Nasogastric tube placement

Nasogastric (NG) tube placement is a common procedure in which a flexible tube is inserted through the nose into the stomach. It is performed for many indications, including ileus, gastric bleeding, bowel obstruction, and enteral feeding. Multiple types of NG tubes exist and the appropriate size varies based on age. Before insertion, steps should be taken to ease patient discomfort and ensure the correct length of tube is used. Proper NG tube placement can be confirmed at bedside via auscultation and aspiration and/or using radiographic confirmation. Complications include iatrogenic injury (e.g., esophageal perforation, bronchial perforation, pneumothorax), epistaxis, and gastric bleeding.

• Conditions requiring GI decompression, e.g.:
  • Bowel obstruction or ileus with significant distention, nausea, and/or persistent vomiting ^[3][4]
  • Hollow viscus perforation
  • Increased aspiration risk in intubated patients
• Suspected upper GI bleeding ^[1][5]
• Conditions requiring short-term enteral nutrition and/or medication administration ^[2]
• Conditions requiring gastric lavage (e.g., poisoning)

• Absolute ^[1][2]
  • Facial trauma and/or basilar skull fracture
  • Esophageal stricture
  • Alkaline ingestion
• Relative ^[1]
  • Coagulopathy
  • Prior gastric surgery (e.g., gastric bypass)
  • Recent nasal surgery

For patients with midface injury, basilar skull fracture, or coagulopathy, consider placing an orogastric tube. ^[1]

We list the most important contraindications. The selection is not exhaustive.

NG tube types ^[1][6]

• Levin tube
  • Single lumen with multiple holes at the distal end
  • Should not be used with continuous suction ^[1]
• Salem sump tube
  • Dual lumen tube: The second lumen vents to air and prevents excessive vacuum, protecting the gastric mucosa.
  • Suitable for longer-term drainage and/or continuous suction
• Dobhoff tube ^[2]
  • Flexible and narrow tube with a weighted tip, inserted using a stylet
  • Used to provide enteral nutrition; cannot be used with suction

NG tube sizing ^[6]

• Adults: 16–18 Fr
• Children
  • Calculated via formula: age/2 + 8
  • Typical sizes range from 8 Fr for infants to 14 Fr for older children.

• Nasogastric tube
• Emesis basin
• Nonsterile gloves and gown
• Water-soluble lubricant
• Local anesthetic (e.g., viscous lidocaine, topical benzocaine, lidocaine 2% or 4% for nebulization)
• Topical vasoconstrictor (e.g., phenylephrine, oxymetazoline)
• Tape or commercial NG tube holder
• Syringe
• Cup of water and straw
• Suction tubing

• Patient positioning: upright, with the neck slightly flexed and head tilted down (if alert)
• Length of insertion ^[1]
  • Distance from xiphoid process to earlobe, then to tip of nose
  • Add 15 cm (6 in).

• Obtain informed consent.
• Provide an emesis basin to the patient.
• Measure the appropriate length of insertion.
• Evaluate the nares for obstruction and select the more patent nostril.
• Administer a topical vasoconstrictor (e.g., oxymetazoline )
• Anesthetize the nares, nasopharynx, and oropharynx with local anesthetic (e.g., nebulized lidocaine, benzocaine, lidocaine gel).
• Lubricate the end of the NG tube.
• Allow time for the local anesthetic to take effect.
• Put on PPE.

Ensure adequate anesthesia, as simply lubricating the tube with viscous lidocaine will not provide sufficient pain relief. ^[1]

1. Insert and advance the tube into the nostril along the floor of the nasal cavity; avoid angling it upwards or laterally.
2. Ask the patient to swallow as the tube enters the oropharynx.
3. Advance the tube into the stomach until the predetermined depth is reached.
4. Confirm NG tube placement by either:
   • Auscultating the stomach while insufflating air into the NG tube, listening for a confirmatory rush of air
   • Aspirating stomach contents ^[1]
   • Obtaining a chest and/or abdominal x-ray ^[2]
5. Secure the tube using tape or a commercial holder.
6. Attach the tube to suction or place a tube cap.

Withdraw the NG tube immediately if there is significant resistance to advancement, respiratory distress, significant nasal hemorrhage, or the patient loses the ability to speak. ^[6]

Gagging is expected during NG tube insertion and is not an immediate indication to abort the procedure. Use clinical judgment. ^[1]

• Tube coiling
  • Consider using a larger NG tube.
  • Cool the NG tube just prior to placement.
• Resistance after advancing past the oropharynx
  • Place pressure on the neck at the thyrohyoid membrane to collapse the piriform sinus.
  • Sedated/unconscious patients: Lift the thyroid cartilage upwards and anteriorly to help open the esophagus.
• Patient having difficulty tolerating procedure
  • Consider antiemetic therapy, e.g., ondansetron (off-label) , 5 minutes prior to the procedure. ^[1]
  • Ensure proper anesthesia is provided and the NG tube is lubricated.
  • Ask the patient to sip and swallow water from a straw as the NG tube is advanced.
  • Advance the tube quickly once it enters the esophagus.
• Intubated or obtunded patient
  • Deflate the endotracheal tube balloon prior to NG tube insertion.
  • Insert a lubricated, soft nasopharyngeal airway into the nostril. ^[1]
  • Consider using the fingers to guide the NG tube into the pharynx. ^[1]
  • If tube insertion remains difficult, use direct visualization (e.g., laryngoscope or endoscope).

• NG tube placement confirmed clinically and/or radiographically
• Tube secured
• Tube connected to suction, if indicated
• Procedure documented

Obtain a chest and/or abdominal x-ray to confirm placement prior to administration of medication or nutrition.

On chest x-ray, a properly placed nasogastric tube will cross the diaphragm in the midline and terminate below the left hemidiaphragm.

• Complications during placement
  • Iatrogenic injury due to misplacement
    • Pulmonary placement
    • Intracranial placement
  • Epistaxis
  • Esophageal perforation
• Complications of indwelling NG tubes
  • Pressure injury of the nose
  • Fistula formation
  • Gastric bleeding or erosions
  • Mechanical tube problems (e.g., breakage, kinking, obstruction)

We list the most important complications. The selection is not exhaustive.