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What Is Known About Methods of

Correctly Placing Gastric Tubes in
Adults and Children
Marsha L. Cirgin Ellett, DNS, RN, CGRN

n abdominal radiograph is considered the gold standard for

determining the position of flexible small-bore nasogastric/
orogastric tubes. However, placement must be checked

frequently while a tube is in place, and the summative radiation risk of

multiple radiographs, as well as their expense, make the development of
adequate bedside placement-locating methods imperative. Several
methods of detecting tube placement have been investigated in adults,
including: aspirating gastric contents and measuring the pH, bilirubin,
pepsin, and trypsin levels; examining the visual characteristics of aspirate;
placing the proximal end of the tube under water and observing for
bubbles in synchrony with expirations; measuring the carbon dioxide
level at the proximal end of the nasogastric/orogastric tube; auscultation
for a gurgling sound over the epigastrium or left upper quadrant of the
abdomen; and measuring the length from the nose/mouth to the
proximal end of the tube.
Many researchers have already concluded simple auscultation is not a
reliable method to assess tube position because injection of air into the
tracheobronchial tree or into the pleural space can produce a sound
indistinguishable from that produced by injecting air into the
gastrointestinal tract. In adults, only pH and bilirubin of aspirate have
been shown both to reliably predict tube position and to have
inexpensive simple bedside tests. In children, only pH of aspirate has
been shown to be reliable. Research on gastric tube placement in
children is relatively new because children are challenging to study in
that they are considered a vulnerable population.
This review of the literature includes results of both adult and
pediatric studies. Tube placement error rates varied from 1.9% to 89.5%
in adults and between 20.9% and 43.5% in children.

Received May 31, 2004; accepted September 10, 2004.

The author has no conflict of interest.
About the author: Marsha L. Cirgin Ellett, DNS, RN, CGRN, is Associate Professor, Indiana University School of Nursing, Indianapolis.
Correspondence to: Marsha L. Cirgin Ellett, DNS, RN, CGRN, Indiana University School of Nursing, Family Health, Room 439, 1111 Middle Drive, Indianapolis, IN 46202-5107 (e-mail: mlellett@iupui.edu).

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It is estimated approximately 1 million enteral (nasogastric

[NG]/orogastric [OG]/nasointestinal [NI]) tubes are placed
in adults and children in the United States annually
(Metheny, Spies, & Eisenberg, 1986). These numbers reflect
the fact that, in acute care when the gut is functional, feeding by NG/OG/NI tubes is preferred over total parenteral
nutrition (TPN) and gastrostomy, even in the critically ill,
when the need for assisted feeding is expected to be short
term.
Enteral feeding is more physiologic, achieves a positive
nitrogen balance sooner than does TPN (Schroeder,
Gillanders, Mahr, & Hill, 1991; Strong et al., 1992),
enhances gut healing, and reduces bacterial translocation
(Kiyama, Witte, Thornton, & Barbul, 1998; Lipman, 1995;
Van Leeuwen et al., 1994; Zaloga, 1991). Enteral feeding
also is less costly (Jolliet et al., 1999; Zaloga) and is associated with low rates of sepsis (Moore et al., 1992). Even in
adults and children maintained primarily by TPN, small
amounts of nutrients fed into the lumen of the gut through
enteral tubes help to maintain the structure and function of
the small intestine (Bethel et al., 1979; Jolliet et al., 1999).
For many adults and children receiving TPN, as well as others who cannot take food orally, feeding by NG/OG tubes
remains an essential life-saving procedure; therefore, it is
imperative tube feeding be safe.

Review of Literature
This review of the literature is limited to adults and children
having gastric tubes placed for short-term feeding. Many of
the references are old but were cited because they are the
only ones available. When more recent references were
available, they have been cited.

NG/OG Tube Placement Errors

Errors in placement of NG/OG tubes include initial erroneous
placements, as well as displacements over time. Both are
potentially harmful. If a tube is located in the airway, feeding
through the tube will result in pulmonary aspiration or other
pulmonary complications, with subsequent morbidity (and
mortality) (Aronchick, Epstein, Gefter, & Miller, 1984;
Balough et al., 1983; Cardoza & Jeffrey, 1988; Cohen, 1980;
Culpepper, Veremakis, Guntupalli, & Sladen, 1982;
Dobranowski, Fitzgerald, Baxter, & Woods, 1992; Dorsey &
Cogordan, 1985; Harvey, Bull, & Harris, 1981; Treloar &
Stechmiller, 1984; Woodall, Winfield, & Bisset, 1987). Feeding through a tube ending in the esophagus increases the risk
of pulmonary aspiration because of the close proximity of the
feeding formula to the trachea (Ferrer, Bauer, Torres,
Hernandez, & Piera, 1999; Metheny, Eisenberg, Spies, 1986;
Metheny, Stewart, Smith, Yan, Diebold, & Clouse, 1999).
When an NG/OG tube erroneously passes into the duodenum
and the adult or child is fed formula requiring both gastric and
pancreatic enzymes for complete digestion, malabsorption
may occur, resulting in inadequate weight gain (or weight
loss), diarrhea, and possibly dumping syndrome (Allen, 1988;
Heymsfield, Bethel, Ansley, Nixon, & Rudman, 1979).
Previous studies have shown that NG/OG tube placement errors are common. Estimates of the prevalence of
such errors in adults have varied from 1.3% (McWey,
Curry, Schabel, & Reines, 1988) to 89.5% (Niv & AbuAvid, 1988), depending on the definition of error. Lower

254

estimates result when placement error is defined narrowly as

tubes incorrectly placed into the airway or perforating the
gastrointestinal (GI) tract upon insertion (Ghahremani &
Gould, 1986; McWey et al.). Higher rates are found when
error is broadly defined as gastric tubes misplaced in other
ways, such as not in the acid pool when fluid for gastric
analysis was desired (Niv & Abu-Avid; Rombeau & Barot,
1981). Except for two studies done by the author, there have
been no pediatric studies describing the prevalence of
enteral tube placement errors in a clinical setting. In these
two studies conducted in a pediatric teaching hospital, the
respective tube placement error rates were 20.9% and
43.5% when placement error was broadly defined as placement anywhere except where the tube was supposed to be
(Ellett & Beckstrand, 1999; Ellett, Maahs, & Forsee, 1998).
Although the estimates of tube placement errors vary, there
is no doubt that tubes either misplaced on insertion or displaced over time can lead to serious complications.

Detection of Tube Placement Errors

RADIOGRAPHS
Currently an abdominal radiograph provides the only consistently valid and reliable evidence of the position of flexible small-bore NG/OG tubes. Indeed, radiographs have
been recommended by many to determine tube placement in
adults (Biggart, McQuillan, Choudhry, & Nickalls, 1987;
Gharib, Stern, Sherbin, & Rohrmann, 1996; Jackson,
Payne, & Bacon, 1990; Lipman, Kessler, & Arabian, 1985;
Metheny, Spies, & Eisenberg, 1988; Miller, Tomlinson, &
Sahn, 1985; Payne-James, Rees, & Silk, 1987; Stark, 1982;
Walsh & Banks, 1990). However, internal location must be
checked frequently while a tube is in place, and the summative radiation risk from multiple radiographs, as well as
their expense, make the development of adequate bedside
placement-locating methods imperative.

Other Placement-Locating Methods

Determining internal placement must be done at the time
tubes are inserted and on a regular basis while they are in
place (Metheny, 1988). Several methods of detection have
been investigated in adults, including aspirating gastric
contents and measuring the pH, bilirubin, pepsin, and
trypsin levels; examining the visual characteristics of aspirates; placing the proximal end of the tube under water and
observing for bubbles in synchrony with expirations; measuring the carbon dioxide (CO2) level at the proximal end of
the NG/OG tube; auscultation for a gurgling sound over the
epigastrium or left upper quadrant of the abdomen; and
measuring the length from the nose/mouth to the proximal
end of the tube. Each of these methods is discussed in order.
Metheny et al. (1997), Metheny, Stewart et al. (1999), and
Metheny, Smith, and Stewart (2000) found that the combinations of pH, bilirubin, pepsin, and trypsin correctly classified 100% of respiratory placements and 93.4% of GI placements in an adult sample. Gharpure, Meert, Sarnaik, &
Metheny (2000) found a pepsin concentration of

