Definition Nasogastric intubation is the placement of a tube into the stomach through the nose.

Several types of nasogastric (NG) tubes composed of different materials and of varying diameters are available, depending on the purpose of the tube and the length of time it is expected to stay in place. Nasogastric tubes may be inserted in order to remove stomach contents. Removal can be done for therapeutic reasons, such as to remove toxins, or for diagnostic reasons, such as sampling the contents of the stomach. Individuals may be fed (enteral feeding) and receive medication through a tube if their ability to swallow has been compromised. In some situations, the tube is inserted through the mouth rather than the nose (oral gastric intubation). Once in place (whether inserted through the nose or mouth), a NG tube is generally well tolerated. An NG tube may be used on hospitalized individuals or individuals in home care, but generally only for periods of less than a month. This is because of increased use of gastrostomy tubes, which travel directly from the stomach through the skin, and are inserted using a simple procedure. These tubes are shorter and larger in diameter, and are not as prone to obstruction. NG tubes may be used for diagnostic purposes, such as to withdraw (aspirate) a sample of gastric contents, assess gastrointestinal (GI) bleeding, measure volume of stomach contents, and measure the acidity of gastric contents.

Reasons for Procedure Indications: 1. Removing stomach contents A. Diagnostic GI bleeding Penetrating or blunt trauma

B. Therapeutic Paralytic ileus Gastric dilatation Intestinal obstruction Persistent vomiting Removal of toxins and pill fragments Heating or cooling for temperature abnormalities C. Prophylactic Decompression prior to abdominal surgery Prevention of aspiration in multiple trauma 2. Instillation of materials Medications, feedings, contrast, charcoal NG tubes may be used for several therapeutic reasons. They may be placed during surgery in order to keep the stomach empty (decompressed) until the normal functioning (peristalsis) of the GI tract returns. To decompress the GI tract, the tube remains in place with intermittent or constant suction to aspirate the gastric contents and remove gaseous buildup. An NG tube may also be used during emergency treatment of poisonings, when it is desirable to remove all stomach contents. It is also used with certain GI conditions, including GI hemorrhage, loss of intestinal movement (paralytic ileus) with accumulation of gastric liquids, gastric outlet obstruction, and trauma. Nasogastric tubes are also commonly used in hospitals and home care situations to administer medications to individuals who are unable to swallow safely. Placement of an NG tube is also performed for relatively short-term administration of liquid feedings (enteral feeding, tube feeding) both in the inpatient and outpatient setting. This procedure should not be performed on individuals with obstruction of the esophagus or substantial trauma to the face, nose, or jaw. Great care should be taken when inserting an NG tube in those who are having convulsions, are unconscious, are uncontrollable bleeders (i.e., because of blood coagulation abnormalities), or who have large esophageal varices, which may be prone to significant bleeding. For most patients,

an x-ray is often taken following tube insertion to confirm appropriate placement in the stomach.

How Procedure is Performed The procedure is performed with the individual sitting up and bending the head and neck slightly forward. If there is an injury or an orthopedic condition of the spine at the neck, the tube is placed without using flexion. A local anesthetic gel can be placed in the nostril used for tube placement, as well as on the tube itself. The lubricated tube is then inserted through the nostril into the back of the throat. The individual is instructed to swallow while the tube is being advanced. 1. Check patient ID and explain procedure to the patient. Ensure consent is obtained and documented in the clinical record 2. Discuss contraindications with patient and choose which nostril to intubate. Obstruction, trauma, gross deformity or recent surgery must be considered. 3. Agree a signal with the patient by which they can communicate if they want the procedure to stop. 4. Assist the patient to an upright sitting position ensuring that the head and shoulders are well supported by pillows. If the patient is unconscious or semi conscious it may be preferable to lay them on their side. 5. Mark the distance which the tube is to be passed by measuring the distance on the tube from the patients ear lobe to the bridge of the nose to the Xyphoid Process. 6. Wash and dry hands and assemble equipment on they tray. 7. Check the patients nostrils are patent by asking him/her to sniff with on nostril closed. Repeat with other nostril. 8. Insert the rounded end of the tube into the clearer nostril and slide it backwards along the floor of the nose to the nasopharynx. If any obstruction is encountered pull back and try again at a slightly different angle or use the other nostril. 9. As the tube passes down into the nasopharynx ask the patient to start swallowing and sipping water (unless this is contraindicated).

11. Advance the tube through the pharynx as the patient swallows until the tape marked tube reaches the point of entry to the external nares. If the patient shows signs of distress e.g. gasping or cyanosis remove the tube immediately. 12. Do not remove the guide wire until the position of the tube has been confirmed. 13. Secure the tube to the nostril with appropriate tape. 14. Complete the NG Tube insertion label and stick in the patients hospital record. 15. Check the position of the tube to confirm that it is in the stomach by the following methods: a. Aspirate 2 mls of stomach content and test using a ph indicator strip. A ph level of <5.5 is unlikely to be pulmonary aspirate and is considered to be gastric in origin. If unable to obtain aspirate and the tube is radio-opaque b. Request an xray of the upper abdomen and chest. A doctor must check this xray and confirm whether the tube is correctly sited. If the tube is not in the correct place the doctor should inform ward staff verbally so that the tube may be removed. When the tube is properly positioned, the tubing is taped to the nose to prevent pulling and dislodgment.

