Nasogastric Tube Feeding

Nasogastric tube (NGT) feeding is done to improve a patient’s nutritional intake, as well as to sustain their nutritional status. It is a procedure wherein a thin plastic tube is inserted through a patient’s nose, towards the esophagus, and down the stomach. The tube is often short and it is mostly used for suctioning contents and secretions. 

This procedure is often done for patients who are not able to eat or swallow properly, and those who are unable to acquire an adequate oral intake from food and nutritional supplements. It is used to deliver food and medicine directly to the stomach or to obtain substances from it. 

For instance, nasogastric tube feeding is done to patients who suffer from dysphagia, because they are unable to meet their nutritional requirements even with food modifications. 

We cover some important concepts in NGT feeding in this review guide.

What are the different types of tubes?

Nasoenteric tubes

These are tubes that pass from the nostrils into the duodenum or jejunum. Their length ranges from medium to long. Medium length nasoenteric tubes are often used for feeding, whereas the long nasoenteric tubes are used for decompression and aspiration.

Levin tube

The levin tube is a single-lumen multipurpose plastic tube, which is most commonly utilized in nasogastric intubation.

Salem sump tube

Salem sump tubes are double-lumen nasogastric or orogastric tubes that are used for intermittent or continuous suction.

What are the advantages of this procedure?

As mentioned earlier, this technique is used on patients, who are unable to eat and drink,  so that they would still be able to acquire adequate nutrition and medication. In addition, this procedure is much less invasive as compared with surgery, in the event that the intestinal obstruction could easily be eliminated without surgery.

What are the therapeutic indications for nasogastric intubation?

Through the insertion of the tube, a direct connection is made to the stomach and its contents. With this, it is able to alleviate a patient’s condition, one of which is through gastric compression. Suction is attached to the nasogastric tube to aid decompression by eliminating stomach contents. Gastric decompression is used to treat bowel obstruction, paralytic ileus, and surgery on the stomach or intestine. Another is aspiration of gastric fluid content, which may be for either lavage or to acquire a sample for examination. It will also enable drainage or lavage in cases of medication overdose or poisoning. As stated earlier, the technique could help in feeding or administration of drugs. Creating a passage through the gastrointestinal (GI) tract will allow for feeding and medication administration. Nasogastric tubes could also be used for enteral feeding. Lastly, this could also prevent vomiting and aspiration. These tubes can be used in trauma settings to help reduce vomiting and aspiration, as well as to check if there is any GI bleeding.

What are the contraindications of the procedure?

Do not take this procedure if you had a recent nasal surgery or severe midface trauma, due to the possibility that the tube may be inserted intracranially. However, in this case, an orogastric tube may be inserted. Some other contraindications may include recent banding of esophageal varices, coagulation abnormality, esophageal varices, and alkaline ingestion.

What are the possible risks and complications that can be acquired from the procedure?

Like all other procedures, it is important to be aware of the possible complications that may arise from it. Some possible risks/complications related to nasogastric intubation are aspiration, discomfort, trauma, wrong placement, abdominal cramping or swelling from feedings, diarrhea, regurgitation of the food or medicine, tube obstruction/blockage, tube perforation/tear, and tube coming out of place, which could cause further and more severe complications. 

A patient that is conscious may experience a bit of discomfort as the tube is passed through the nostril into the stomach. This may cause gagging or even vomiting. With this, a suction must always be made available in this case. In addition, the wrong placement of the tube into the lungs could be fatal to the patient as food and medicine may pass through the lungs. 

The use of the nasogastric tube must only be for a short period of time, as prolonged usage may result in sinusitis, infections, and ulcerations on the tissue of your sinuses, throat, esophagus, or stomach. 

What are some tips for you to become a pro in starting this procedure?

Take care of your mouth and skin. Apply mouthwash and lubrication to the patient’s lips and nostrils. Lubricate the catheter till it contacts the nostrils using a water-soluble lubricant, since the client’s nose may become itchy and dry.

Check the nasogastric tube placement, and always aspirate a tiny amount of stomach contents to ensure that the nasogastric tube is in the stomach. In fact, an X-ray examination could be done to check the specific location.

Gloves should always be worn when starting an nasogastric intubation due to the increase in the possibility of coming into contact with the patient’s blood or bodily fluids, especially with inexperienced operators Lastly, make sure to wear the proper face and eye protection. 

How do you start a nasogastric intubation?

You will need gloves, nasogastric tube, stethoscope, water-soluble substance (K-Y jelly), protective towel covering for client, emesis basin, tape for marking placement and securing tube, glass of water (if permitted), straw for glass of water, 60-mL catheter tip syringe, rubber band and safety pin, and a suction equipment or tube feeding equipment. It may be necessary to have someone assist you with this procedure.

Patients, unlike the person doing the surgery, do not need to prepare for a nasogastric intubation or feeding. However, before the treatment, a patient may need to blow their nostrils and drink a few sips of water (if permitted). After inserting the tube into the nose, the patient may need to swallow or drink water to help the nasogastric tube pass down the esophagus. Topical anesthetic, used to relieve discomfort and increase the likelihood of successful intubation, has been considered at several institutes. Viscous lidocaine is another approach utilized before the surgery (the sniff and swallow method). It was discovered to considerably minimize discomfort and gagging associated with NG tube placement. Some alternative techniques may include: Nebulization of lidocaine 1% or 4% through a face mask, or an anesthetic spray of benzocaine or a tetracaine/benzocaine/butyl aminobenzoate combination.

