# Nasogastric Tube (NGT) Insertion

## Overview

This module describes how to insert a nasogastric or orogastric tube.

## Indications

Diagnostic:

1. Suspected upper GI bleeding or obstruction

2. Gastric fluid content aspiration

3. Administering radiocontrast for imaging

Therapeutic:

1. Decompression of a distended stomach

2. Prevention of aspiration during surgery

3. Nutritional support

4. Gastrointestinal lavage (washout)

## Contraindications

1. Severe facial trauma

2. Suspected basal skull fracture

3. Obstruction of the oesophagus or nose, such as oesophageal strictures or choanal atresia

4. History of bariatric or recent nasal surgery

5. Bleeding tendency

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I am going to put a tube through your nose into your stomach so that we can …”

### What can my patient expect?

“Placing the tube is uncomfortable and sometimes painful. You may want to vomit, but once it is in place it is not painful.”

### What is my patient’s role?

“Please tell me if you have had any surgery on your face, throat or stomach, or a bleeding tendency. Stay very still while I put in the tube, and swallow when I tell you to.”

## Preparation

Prepare a trolley with equipment.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves

2. Linen saver

3. Nasogastric drainage bag or spigot

4. Appropriately sized gastric tube
   Appropriately sized gastric tube

   Neonates: 5-6 F
   Infants: 8 F
   Small children: 10 F
   Larger children: 12 F
   Up to 18 F for adults

5. Lubricant

6. 50 ml catheter tip syringe

7. Stethoscope

8. pH (litmus) paper

9. Tape to secure

10. Emesis basin

11. Glass of water and a straw

12. Suction equipment and connection

## Site & Positioning

Sit the patient up at a 45° angle, with their neck flexed forward, so that the tube follows the curvature of the nasopharynx.

To determine the insertion depth of the NG tube, measure along the tube from the tip of the patient’s nose to the earlobe and down to the xiphoid process. Take note of the insertion depth.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don non-sterile gloves.

2. Place the linen saver on the patient’s chest and give them the emesis basin to catch any vomit.

3. Lubricate the tip of the tube with KY jelly.

4. Nasogastric insertion: Use the most open nostril. Insert the tube horizontally through the nostril, then aim it downwards towards the opposite ear.

5. Orogastric insertion: Aim downward and backwards towards the pharynx while advancing the tube.

6. When the tube reaches the pharynx, flex the patient’s head forward and instruct them to swallow, or sip water if allowed.

7. Continue advancing until the insertion depth mark is at the nostril.

8. Secure
   Secure

   the gastric tube with tape or a tube holder at the nostril and on the cheek. Make sure the tube puts no pressure on the nostril, as it can cause necrosis.

9. Ensure correct tube placement by obtaining a chest X-ray OR aspirating gastric content with the catheter tip syringe and checking the pH (litmus paper turns pink) OR auscultating epigastrium for bubbles whilst rapidly injecting 20 ml air through the tube with the syringe.

10. Attach gastric drainage bag or spigot as required.

11. Discard medical waste safely.

12. Record completion of the procedure in patient notes.

## Troubleshooting

My patient is now struggling to breathe.

Ask the patient to speak. If the patient cannot speak, you have probably gone down the trachea through the vocal cords. Retract the tube and try again.

I feel resistance while I try to insert the tube.

It is normal to feel some resistance as the tube approaches the pharyngeal curvature, but if you cannot gently push past, you may be entering the trachea or coiling the tube in the pharynx. Retract the tube and try again.

The tube is too floppy to insert.

Cool the tube in the fridge before using it. You can bend it into a slight curve to help you slide down into the oesophagus.

My patient gags and panics.

Pause, retract the tube a little, ask the patient to take deep breaths, and continue once they have calmed down, while the patient sips water. Try to time the tube insertion with the sips.

I am unable to advance the tube in a neonate.

The baby might have a congenital abnormality of the nose and oesophagus such as choanal atresia or a tracheo-oesophageal fistula. Abandon the procedure and call a senior.

I’m unsure when to insert an NGT in a neonate.

1. Babies <34 weeks gestation with feeding problems

2. Abdominal distention secondary to nasal CPAP, bowel obstruction, necrotising colitis, etc

3. Babies with respiratory distress

4. Babies with feeding difficulties

5. Babies with certain neurological deficiencies

I’m unsure how to insert an NGT in a neonate.

1. Always use

   orogastric insertion
   orogastric insertion

   Nasogastric insertion increases airway resistance and the work of breathing in small neonates particularly.

   for neonates.

2. To determine the insertion depth of the NG tube, extend the tube from the sternal notch to the xiphoid process, then double its length and add 2 cm.

3. Test the position of the tube as above, but only use 1 ml of air.

4. The tube will need to be changed at least three times a week.

5. When

   removing the tube
   removing the tube

   Pinch the tube between thumb and forefinger before removing as this prevents milk from flowing into the baby's lungs.

   , wait at least 2 hours following the feed. If not, aspirate prior to removing.

## Risks

1. Splash injury

2. Local infection (rhinitis, sinusitis, oesophagitis)

3. Tracheal intubation and trauma to the trachea and lungs

4. Epistaxis

5. Hypoxia or respiratory arrest

6. Oesophageal perforation

7. Necrosis/erosion of the nasal or gastric tissues

8. Aspiration and resultant pneumonia due to vomiting or reflux

9. Vagal response

## References

1. Vetrosky D. Nasogastric Tube Placement. In: Dehn R, Asprey D, eds. Essential Clinical Procedures. 3rd ed. Philadelphia: Elsevier; 2013.

2. Mynhardt K. How to Insert a Nasogastric Tube. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 331-332.

3. Henning P. Insertion of the gastric tube. In Neonatology: A guide for doctors. Department of Paediatrics and Child Health and Stellenbosch University. Tygerberg Hospital South Africa. 2012. p. 159

4. Joolay Y, Horn A, et al. Guidelines for the insertion of a nasogastric tube: some aspects. In: Neonatal Guidelines and Drug Dosages. Division of Neonatal Medicine Groote Schuur Hospital. 2012. p. 136