CHAPTER 217

Nasogastric and Nasoenteric

Tube Insertion and Removal
Yong Sik Kim

Nasogastric tube insertion is a common procedure performed in the

hospital and emergency department; it is also occasionally performed
Anatomy
in the office setting. The nasogastric tube was initially developed The nasal cavity is lined by highly vascularized and innervated
for gastric feeding in 1760. The indications were expanded to gas- mucosa and continues posteriorly as the nasopharynx. Within the
tric lavage in the case of poisoning in the early 1800s. One current nasal cavity are the superior, inferior, and middle nasal conchae
design, by Dr. Levin, became available in 1921, and soon became (turbinates), which divide the cavity into four passages (Fig. 217.4),
popular for preventing intraoperative and postoperative gastric dis- the meatuses. Traditionally, the nasogastric tube is inserted blindly
tention. In the 1960s, improved technology allowed the manufac- through the middle or inferior meatus. Beyond the nasal cavity, the
ture of a double-lumen tube; later developments include special soft pharynx extends from the base of the skull to the inferior border of
tubes made of polyurethane and silicone. These later tubes are also the cricoid cartilage. It is divided into three parts: the nasopharynx,
very thin and have a noncomplicated, smooth surface—useful char- oropharynx, and laryngopharynx (hypopharynx). The nasopharynx
acteristics for prolonged nasoenteric feeding. gives rise to the oropharynx at the level of the soft palate, which
A nasogastric tube can be used for either diagnostic or therapeutic then gives rise to the laryngopharynx (hypopharynx) at the superior
purposes. The Levin nasogastric tube is a firm, straight, single-lumen border of the epiglottis (see also Chapter 64, Nasolaryngoscopy, Fig.
tube with multiple distal side ports, and is used predominantly for 64.6). The laryngopharynx becomes continuous with the esophagus
diagnostic aspiration or to instill materials into the stomach. Unfor- at the inferior border of the cricoid cartilage. The posterior part of
tunately, even when low–flow-rate suction is applied to a Levin tube, the upper nasopharynx is surrounded by the cribriform plate and the
or if it is applied for a very long time, the lumen frequently becomes body of the ethmoid and sphenoid bones, which can easily be bro-
occluded with gastric mucosa. This can damage the gastric mucosa. ken by a traumatic blow to the midface, resulting in a maxillofacial
In contrast, the Salem nasogastric sump tube is a double-lumen tube.
The second lumen, or vent lumen, is smaller than the main suction
lumen and runs alongside the larger lumen, providing a low level of Air vent pigtail (may be used CROSS
continuous airflow to the stomach. This airflow prevents the main as cap for suction lumen SECTION
when tube is not in use) Vent
lumen from becoming occluded by gastric mucosa, thereby minimiz-
lumen
ing the risk of damage (Fig. 217.1). The blue “pigtail” on the Salem
sump is an extension of this vent lumen (Fig. 217.2). Similar to the Suction drainage
Levin tube, the Salem sump has multiple distal side ports. Antireflux Air lumen
valves are available to prevent gastric contents from leaking out of
the vent lumen. Multiport adapters are available for the proximal end
so that the same tube can be used for feeding, irrigating, suctioning,
or medicating. Even though the Levin tube is still manufactured and
available, hospitals predominantly stock the Salem sump tube because
it can be used for most applications, is more effective, and is safer. 5-in-1 Depth Sentinel Drainage
adapter marking eye bisects eyes
Salem sump tubes are usually clear, yet radiopaque, and made of sentinel line
polypropylene or silicone, whereas Levin tubes are available in vari- A
ous versions, including red rubber and clear polypropylene. Levin
tubes can be either radiopaque or radiolucent. Although both can
be used for short-term (up to 4 weeks) gastric or nasoenteric feeding,
polypropylene is too rigid for long-term use, so most facilities now Suction drainage
have the longer and smaller-diameter polyurethane tubes specially Vent lumen lumen
designed for this purpose (Fig. 217.3). These softer tubes (especially
softer at body temperatures) usually have a tungsten-weighted tip or
balloon near the tip to facilitate passage beyond the pylorus. They
may also have a stiffening wire or stylet available for use during inser-
tion; many have been designed to resist collapse when checking the
gastric residual. Other styles of tubes include those equipped with a Gastric contents
large esophageal balloon that can be used to tamponade a bleeding B
esophageal lesion (e.g., esophageal varices). Larger gastric tubes are Fig. 217.1  Diagram of the Salem sump tube. (A) General design. (B)
also available for gastric lavage (see Chapter 209, Gastrointestinal Diagram of the double lumen principle for suction. (Courtesy Covidien
Decontamination). Medtronic, Dublin, Ireland.)

