medication
Feeding
Bowel irrigation

6. Nasogastric Tube Insertion
Contraindications of NGT
Absolute contraindications for NG intubation include:
Severe midface trauma
Recent nasal surgery
Relative contraindications for NG intubation include:
Coagulation abnormality
Esophageal varices or stricture
Recent banding or cautery of esophageal varices
Alkaline ingestion

7. Securing device or tape Cup of water pH indicator paper
Gather your equipment
Gloves
Fine bore nasogastric tube (feeding only) or  nasogastric “Ryles”  tube 16Fr (all other indications)
Water based lubricant
Syringe
Bile bag
Securing device or tape
Cup of water
pH indicator paper
Anaesthetic throat spray
For this procedure the patient should be positioned on the bed upright and facing forward.  Put on your gloves. -

8. Step I
Wash your hands, introduce yourself to the patient and clarify their identity.  Explain the procedure to the patient and gain their consent to proceed.

9. The types of NG Tubes
Stomach tube (Levin type), 18 Fr × 48 in (121 cm)
Polyurethane NG tube This fine bore tube is appropriate for longer use (up to 4 weeks).

10. NEX measurement
Estimate the length of the tube to be inserted.  Do this by measuring the NG tube from the tip of the nose, to the earlobe and then to the xiphisternum .
NEX MEASUREMENT

11. Actual Procedure Apply a small amount of lubricant to the tube.
Give patient glass of water
Get patient to sniff. The nostril with better airflow is usually the easier side (not universal).
Your patient will usually be awake during this procedure so ensure they are not experiencing too much discomfort.
Pass the tube horizontally along the floor of the nasal cavity. Passing it upwards will hit the turbinates (painful)
Ask the patient to indicate when the tube is at the back of the throat, or if they have had anaesthetic spray ask the patient to open their mouth and look for the end of the tube.

12. Actual Procedure
Once the tube has advanced to the back of the throat, ask the patient to hold some water in their mouth.
As they swallow, advance the tube slowly, but firmly. It should slide easily. If you encounter resistance, it may be that the tube has curled up in the back of the mouth.
Sequential swallows of sips of water will allow gradual progress
The gastro-oesophageal junction is usually at cm from the incisor, so the tube must pass at least that distance plus 15-20cm.
Aspirate from the tube using a syringe. Test the aspirate using pH indicator paper. The pH should be 1 – 5.5.
If satisfied that the pH is correct, and the tube is draining gastric fluid, secure the tube with tape and attach a bile bag to allow drainage.

13. Confirming Position
This is more important if the tube is being used to administer water or liquid feed. If the a wide-bore tube is being used for decompression of the stomach, then misplacement is less likely to be lethal, but if there is doubt, radiological confirmation is helpful.
Methods of confirmation include:
Aspiration of stomach contents; Note that NG tubes have been known to curl up in the back of the throat with small intermittent vomits giving the impression of being in the stomach.
Measuring pH; can be confusing if on antacids or proton pump inhibitors
Auscultation while injecting air, listening for bubbling. This can be unreliable as bowel sounds may be mistaken for correct placement.
Radiological, with chest radiograph. If still uncertain, a small amount of contrast can be injected

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