After your procedure:

Monitoring:
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Intake and output: Caregivers will keep track of the amount of

liquid you are getting. They also may need to know how much you are urinating. Ask how much liquid you should drink each day. Ask caregivers if they need to measure or collect your urine.
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NG tube: Different devices may be attached to the NG tube. This

will depend on the purpose of the tube insertion. If your stomach needs to be emptied, a suction (vacuum) may be connected to it. If the tube is mainly a way to feed the patient or give medicines, a feeding pump may be used. While the tube is inserted, caregivers will check on the tube regularly to make sure it stays in the proper place. This may be done by

sucking fluid out of the tube and testing for its content or acidity. If the tube seems to be blocked, it may have to be flushed with saline (saltwater solution) or blown with air. Tape used to secure the NG tube may have to be checked everyday or whenever it becomes soaked.
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Skin and abdomen: Your skin in the area of tube insertion will be

checked often to make sure it is not causing sores or problems. Caregivers will look for redness, swelling, drainage, or bleeding at the site of insertion. Your abdomen (stomach) will also be checked often to make sure that it is not getting hard or bloated.
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Vital signs: Caregivers will check your blood pressure, heart rate,

breathing rate, and temperature. They will also ask about your pain. These vital signs give caregivers information about your current health.

Removing the NG tube: Taking out the NG tube may be easier than putting

it in. However, you may still experience the same uncomfortable feeling while the tube is being taken out. This includes feeling like you want to vomit (throw up). Your caregiver may do the following steps in taking out the NG tube:
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Your caregiver will turn off and disconnect any device that is

attached to the NG tube. This may include the suction machine or feeding pump.
o o

You will be asked to sit up and a towel will be put over your chest. Tapes or other materials used to secure the tube will be taken

away. The tube will also be removed from the hospital gown.
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With gloves on, your caregiver will gently and quickly pull out the

tube from your nose. The tube is then wrapped in a towel and disposed off properly.

The area where the NG tube was placed will be cleaned. Mouth

and nasal care may also be given.

Prognosis The predicted outcome depends on the purpose of tube placement. When an NG tube is placed to provide gastric decompression, the predicted outcome is adequate removal of air and gastric contents and relief from vomiting. Other outcomes of decompression include adequate removal of blood and other gastric contents, return of normal bowel function and motility, relief of paralytic ileus, and removal of an overdose. The outcome of a NG tube placed to administer feedings is adequate nutrition and an increase in or maintenance of body weight.

Complications In general, NG tubes are inserted and removed without difficulty. However, several complications may occur. A nosebleed (epistaxis) may be induced as the tube is inserted through the nose. The tube may be inadvertently introduced into the trachea, resulting in coughing, choking, and difficulty talking. Inadvertent placement of certain tubes (those with weighted tips or metal stylets) into the trachea may cause injury to the lung. Puncture (perforation) of the esophagus may also occur. Gastric contents may be introduced into the lungs, causing injury and inflammation. If an NG tube is used for feeding, the liquid feeding solution may go into the lungs and result in aspiration pneumonia. When tubes are left in the same nostril for a prolonged period of time, the skin and tissue of the nostril may break down (ulcerate) due to pressure of the tube. The tissue lining the stomach (gastric mucosa) may erode and perforate if a NG tube is connected to suction to provide decompression. Inflammation of the paranasal sinuses (sinusitis) and the esophagus (esophagitis) may also occur. There may be an imbalance of electrolytes in the blood following the removal of a large

volume of gastric fluid.

Complications: Prevention and Management Complication: Prevention: Management: Try other naris; a smaller caliber tube; or consider oral gastric intubation. Topical vasoconstrictor. Rule out coagulopathy. Local pressure. Consider oral gastric intubation. Excessive gagging: Coiling of the tube in the oral cavity: Topical anesthetic. Mild neck flexion; stiffening Partially withdraw, and of the tube tip by cooling in again encourage patient to ice. Tracheal intubation: swallow. Withdraw and re-advance with slight neck flexion. Reflux of gastric contents Do not clamp vent lumen. Flush vent lumen with a into the vent lumen: Bronchial placement: Radiologic exam is mandatory in comatose patients. Obstruction of tubes used for instillation: Only liquids should be administered, followed by 30 -50cc water flush. Attempt to flush with 50cc water. syringe filled with air. Remove and replace.

Inability to insert tube into Topical vasoconstriction the naris due to resistance: Nasal bleeding: