How to Perform Nasogastric Intubation

• Indications:
  • Acute gastric dilatation
  • Gastric outlet obstruction
  • Upper gastrointestinal bleeding
  • Ileus
  • Small bowel obstruction
  • Enteral feeding

• Contraindications:
  • Recent esophageal or gastric surgery
  • Head trauma with possible basilar skull fracture
• Anesthesia:
  None or viscous lidocaine in the nose
• Equipment:
  • Levin or Salem sump tube
  • Water-soluble lubricant
  • Catheter-tip syringe (60 ml)
  • Cup of ice
  • Stethoscope
  • Cup of water with a straw
• Positioning:
  Sitting or supine
• Technique:
  • Measure tube from mouth to earlobe and down to anterior abdomen so that last hole on tube is below the xiphoid process. This marks the distance that the tube should be inserted.
  • Some surgeons will place tip of tube in cup of ice to stiffen it or bend the tip downward to facilitate the tube's passage into the proximal esophagus.
  • Apply lubricant liberally to tube.
  • Ask patient to flex neck, and gently insert tube into a patent naris.
    
  • Advance tube into nasopharynx aiming posteriorly, asking the patient to swallow if possible.
  • Once the tube has been swallowed, confirm that the patient can speak clearly and breathe without difficulty, and gently advance tube to estimated length. If the patient is able, instruct him or her to drink water through a straw; while the patient swallows, gently advance the tube.
  • Confirm correct placement into the stomach by injecting approximately 20 ml of air with catheter-tip syringe while auscultating epigastric area. Return of a large volume of fluid through tube also confirms placement into stomach.
  • Carefully tape tube to the patient's nose, ensuring that pressure is not applied by tube against naris. Tube should be kept well lubricated to prevent erosion at naris. With the use of tape and a safety pin, the tube can be secured to the patient's gown.
  • Irrigate tube with 30 ml of normal saline every 4 hours. Salem sump tubes will also require the injection of 30 ml of air through the sump (blue) port every 4 hours to maintain proper functioning.
  • Constant low suction may be applied to Salem sump tubes, whereas Levin tubes should have only low intermittent suction.
  • Monitor gastric pH every 4–6 hours and correct with antacids for pH < 4.5.
  • Monitor gastric residuals if tube is used for enteral feeding. Obtain a chest radiograph to confirm correct placement before using any tube for enteral feeding.
  • The tube ideally should not be clamped because it stents open the lower esophagus, increasing the risk of aspiration if the patient's stomach should distend.
  • Complications and Management:

    • Pharyngeal discomfort
      • Common due to the large caliber of these tubes.
      • Throat lozenges or sips of water may provide relief.
      • Avoid using aerosolized anesthetic for the pharynx because this may inhibit the gag reflex, interfering with the protective mechanism of the airway.
    • Erosion of the naris
      • Prevented by keeping tube well lubricated and ensuring that tube is taped so that pressure is not applied against naris. Tube should always be lower than the nose and never taped to the forehead of the patient.
      • Frequent checking of the tube position at the naris can help prevent this problem.
    • Sinusitis
      • Occurs with long-term use of nasogastric tubes.
      • Remove the tube and place in other naris.
      • Antibiotic therapy if needed.
    • Nasotracheal intubation
      • Results in airway obstruction that is fairly easy to diagnose in the awake patient (cough, inability to speak).
      • Obtain a chest radiograph to confirm placement prior to use for enteral feeding.
    • Gastritis
      • Usually manifests itself as mild, self-limited upper gastrointestinal bleeding.
      • Prophylaxis consists of maintaining gastric pH > 4.5 with antacids via the tube, intravenous (IV) histamine₂ receptor blockers, and removal of tube as soon as possible.
    • Epistaxis
      • Usually self-limited.
      • If persists, remove the tube and assess location of bleed.
      • Refer to Chapter 1 for treatment of anterior and posterior epistaxis.