1446
Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
 217 –––– NASOGASTRIC AND NASOENTERIC TUBE INSERTION AND REMOVAL 1447

Fig. 217.2  Sump suction (Salem) tube. (Courtesy Covidien Medtronic,
Dublin, Ireland.)
Fig. 217.3  Feeding nasogastrostomy tube with weighted, radiopaque
tip. (COMPAT Nasogastric Tube, courtesy Nestlé Nutrition, Minnetonka, MN.)
or basilar skull fracture. Such fractures can create a route into the
cranial vault, which is a prerequisite for one of the most disastrous
complications of inserting a nasogastric tube, intracranial intuba-
tion. This can result in brain damage or death. Therefore, placement
of a nasogastric or nasoenteric tube in a patient with a possible skull
or maxillofacial fracture should be avoided, if possible (an orogastric
route may be a better option).
Beyond the laryngopharynx and the larynx, the trachea lies ante-
rior to the esophagus at the level of the cricoid bone and is supported
by fibrocartilaginous tracheal rings. The superior aperture is covered
by the epiglottis of the larynx during swallowing.
Editor’s note: Knowing whether the patient has had bariatric
surgery is important, because the anatomy may have been changed.
Normally the stomach wall is thick and there is plenty of room to
accommodate even an extra loop of nasogastric tube. However, the
gastric pouch may have been significantly reduced; the intestinal
wall is also very thin. (Van Dinter reported a case of late intestinal
perforation [9 years] after a Roux-en-Y gastric bypass.) So, prefer-
ably, the clinician will know what type of bariatric procedure was
performed. At a minimum, the clinician should proceed with cau-
tion. If a band is in place, more resistance may be encountered with
nasogastric tube insertion. If the surgery is recent, consultation with
the surgeon should be considered.
Knowing the anatomy also confers the ability to estimate the
length of tube that should be inserted. Because the median distance
from the anterior aspect of the nasal septum to the cricopharyn-
geus muscle (tracheoesophageal junction) is about 8 inches and the
esophagus is on average about 10 inches long, and given that the
tip of a nasogastric tube should lie 4 inches below the gastroesopha-
geal junction when in place, the nasogastric tube should ideally be
secured at the 20- to 24-inch mark at the nasal vestibule. Alterna-
tively, the distance can be approximated by holding the tube up to
the patient’s ear and across to the nose, and then extending it to
the xiphoid process and adding 6 inches (adding 8 to 10 inches for a
nasoenteric tube; described later in the “Technique” section).
The anatomy of children regarding the insertion of a nasogas-
tric tube warrants a special note. Children have larger tonsils and
adenoids, and their tongues are large compared with adults and may
push into the oropharynx; all of this can hamper the insertion of

Frontal air sinus

Nasal bone Sphenoidal
Superior concha air sinus
Middle concha Pharyngeal
Opening of auditory tonsil (adenoids)
(eustachian) tube Nasopharynx
Inferior concha Uvula
Hard palate Palatine tonsil
Soft palate Oropharynx
Tongue Epiglottis
Lingual tonsil Laryngopharynx
Hyoid bone
Thyroid cartilage
(part of larynx)
Vocal cords Esophagus
Trachea
Fig. 217.4  Pharyngeal anatomy: sagittal section
of the head and neck. (From Thibodeau C, Patton KT.
Structure and Function of the Body. 11th ed. St. Louis:
Mosby; 2000.)

Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
1448 HOSPITALIST
a tube. At the same time, these tissues are soft and easily injured,
thereby increasing the risk of bleeding with nasogastric intubation.
Limiting the size of the tube to the smaller sizes of the nostrils and
nasal cavity in children usually minimizes the difficulty with inser-
tion, as well as tissue damage, despite these anatomic differences.
See the “Equipment” section to estimate size for nasogastric tubes
in children.  • Tongue depressor
Indications
Therapeutic
• D  rainage of gastric contents/gastric decompression. Examples
include small bowel or gastric outlet obstruction, paralytic il-
eus, upper gastrointestinal bleeding, refractory vomiting, severe
pancreatitis with obstruction, gastric lavage (for drug overdose),
prevention of aspiration, or before diagnostic peritoneal lavage
or pericardiocentesis.
• Instillation of feedings or medications for patients unable to take
by mouth (e.g., nutritional supplements, activated charcoal for
drug overdoses).
Note: In patients with upper gastrointestinal hemorrhage, extended
irrigation of the stomach with water can result in hypokalemia; ani-
mal studies suggest that cold water lavage can cause rather than con-
trol the bleeding. 
Diagnostic
• S  ampling gastric contents (e.g., gastrointestinal bleeding, myco-
bacterial infection)
• Instillation of diagnostic agents (e.g., radiopaque contrast media
for delineation of a transdiaphragmatic hernia, air inserted to as-
sess for an intraperitoneal perforation)  
Note: The fecal Hemoccult should not be used to test for occult
blood in gastric contents; instead, the Gastroccult card uses a devel-
oper that neutralizes pH, rendering it able to detect hemoglobin.  • Soft nasal trumpet airway (optional)
Contraindications
All the following contraindications are relative:
• Facial fractures, especially midface, or basilar skull fractures with
possible cribriform plate injuries (may result in intracranial intu-
bation; orogastric intubation may be a better option)
• Esophageal obstruction, strictures, or a history of alkali ingestion
(increases the possibility of esophageal perforation)
• Esophageal varices (may lead to rupture and uncontrollable hem-
orrhage)
• Comatose patients without protected airways (increases the risk
of aspiration)
• Penetrating neck wounds in the awake trauma victim (gagging
might stimulate increased bleeding from the wound)
• Choanal atresia
• Recent oropharyngeal, nasal, or gastric surgery (especially bariat-
ric surgery, consider consultation with the surgeon)
• Zenker diverticulum
• Percutaneous endoscopic gastrostomy tube indicated (see Chap-
ter 92, “Percutaneous Endoscopic Gastrostomy Placement and
Replacement”)
• Severe coagulopathy (orogastric intubation may be a better op-
tion)
• Tube feeding in patients with advanced dementia (there is little
evidence that the outcome will be improved)
  
Previous bariatric surgery is not a contraindication; however,
it may be helpful to know the type of bariatric surgery performed.
Clinicians inserting a nasogastric tube should be somewhat familiar
with the resultant anatomy and proceed with caution.  they are not able to swallow, mimicking swallowing or saying “eeee”
Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Equipment and Supplies
•  loves, mask, goggles, and an impervious gown
G
• Towel or surgical Chux for covering patient’s clothing
• Paper tissues
• Emesis basin
• Nasogastric tube (For adults, use a 16- or 18-Fr Salem sump [with
antireflux valve, if possible] or Levin tube. Use 10- to 12-Fr tube
for smaller children, 12- to 14-Fr for larger children, or use for-
mula [age in years+16]/2.)
• For nasoenteric feeding tubes (5 to 12 Fr). Larger tubes (12 Fr)
should be used for shorter periods because they are less comfort-
able and more likely to become occluded than smaller tubes (5 to
8 Fr).
• Tincture of benzoin
• Hypoallergenic tape (e.g., Hy-Tape), NG Secure, or NG Strip
• Stethoscope
• Large (60-mL) syringe with catheter tip (Toomey)
• Suction equipment
• Cup of water with drinking straw
• Decongestant such as phenylephrine (0.25% to 2%) spray (Neo-
Synephrine, Vicks), oxymetazoline hydrochloride 0.05% spray
(Afrin, Neo-Synephrine 12 hour), or ephedrine 3%
• Water-soluble lubricant gel (Surgilube) or 2% lidocaine gel (Xy-
locaine Jelly)
• Topical anesthetic spray such as benzocaine (Hurricaine) or tet-
racaine hydrochloride (Cetacaine), or both. Topical cocaine is
an option, and it works as both a decongestant and anesthetic.
However, its use may be a problem if the patient must undergo
drug testing. In addition, purchase and storage by clinician or
hospital requires significant record-keeping and may increase the
risk of theft.
• Laryngoscope for difficult insertions
• pH indicator strips with 0.5 gradations or paper with a range of 0
to 6 or 1 to 11
 
