NASOGASTRIC INTUBATION

By Dr Ufelle,C.Sim
 INTRODUCTION
WHAT IS NASOGASTRIC TUBE ?

A flexible rubber or plastic tube made of

either Polyvinyl Chloride (PVC) for short
term use up to 10 days (e.g. Ryles tubes -
or Polyurethane (PUR) for long term use
greater than 10 days (Merck
corflo).Various lengths and lumen
diameters are available for adult patients.
 .
This is passed through the nose
and down through the nasopharynx
,through the esophagus into the
stomach.

This may be performed for

diagnostic,decontamination or
therapeutics purposes
 Equipment:
All necessary equipment should be prepared, assembled
and available at the bedside prior to starting the NG tube
insertion. Basic equipment includes:
Gloves.
Personal protective equipment(Gown/fFacial shield)
NG tube.
Syringe/Stethoscope.
Water-soluble lubricant, preferably 2% Xylocaine jelly.
Adhesive tape.
Low powered suction device OR Drainage bag.
Cup of water/Straw
kidney Dish.
Towel or Pad.
pH indicator strips.
 Universal precautions:

The potential for contact with a patient's

blood/body fluids while inserting an NG
tube is present and increases with the
inexperience of the operator. Gloves must
be worn while inserting an NG tube; and if
the risk of vomiting is high, the operator
should consider face and eye protection
as well as a gown.
 PREPARATION
Explain the procedure and obtain consent
Provide a signal for the patient to stop the
procedure.
Sit the patient in a semi-upright position
with the head supported with pillows and
tilted neither backwards nor forwards
Examine the nostrils for deformity or
obstructions to determine the best side for
insertion .
Select the appropriate distance on the tube
by measuring the distance on the tube
from the xiphisternum (a) to the top of the
patients ear (b) to the tip of the nose).
 INSERTION
Mark the measured length with a
marker or note the distance.
Lubricate 2-4 inches of tube with
lubricant (e.g. 2% Xylocaine)
Pass the tube via either nostril, past
the pharynx, into the oesophagus and
then into the stomach
Instruct the patient to swallow or sip
some water and advance the tube as
the patient swallows.
 Ifresistance is met, rotate the tube
slowly while advancing downwards.
Do not force .
Stop immediately and withdraw the
tube if patient becomes distressed,
starts gasping or coughing, becomes
cyanosed or if the tube coils in the
mouth .
Advance the tube until the mark is
reached.
Check the tube's position (see below)
Secure the tube with tape.
 NB:

Withdraw tube immediately if

changes occur in patient's
respiratory status, if
tube coils in the mouth, if the
patient begins to cough.
 CHECKING TUBES POSITION
OR PLACEMENT.
It is essential to confirm the position of the tube
in the stomach by one of the following:
Check for placement by attaching syringe to free
end of the tube, aspirate sample of gastric
contents.
NB:The old test of introducing a small quantity of
air into the stomach and checking for a bubbling
sound over the epigastrium is not recommended
as it is unreliable and can give false
reassurance,as the best practice is to test the
pH of the aspirated contents to ensure that the
contents are acidic.
 Testing pH of aspirate: gastric placement is
indicated by a pH of less than 4, but may
increase to between pH 4-6 if the patient is
receiving acid-inhibiting drugs.
pH paper test strips with 0.5 pH increment
markers are used. Other pH strips are
available which measure in 1.0 pH
increments.

The use of blue litmus paper to check the

acidity of aspirate is insufficiently sensitive
to distinguish between levels of acidity.
 USE OF X-RAYS.
This will only confirm position at the time
the X-ray is carried out. The tube may
have moved by the time the patient has
returned to the ward.
In the absence of a positive aspirate test,
where pH readings are more than 5.5, or
in a patient who is unconscious or on a
ventilator, an X-ray must be obtained to
confirm the initial position of the
nasogastric tube.
.
 Documentation
The documentation regarding the insertion
of Nasogastric Tube should be done and
this includes:
Time and date of insertion.
Name and signature of the practitioner.
Type of Nasogastric Tube inserted and
batch Number.
How correct tube position was confirmed
 Indications

By inserting a nasogastric tube, you are gaining access

to the stomach and its contents.
This enables you to drain gastric contents,
decompress the stomach,
obtain a specimen of the gastric contents, or introduce a
passage into the GI tract. This will allow you to treat
gastric immobility, and bowel obstruction. It will also
allow for drainage and/or lavage in drug overdosage or
poisoning.
In trauma settings, NG tubes can be used to aid in the
prevention of vomiting and aspiration, as well as for
assessment of GI bleeding.
NG tubes can also be used for feeding.
 INDICATIONS
Decompression of the Gastrointestinal Tract
Nasogastric intubation is required to
remove enteric secretions and
swallowed air in patients with
obstructions of the small bowel or
gastric outlet. However, routine
placement of nasogastric tubes in
patients with mild or moderate
symptoms is not indicated, since this
may result in prolonged nausea and
vomiting and extended
hospitalization.
Nasogastric intubation and suction
may be beneficial in patients
undergoing mechanical ventilation
with the use of an endotracheal tube
in order to prevent aspiration of
gastric contents.
 Administration of Oral Agents

Oral agents (e.g., activated charcoal or

radiographic contrast material) may be
administered through a nasogastric tube in
patients unable to tolerate fluids delivered
orally.
 Gastrointestinal Hemorrhage
Nasogastric intubation and suctioning may
be performed in patients with severe upper
gastrointestinal bleeding in order to
provide symptomatic relief and to facilitate
endoscopic visualization of the gastric and
duodenal mucosa. In the absence of frank
bloody return, examination of nasogastric
aspirates has a suboptimal sensitivity and
specificity and cannot be relied on to
confirm or rule out active hemorrhage in
patients with history of hematemesis or
melena.
 CONTRAINDICATIONS
Patient non-consent to procedure.
Anticoagulation or coagulopathy .
Basilar skull fracture .
Nasal or other trauma that might affect insertion.
Sinus surgery .
Recent sphenoidal or transsphenoidal surgery
Nasopharyngeal tumours.
Oesophageal varices .
Recent oesophageal surgery.
Oesophageal stricture.
 COMPLICATIONS

Minor complications
Epistaxis,Sinusites or Sore throat.
Major complications:
Esophageal perforation.
Intracranial placement .
Pleural Space Insertion.
Lung insertion .
Bleeding .
Knot formation.
THE END
.
Thank You.