20 mcg/mL and a trypsin concentration 50 mcg/mL was
a good predictor of intestinal placement in neonates. Westhus
(2004) found a mean pepsin level of 215.4 mcg/mL in gastric
placements compared with a mean pepsin level of 24.8
mcg/mL in intestinal placements in children. Conversely, she

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found trypsin levels averaged 10.6 mcg/mL in gastric aspirates and 70.4 mcg/mL in intestinal aspirates. However, no
bedside tests are currently available for measuring pepsin
and trypsin, thus limiting their clinical usefulness.
Metheny, Reed, Berglund, and Wehrle (1994) showed
visual characteristics improved nurses predictions of stomach and intestinal placements but reduced discrimination of
respiratory placements. Placing the proximal end of the tube
under water and observing for bubbles in synchrony with
expirations involves a slight risk that adults or children will
aspirate some of the water on inspiration, especially when
such patients are receiving mechanical ventilation. Measuring CO2 emitted from the proximal end of both the endotracheal tube and the NG/OG tube under research conditions indicates that CO2 monitoring has the potential to
differentiate respiratory from GI placement; however, it has
yet to be used clinically to detect respiratory placements.
Many researchers have concluded simple auscultation is
not a reliable method for assessing tube position because
injection of air into the tracheobronchial tree or into the
pleural space can produce a sound indistinguishable from
that produced by injecting air into the GI tract (Aronchick
et al., 1984; El-Gamel & Watson, 1993; Meguid, Gray, &
Debonis, 1984; Miller & Sahn, 1986; Neumann, Meyer,
Dutton, & Smith, 1995; Silberman & Eisenberg, 1982;
Theodore, Frank, Ende, Snider, & Beer, 1984; Thomas &
Falcone, 1998). Serial measurements of the distance from
the nose/mouth to the proximal end of a tube known by
radiograph to have been correctly placed initially have not
been found to be a reliable indicator of whether or not the
tube has dislodged internally (Metheny, 1988). In conclusion, in adults only pH and bilirubin of aspirate have been
shown both to reliably indicate tube position and to have
inexpensive simple bedside tests available. These two tests
are discussed in detail.
pH OF ASPIRATE
Testing of pH is based on the premise that fluids aspirated
from different organs have different mean pH values.
Metheny et al. (1993) suggested these expected differences
could theoretically be used to test for feeding tube placement errors. Although a major advance over auscultation,
pH testing alone has been found to be an inadequate locator in both adults and children because of overlap in pH
between sites, difficulty in obtaining aspirate, and other factors affecting pH readings (Ellett & Beckstrand, 1999;
Metheny, Stewart et al., 1999).
OVERLAP IN pH BETWEEN SITES
In a study of 800 aspirates collected from 605 fasting adults,
Metheny, Stewart et al. (1999) found gastric aspirates had
significantly lower pH values than did intestinal aspirates
(mean  3.5 versus 7.0). However, about 15 % of the gastric aspirates had equivocal pH values (more than 6.0) that
overlapped with the pH readings of intestinal aspirates. In
addition, the range of pH values obtained from four tubes
inadvertently placed in the respiratory tract overlapped the
range in intestinal placements. In addition, it is possible that
an aspirated fluid with an acid pH
4 could be obtained
from the bronchial tree after an unsuspected aspiration of
gastric contents (Harris & Huseby, 1989; Widmann, 1987;
Winterbauer, Durning, Barron, & McFadden, 1981).

