Nasogastric tube insertion is performed in the hospital setting for a variety of indications, including enteral feeding. The actual process of nutrients passing through the gastrointestinal (GI) tract appears to stimulate a complex series of responses that affect immunologic integrity. There is a lower incidence of infection, multiorgan failure, and mortality associated with enteral feeding than with total parenteral nutrition (TPN). Feeding tubes will not prevent microaspiration from oropharyngeal contents in cognitively impaired patients (see Table 123-1).
Although relatively simple to perform, it is probably one of the most uncomfortable procedures for the hospitalized patient and carries with it a risk of potentially life-threatening complications. It is crucial to take the necessary steps to ensure patient comfort, obtain a CXR for confirmation of correct placement of the tube, and to take a few simple measures to reduce aspiration risk during enteral feeding (see Table 123-2).
Chest radiograph showing properly placed nasogastric feeding tube with tip visible below the diaphragm.
Table 123-1Basic Considerations ||Download (.pdf) Table 123-1 Basic Considerations
Drain gastric contents
Prevent aspiration of stomach contents
Decompress GI tract proximal to obstruction
Administer medications in patients who are NPO
Provide enteral feeding
Prior to Insertion
Is this indicated?
Will the patient be able to cooperate?
Does the patient have risk factors for misplacement of NG tubes?
What type of feeding tube is required?
Who will perform the procedure?
Nutritional support cannot be provided in complete obstruction
Comatose patients require prior intubation because the procedure may precipitate vomiting and aspiration
Risk factors for misplacement (especially tracheobronchial tree):
Altered mental status, sedation
Recent prolonged endotracheal intubation (due to ↓airway reflexes)
Patient s/p radiation therapy for head and neck cancer may not be able to swallow due to edema, mucositis, abnormal anatomy, and sensation
Severe maxillofacial trauma
Repair of choanal atresia and transnasal transphenoidal surgery
↑risk of perforation due to esophageal abnormalities (recent ingestion of caustic substances, strictures, diverticula)
Prior pulmonary complication from NG tube placement
Altered mental status and/or sedation
Types of Feeding Tubes
A large tube inserted blindly through patient’s nose until its tip lies ∼10 cm below the GE junction
Postpyloric Dobhoff Tubes
Nasoduodenal/nasojejunal small-bore feeding tubes
may require endoscopic placement for tube to go beyond pyloris by GI or IR; flexible transnasal endoscopes can pass small-diameter (5-6 mm) feeding tubes over a guide wire with simultaneous gastric decompression via double-lumen
Percutaneous or surgical placement
Endoscopic or surgical placement
Can be rapidly inserted at the bedside in the following settings: drug overdose, poisoning;
trauma; acute stroke, other neurologic states;
severe UGI bleeding in preparation for endoscopic visualization; gastric motor failure, partial small bowel obstruction, postoperative ileus, palliation in metastatic cancer...