The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Nasogastric Intubation

by Richard Cashio with
Patrick Hymel

Indications
Contraindications
Equipment
Procedure
Follow-up
Complications

Indications

• Aspiration of stomach contents for management of an upper GI bleed or pancreatitis
  
• Prevention and treatment of intestinal obstruction, paralytic ileus, and acute gastric dilation
  
• Prevention of aspiration in a patient with multiple trauma
  
• Assessment of gastrointestinal trauma
  
• Gastric decompression before peritoneal lavage
  
• Postoperative intubation to protect gastric sutures
  
• Feeding or the administration of medicines

Contraindications

• Facial fractures with possible cribriform plate involvement
  
• A history of alkali ingestion
  
• Esophageal strictures
  
• Deep cervical wounds where patient gagging can cause hemorrhage
  
• Patient is unconscious with an unprotected airway

Equipment

• Towel, emesis basin and drainage collection bottle
  
• Appropriate size nasogastric tube ; (one French unit is equal to 1/3 mm)
  • Adults-16 French (Fr) or larger
    
  • Ages: Neonatal - 6 mo (5 Fr), 1-2 yr (8 Fr), 3-7 yr (10 Fr), 8-12 yr (12 Fr), 13-16 (14 Fr) NGT
• Glass of water with straw
  
• Safety pin, tape, and rubber band
  
• Bulb syringe
  
• Anesthetic jelly (e.g. lidocaine gel) and water-soluble jelly (e.g. K-Y)
• Vasoconstrictor nasal spray

Procedure

1. Place the head of the bed in the Fowler position (this is a semi-sitting position with the bed at 450 to 600).
   
2. Place a towel over the patient's chest and the emesis basin in the patient's lap. The largest possible tube for patient nostril size should be selected to avoid possible complications such as tube blockage. Again, typically this is a 16 French or larger for an adult.
   
3. Lubricate the distal 7-10 cm of the tube with water soluble jelly(K-Y).
   
4. Select the patient's nostril with the greatest air flow by asking the patient to inhale.
   
5. The nostril should then be investigated with a penlight and a nasal speculum. If the patient is congested, a vasoconstrictive nasal spray should be applied.
   
6. The nostril should now be lubricated with the anesthetic jelly (Lidocaine gel). This can be accomplished by slowly injecting 2-5 ml of the gel into the nostril using a syringe. This will aid in insertion and decrease patient discomfort.
   
7. 2% Lidocaine can be sipped to anesthetize the patient's pharynx at the physician's discretion or the oropharynx can be sprayed with a topical anesthetic such as Hurricaine Spray.
   
8. Prior to insertion, the insertion distance is obtained by placing the tube along side the patient's nose, to the ear, then down to the xiphoid process. This approximates the length of tube to be inserted and should be marked with tape.
   
9. With the patient's head supported to prevent reflex withdrawal, the tube is inserted toward the floor of the nasal cavity. The tube should never be forced. If passage is not obtained after multiple attempts, the other nostril should be tried.
   
10. Upon passage through the nasal cavity, the tube may encounter resistance (the nasopharynx). To assist passage, the patient can take a sip of water or the tube can be slightly rotated 180 degrees.
    
11. If the tube kinks or enters the mouth during insertion, it should be withdrawn to the nasopharynx, but not removed.
    
12. To gain access to the stomach, the patient should be asked to continually take sips of water through a straw and swallow while the physician is inserting the tube. Insertion should be done quickly once the patient begins to swallow.

Follow-up

• Confirmation of tube placement by one of 5 ways:
  1. The tube lumen is gently suctioned. If gastric contents are withdrawn, then the stomach has been intubated.
     
  2. Ask the patient to hum or talk and if the patient is able, the location is correct.
  3. A 60 ml syringe filled with air is slowly emptied into the tube while auscultating the stomach. A "whooshing" sound is confirmatory for correct placement.
     
  4. Place the open end of the tube into a glass of water. If no bubbles are observed, then the stomach has been intubated.
     
  5. Order X-ray of the chest or flat plate of the abdomen
• When the tube is confirmed to be in the correct position, the tube is secured to the nose with tape.

Complications

• Epistaxis or ulceration and necrosis of the nares
• Esophageal perforation, reflux, esophagitis, esophageal erosion, and stricture
  
• GI tubes interfere with swallowing and GE sphincter competency that can cause aspiration pneumonia Loss of fluids leading to electrolyte imbalances GI bleeding
  
• Choking - indicating tube placement in the trachea
• Sinusitis