VOLUME 27

NUMBER 6

In previous pediatric studies, the accuracy of pH testing

also was questionable because of overlap in pH between
sites. Jarczyk (1994), in a study of children
2 years of age,
was able to aspirate fluid from five of six gastric tubes and
found aspirate pH was
4 in all of the five children.
Although not stated, the children were probably fasting.
Pate (1998) obtained sufficient aspirate for pH testing from
100% of 49 tubes in critically ill children (neonate to adolescent), most of whom were fasting. Of the 23 (46.8%)
tubes placed in the stomach, all had pH values of 4.5 to 5.0.
Of the 30 (61.2%) tubes placed beyond the pylorus, all had
pH values between 6.0 and 7.5. The one tube placed in the
esophagus had a pH value of 7.5. There were no respiratory
placements. In this study, there was no overlap in the pH of
aspirates between gastric and intestinal placements; however, there was overlap between the esophageal and intestinal placements. Metheny, Eikov, Rountree, & Lengettie
(1999) found the mean gastric pH to be 4.3, compared with
a mean intestinal pH of 7.8, in 90 aspirates from 39 acutely
ill neonates. In a recent study of 56 children, Westhus (2004)
found the mean gastric pH to be 4.1 (n  49, range 
1.28.3), compared with a mean intestinal pH of 7.5 (n 
7, range  5.98.2). In summary, although there are mean
pH differences related to location, the large within-group
differences and the effects of acid-inhibiting medications
limit the usefulness of using this method alone for individual cases.
DIFFICULTY IN OBTAINING ASPIRATE
It may be impossible to obtain any aspirate, even when the
tube is properly positioned in the GI tract if one or more of
the orifices are not in a pool of fluid. Furthermore, aspiration
of fluid may be difficult because flexible small-bore tubes
tend to collapse when negative pressure is applied with a
syringe (Crocker, Krey, & Steffee, 1981; Orr, Shinert, &
Gross, 1981; Rombeau & Barot, 1981); therefore, the
absence of fluid is not necessarily evidence of improper
placement.
Theoretically, the inability to aspirate fluid is expected to
be more likely to occur in children because the tubes are
smaller in diameter than those used in adults and thus are
more likely to collapse. By first insufflating as much as 30
milliliters (mL) of air, Metheny and coworkers (1989) were
able to aspirate sufficient fluid for pH testing from 92.5%
of NG and 91.8% of NI tubes in adults. Others have been
less successful in obtaining tube aspirate. Welch, Hanlon,
Waits, and Foulks (1994) attempted to obtain aspirate after
injecting 60 mL of air to indicate a change in tube position
from gastric to intestinal. In their study (n  106 adults) of
the ability to document a change in pH from
4 to 6, only
one third of subjects produced aspirates from tubes inserted
to estimate both prepyloric and postpyloric lengths.
With respect to obtaining aspirate in children (1 week to
13 years of age, mean  20.4 months, median  4.8
months), Ellett and Beckstrand (1999) showed that injection
of 1 mL (infants) to 5 mL (adolescents) of air in multiport
tubes was sufficient to aspirate fluid from 88.2% of gastric
tubes and 78.6% of intestinal tubes. However, among the
small number of tubes from which no aspirate could be
obtained, 87.5% were in children
100 months of age,
suggesting the possibility that obtaining aspirate may be
more difficult in young children. In summary, the research

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evidence suggests the inability to obtain aspirate in many

cases further limits reliance on pH testing alone to indicate
tube location.
OTHER FACTORS AFFECTING pH READINGS
In infancy, the stomach is pear shaped and lies in a transverse position. Infants also have rapid transit times and
small stomach capacities. Not until the age of 7 years does
the shape and position of the stomach and the transit time
through the GI tract approximate that of the adult stomach
(Metheny et al., 2000). Currently, very little is known about
how the differences between adults and young children (
7
years) may affect testing for gastric tube location.
Other factors reducing the usefulness of pH testing in
adults also can occur in children, including administration
of gastric acid-inhibiting medications resulting in an elevated gastric pH; administration of TPN (Metheny, 1988);
and decreased acid secretion in young infants. For example,
in one study, Metheny et al. (1993) found gastric aspirates
from adults receiving acid-inhibiting medications had higher
pH values (mean  3.8) than did those from adults not
receiving such medications (mean  3.1). About 18% of the
gastric aspirates from adults receiving acid-inhibiting medications had pH values 6, compared with 11% in adults
not receiving them.
In a recent study of fed adults, Metheny and Stewart
(2002) suggested tube aspirate with a pH
6 was likely in
the stomach and with a pH of 6, was likely in the intestine. Westhus (2004) found a mean pH of 3.3 in children
not receiving acid-inhibiting medications and a mean pH of
5.0 in children receiving acid-inhibiting medications. On the
other hand, in a second pediatric study of 96 GI aspirates
(Gharpure et al., 2000), the use of acid-inhibiting medications in 53 of the 96 aspirates (55.2%) did not significantly
alter the pH of gastric aspirates (means  4.6 versus 4.4) or
of intestinal aspirates (means  6.8 versus 6.9).
Hyman, Feldman, Ament, Byrne, and Euler (1983) studied 14 infants with a history of intestinal disease (mean age 
9.6 months) fed exclusively by TPN and found these infants
secreted only 37% of the basal gastric acid output of both
26 normal infants receiving oral feedings and 11 infants,
also with a history of intestinal disease, receiving a combination of enteral feedings and TPN. Likewise, De Angelis
and co-researchers (1988) studied seven infants receiving
only TPN and found their maximal gastric acid output after
pentagastrin stimulation was significantly less than that of
14 infants receiving enteral feedings. Decreased acid output
would have the effect of increasing gastric pH. In addition,
it is routine practice to add an acid-inhibiting medication to
TPN for ulcer prophylaxis in both adults and children. This
practice would further increase the pH of gastric contents in
young children.
A final complicating factor is that gastric pH does not
decrease to adult levels until infants are 3 to 4 months of age
(Nord, 1989); therefore, it would be even harder to differentiate gastric from intestinal aspirate. In conclusion,
because of the overlap in obtained pH values for respiratory,
gastric, and intestinal placements; the inability sometimes to
obtain tube aspirate to test pH; and the possible effect of
anatomical differences, acid-inhibiting medications, TPN,
and physiologic immaturity in young infants on the pH of
aspirate, it appears pH alone is not likely to be a reliable