The steps for placing a nasogastric tube are outlined below:

Read the doctor’s order and understand the kind, size, and function of the NG tube. For adults, sizes 16 or 18 French are usually accepted, while sizes suited for children range from a very tiny size 5 French for youngsters to a size 12 French for older children. You must also examine the client’s identifying band. It is critical, just as it is when providing pharmaceuticals, to ensure that the operation is performed on the correct client.

Gather the needed equipment and set up the tube-feeding or suction apparatus, to ensure that the equipment is in good working order before utilizing it.

Describe the procedure to the client and assess his capacity to participate. Keep in mind that it is not recommended to discuss the operation too extensively ahead of time since the client’s concern about the treatment may interfere with its success. It is critical that the client remains calm so that he may swallow properly, and comply.

Wash your hands well and put on non-sterile gloves. Since the GI tract is not sterile, a clean, non-sterile method is required.

If feasible, place the client upright or in full Fowler’s posture. Cover the client’s chest with a clean towel. To help the patient swallow better, a full Fowler posture is recommended. It ensures proper neck-stomach alignment, and stimulates peristalsis. To preserve bed linens and the client’s gown, a towel is utilized as a covering.

Measure the tubing from the bridge of the nose to the earlobe, then midway between the end of the sternum and the navel. With the use of a small piece of temporary tape, mark this location or try to remember the distance. Each client’s terminal insertion position will be somewhat different, therefore anatomical measurements must be taken for each individual.

Using a moist cloth, wipe the client’s face and nose, and using an alcohol swab, clean the outside of the nose. If the tube is taped to a clean, non-oily nose, it will be more secure. If the nose has been cleansed with an alcohol swab, the tape will remain in place better and the tube will not wander around in the throat, causing choking or pain later.

Do not forget to use a cloth to protect the eyes of the patient, to ensure that no alcohol fumes from the alcohol swab will enter the eye.

Close one nostril, then the other, and ask the client to breathe through the nose for each effort to check for deformity or blockage. If the client has trouble breathing out of one nostril, try inserting the tube through that one. Keep in mind that if the better nostril stays open, the client may be able to breathe more easily. The obstructed nasal canal may not be completely occluded, allowing you to pass a tube. It may be essential to place the catheter through the more patent nostril.

Apply a water-soluble lubricant to 4 to 8 inches of the tube. For many patients, the intubation is quite painful, thus a squirt of Xylocaine jelly in the nose and a spray of Xylocaine to the back of the throat will help ease the agony.

Tilt the patient’s head forward, lift the tip of the nose, and gently insert the tube through the nose all the way to the back of the throat. Straighten out the tube. Flexing the head facilitates anatomic tube insertion, making the tube less likely to enter the trachea.

Allow the patient to drop his head slightly after the tube reaches the nasopharynx. Request that the helper hold the glass of water, and prepare the tissues and emesis basin. The placement aids the nasogastric tube by allowing it to follow anatomic features. Swallowing water, if permitted, aids in the passage of the nasogastric tube.

Tell the patient to swallow as the tube moves forward. Advance the tube until it reaches the specified point on the tube. Make sure that you advise your patient to breathe through the mouth. In addition, swallowing little sips of water may also aid the tube passage into the stomach, instead of the trachea.

Immediately remove the tube if the patient’s respiratory condition changes, if the tube coils in the mouth, if the patient starts coughing, or if they become cyanotic. In these cases, it is possible that the trachea may contain the tube. 

Remove the tube and try the other nostril if you feel any restriction. The nasogastric may be redirected in the wrong direction by the patient’s nostril. After a little period of recuperation, let the patient try again on the opposite side. 

Move the tube until it reaches the indicated insertion location. Tape the nose and the tube together temporarily, as this allows you to verify the positioning prior to fastening the tube. If the tube is not fastened before being checked for installation, it could move out of place.

Verify that the tube is not curved in the patient’s throat by looking at the rear of the throat. When this happens, the nasogastric curls up in the back of the throat rather than going to the stomach. In this case, visual investigation is required. If this happens, remove the entire tube and start over. 

Use these techniques to verify tube placement. The tube should be checked for proper placement using at least two and ideally three of the following techniques: 

• Aspirate the contents of your stomach. This may appear murky, green, tan, off-white, bloody, or brown in color. Visual distinctions between stomach and respiratory aspirates are not always possible. Keep in mind that aspiration may be challenging due to the narrow diameters of the nasogastric tubes.
• Verify the aspirate’s pH. Visual inspection is thought to be less precise than measuring the aspirate’s pH. The pH range of stomach aspirate is typically 0 to 4, and most often it is less than 4. The aspirate of respiratory contents often has a pH of 7 or higher, making it more alkaline. 
• With the stethoscope, listen for the “whoosh” of air entering the stomach after injecting 30 mL of air there. It could be challenging to hear air entering the stomach due to the narrow diameter of some nasogastric tubes. Confirm location using an x-ray. Only the X-ray visualization technique is regarded as effective. 

After the tube’s insertion in the stomach has been confirmed, tape it down or use a tube holder that has already been made.The tube should be fixed in place to avoid it being accidentally pulled out or advanced by peristaltic action. Moreover, it is crucial to check that the nasogastric tube is positioned correctly within the stomach because if it were to accidentally go into the trachea, it would create severe complications with the lungs. When the process is finished, the nasogastric tube is secure and undamaged.

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Nasogastric intubation is one of the most standard treatments in treating intestinal obstruction, providing adequate nutrition, and stomach decompression. With this, it is important for you as a nurse to master this procedure. Take note of the steps mentioned in this article so that you can be a pro in starting a nasogastric intubation. Good luck!