256

method for discriminating among gastric, intestinal, and

respiratory placements. Furthermore, these problems may
be worse in children than adults. Joint measurement of
bilirubin and pH may be a possible alternative to the use of
pH alone.
JOINT BILIRUBIN AND pH TESTING OF ASPIRATE
Metheny et al. (2000) recommend the bilirubin level and pH
of aspirates be jointly used as tests to help differentiate gastric, intestinal, and respiratory placement of tubes. They
measured bilirubin and pH of aspirates from NG and NI
tubes (328 and 303, respectively) obtained from fasting
acutely ill adults who then immediately received radiographs to determine tube placement. They also tested levels in 225 tracheobronchial suction and 24 pleural fluid
aspirates. Mean bilirubin levels differed in the predicted
way: 0.09 mg/dL (tracheobronchial/ pleural), 1.28 mg/dL
(stomach), and 12.73 mg/dL (intestine) (Metheny, Stewart
et al., 1999).
In the only previous study of bilirubin levels in children,
Metheny, Eikov, et al. (1999) found very little bilirubin
(mean 0.35  0.10 mg/dL) in the gastric fluid of neonates.
This was comparable to the levels reported for adults. The
pH/bilirubin test was highly sensitive in adults to respiratory placement; it correctly identified 100% of actual respiratory aspirates. However, the test had lower specificity for
respiratory placements and correctly identified only 85.9%
of actual nonrespiratory aspirates. Furthermore, the predictive validity of the test was problematic for respiratory
placements. Only 50 of 170 (29.4%) predicted respiratory
aspirates were actually respiratory (positive predictive value
 29.4%), with 120 (70.6%) mistakenly predicted as being
respiratory placements. The negative predictive value was
87.7%, indicating 87.7% of true nonrespiratory placements
were accurately predicted to be nonrespiratory. In the recent
study of fed adults, Metheny and Stewart (2002) suggested
a bilirubin concentration of 5 mg/dL was a good predictor
of intestinal tube placement, whereas a bilirubin concentration of 5 mg/dL was a good predictor of gastric tube
placement, irrespective of whether or not the adult was
fasting.
Bilirubin can be easily measured at the bedside using the
method developed by Metheny, Smith, and Stewart, in which
reagent strips are compared to a color scale. N-Multistix SG
reagent strips for urinalysis are used with a modified color
scale developed specifically for assessing bilirubin concentration in gastrointestinal secretions and provided by Metheny
et al. (2000) for research purposes. These methods are
expected to perform equally well in fasting children as in
fasting adults but have not been adequately tested. Because
of the previously described problems related to pH testing in
children, there is a critical need to accurately determine the
performance of these bilirubin-testing methods in children.
DETECTION OF CO2
There are currently two ways of measuring CO2 for detecting respiratory placement: CO2 monitoring providing a continuous reading of the CO2 concentration changes in
expired air and a respiratory waveform, and a colorimetric
CO2 indicator device in which there is a rapid color change
from yellow to purple at a CO2 level of 15 mmHg. CO2
monitoring is more accurate than the colorimetric device.

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Both ways are commonly used to verify endotracheal tube

placement because air emanating from an endotracheal
tube misplaced in the esophagus contains little CO2 compared with air emanating from tubes properly placed in the
trachea.
The CO2 method for detecting feeding NG tube placement has been tested in adults in only two studies. In 10 critically ill adults, Thomas and Falcone (1998) found the colorimetric CO2 indicator device attached to the proximal end
of a small-bore feeding tube reliably discriminated between
tubes passed into the airway and those passed into the stomach. In the Thomas and Falcone study, the CO2 concentration was used in the reverse manner to rule out respiratory
placement of NG tubes by demonstrating the absence of
CO2 within the feeding tube lumen in mechanically ventilated trauma patients who served as their own controls. All
10 adults had a rapid color change from yellow to purple
when the colorimetric apparatus was inserted 1 cm past the
distal end of their endotracheal tubes, and none of them had
a color change when the device was attached to their NG
tubes (sensitivity 100% and specificity 100% for ruling out
respiratory placements). The NG tubes were subsequently
shown to be in the stomach by radiograph.
In a second study, Burns, Carpenter, and Truwit (2001)
tested the ability of CO2 monitoring to prevent inadvertent
placement of small-bore tubes into the lungs in 25 ventilated, critically ill adults. A CO2 monitor was attached to
the tube during insertion. In this study, a CO2 level of 15
mmHg or a respiratory waveform denoted respiratory
placement (4/4, 100%), whereas the absence of CO2 and
respiratory waveforms indicated the tube was not inadvertently in the respiratory tract (21/21, 100%). Inadvertent
(unsuspected) enteral tube placement into the respiratory
tract is estimated to occur 5% of the time (Harris &
Huseby, 1989); however, the adult or child show no symptoms, so the morbidity/mortality resulting from this placement error can be very serious. Thus, CO2 monitoring has
the potential for detecting unsuspected respiratory placements; however, the reliability and validity of testing with a
CO2 monitor in children needs to be determined.
In children, the need for a free flow of CO2 to effect a
color change may hamper use of the colorimetric CO2 indicator device because if an NG/OG tube is lodged in a small
airway, a lack of color change may falsely indicate GI tube
placement. In addition, gulping of a mixture of inspired and
expired air in the stomach, which occurs frequently in children who are crying, may cause some CO2 to be present.

What We Know and What We

Do Not Know
In summary, the high tube placement error rates indicate
enteral tube feeding is unsafe. Measuring pH is a promising
method for determining tube position in both adults and
children. Adequate amounts of aspirate to measure pH have
been obtained in a large percentage of cases in research
studies. In addition, important information related to selecting a pH value to use as a cutoff has been obtained. Study
results suggest a pH
5 in fasting adults and children differentiates gastric from esophageal and intestinal placements; however, a pH  5 does not appear to be able to differentiate intestinal or esophageal from gastric placements.

VOLUME 27

NUMBER 6

Adequate amounts of aspirate to measure bilirubin were

obtained in slightly fewer cases in research studies and were
shown in adults to be helpful in differentiating intestinal
and esophageal from gastric placements. Bilirubin has not
been adequately tested in children. Finally, the use of CO2
monitoring has the potential to differentiate respiratory
from nonrespiratory tube placement; however, it has not
been adequately tested in either adults or children.

What is the Current Best Evidence

for Practice?
At the time a gastric tube is inserted in an adult or child,
placement should be determined at the bedside by aspirating
fluid and testing pH. In both adults and children, if the pH
is
5, the tube can be presumed to be in the stomach. In
children, if the pH is 5, the nurse should request an
abdominal radiograph to determine tube location because
bilirubin has not been adequately tested as an accurate indicator of tube placement. In adults, as soon as the modified
color scale becomes commercially available, if the bilirubin
is  5 mg/dL, the tube can be presumed to be in the intestine; however, if the pH is 5 and the bilirubin is 5 mg/dL,
the nurse should request an abdominal radiograph to determine tube location.

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