Preprocedure Patient Preparation
Although the insertion of a nasogastric tube is a common and fairly
simple procedure, serious complications can occur. The risk for com-
plications can be minimized by taking a few precautions: obtaining
the full cooperation of the patient, informing the patient carefully at
each step of the process, using a decongestant and local anesthesia
for the nasal and retropharyngeal mucosa, premeasuring and mark-
ing the length of the tube needed for insertion, using gentle tech-
nique during insertion, and carefully confirming that the tube is in
the proper position before use.
To have a nasogastric tube inserted into them is considered by
many patients to be one of the most uncomfortable and distressful
procedures they have ever experienced. Although most hospitals do
not require written informed consent, the risks, benefits, indications,
and any possible alternatives should be explained to patients. Even
with the use of decongestants and anesthetics, patients should be
prepared for some discomfort. The unpleasant nature of the proce-
dure should not be minimized.
Patients should know that their eyes may water and they may
have some tearing. They may have an intense tickling sensation or
an urge to sneeze. During insertion, they may experience a gagging
sensation. (Some clinicians premedicate with ondansetron 4 mg or
metoclopramide 10 mg intravenously 5 minutes before the proce-
dure, although there is scant evidence supporting this intervention.)
Swallowing rapidly will minimize this response and shorten the total
length of the procedure. At some point during the procedure, they
will probably be asked to assist by sniffing or later by swallowing.
To help them swallow, give them a glass of water and a straw. If
 217 –––– NASOGASTRIC AND NASOENTERIC TUBE INSERTION AND REMOVAL 1449

may help. Patients should be reassured that after the tube has been
placed, they will usually adapt to it very soon and no longer notice it.
Before nasogastric tube removal, the patient should be informed
of the procedure and what to expect. Towels, surgical Chux, or other Add 6˝ and
drapes should be placed around the patient’s neck and chest. He or 8˝
mark 20–24˝
she should be handed an emesis basin and tissues. 

Technique
Observe universal blood and body fluid precautions during the pro-
cedure. Wear gloves, goggles, a face mask, and an impervious gown.
  
1. Elevate the head of the bed into a high Fowler (sitting) or semi-
Fowler position. Rest the back of the patient’s head on a pillow 10˝
or directly on the bed for support. The patient’s clothing needs
to be protected with a towel or surgical Chux. An emesis basin
should be available on the patient’s lap.
2. Check for a clear nasal passage. Various conditions may cause
asymmetric nostril openings—for example, septal deviation, na-
sal polyps, septal spurs. So examine both nostrils to determine
which is the largest and most open. You can also watch the pa-
tient inhaling through his or her nose to determine which nos-
Xiphoid
tril is more open. process
3. After the application of a nasal decongestant such as phenyle-
phrine, oxymetazoline, or ephedrine, adding a topical anesthetic Fig. 217.5  Measuring the length of nasogastric tube for placement into
usually increases the patient’s comfort. Although this procedure stomach.
is usually brief, application of the decongestant before the an-
esthesia usually results in the anesthesia lasting longer. The de-
congestant may also minimize damage to the nasal mucosa and
decrease the incidence of epistaxis.  
Note: A randomized, controlled trial (Singer and Konia,
1999) showed improved comfort when a decongestant/anes-
thetic was used, compared with plain lubrication for nasogas-
tric tube insertion. In the study, topical anesthesia was applied
(after the decongestant) by injecting 5 mL of 2% lidocaine gel
(Xylocaine Jelly) into the nostril before insertion. The pharynx
was then sprayed with both benzocaine (Hurricaine) and tet-
racaine hydrochloride (Cetacaine) to minimize the gag reflex.
If possible, allow a few minutes for the decongestants and anes-
thetics to take effect before inserting the tube. Topical cocaine
solution can also be used, but it often causes a strong burn-
ing sensation on application (see the “Equipment” section for
other warnings). Application of topical anesthesia should be
considered the standard of care, except in emergency situations
where adequate lubrication alone may be acceptable.  
4. An alternative option is to lubricate a soft nasal airway with 2%
lidocaine gel and allow the patient to insert the lubricated airway
into his or her nares. The nasogastric tube can then be inserted
through the soft airway. As the patient swallows the gel, it will
anesthetize the pharynx. A soft airway not only minimizes patient
discomfort; it can also decrease the risk of severe epistaxis, intrac-
ranial intubation, and kinking of the nasogastric tube into the
mouth.
5. While waiting for the anesthetic to take effect, choose an opti-
mal tube for the patient. A large-bore nasogastric tube (16 or 18
Fr), Salem sump (with antireflux valve, if available), or Levin
tube should be used for adults. Select the largest tube possible for
Fig. 217.6  Horizontal insertion of nasogastric tube into nasopharynx.
the patient’s nostril size. The Salem sump tube has marks at 18,
22, 26, and 30 inches from the distal end. Measure the tube to
fit the patient by holding the nasogastric tube above the patient 6. Lubricate the tip of the tube with additional anesthetic jelly or a
with the distal end at the xiphoid process. After looping the water-soluble lubricant. Curl the tube by rolling 18 to 20 inches
midportion over the patient’s earlobe, extend the proximal end of the distal tube clockwise onto the first three fingers of your
to the nose, and then add 6 inches for a nasogastric tube (add 8 nondominant hand.
to 10 inches for a nasoenteric tube). Note the tube marks based 7. Introduce the lubricated tube tip into the nostril, pointing straight
on these measurements or mark the tube with a piece of tape to the back of the nasal cavity and toward the base of the skull (Fig.
to avoid inserting the tube too far (Fig. 217.5). The nasogastric 217.6). Recalling the anatomy, it should be inserted horizontally,
tube should generally be secured with the 20- to 24-inch mark along the floor of the nasal passage, and directed straight back, not
at the nasal vestibule. upward. Feed the tube slowly with the dominant hand into the

Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
1450 HOSPITALIST
• I n refractory cases, metoclopramide 10 mg may be given in-
10b. Extra steps to facilitate any tube placement include the following:
Fig. 217.7  Have the patient flex his or her head. Next, gently advance
the tube while asking the patient to swallow.
nostril using continuous movement while unrolling the curled
tube with the nondominant hand. The patient can sniff to assist
the insertion. Never force a tube against resistance; however, spin-
ning or twisting the tube slightly may help overcome resistance.
8. Have the patient flex his or her neck slightly forward to nar-
row the pharyngeal airway. When the tip of the tube reaches
the pharynx, a slight increase in resistance will be noted (Fig.
217.7). Continue to advance the tube, and when the resistance
decreases again, ask the patient to swallow or drink some water
with a straw. Continue to push the tube with the same motion
while asking the patient to continue swallowing. If the patient
11. Confirm the location of the tip as soon as possible after the tube
starts coughing or becomes distressed, or fog is seen in the tube,
the tube has probably entered the trachea. The tube should be
withdrawn a few inches, but not entirely, twisted slightly, and
the process started again. If a patient cannot swallow, it is also
helpful to mimic swallowing or say “eeee.”
9. Continue to push the tube until the desired mark is reached if
the patient is not coughing. In adults, this is slightly past the 22-
inch mark—the second mark—on a Salem sump tube. The gas-
troesophageal junction is usually about 16 to 18 inches from the
nose—the first mark—and the tube should be inserted about 4
inches beyond the gastroesophageal junction. If the stomach is full,
an immediate return of fluid may occur. Use the emesis basin to
collect this. If there is no return of fluid, open the patient’s mouth
to confirm that the tube is not curled in the mouth or pharynx.  
Note: If significant resistance, respiratory distress, or a nasal
hemorrhage occurs, or the patient suddenly becomes unable to
speak, the tube should be withdrawn.   verse outcome. Fortunately, placement can also be confirmed by
10a. Extra steps to facilitate placement of a nasoenteric feeding tube
include the following:
• Having placed the tube into the stomach, leave some ex-
tra tubing or slack to facilitate passage of the tip into the
duodenum.
• Place the patient in a right lateral decubitus (right side
down) position.
• A 60-mL syringe (Toomey) can be used to inject 400 mL of
air to distend the stomach. This may allow a feeding tube
coiled in the fundus of the stomach to uncoil and pass more
freely into the duodenum.
Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
travenously, with or without erythromycin 250 mg intrave-
nously, to increase gastric motility.
• If the tube persistently kinks or coils into the mouth, cooling
the tube in ice chips or a refrigerator for 5 minutes may stiffen
it to prevent coiling. A larger-bore tube is also less likely to
coil.
• Applying external and medially directed pressure on the ip-
silateral neck at the level of the thyrohyoid membrane may
increase the success rate in difficult insertions. This maneu-
ver collapses the piriform sinus and further clears the way
for the nasogastric tube. If the tube passes to the level of the
hypopharynx but then meets resistance, grasping the thyroid
cartilage and lifting it anteriorly and upward may facilitate
passage into the upper esophagus. Simply elevating the jaw
or having the patient flex their neck slightly more, into the
“sniffing” position, may also assist with passage.
• Orotracheally intubated patients often present the most dif-
ficult challenge for inserting a nasogastric tube. If nasogastric
insertion is deemed impossible, a second endotracheal tube
may facilitate orogastric tube placement. Remove the respir-
atory adapter from the proximal end of the second endotra-
cheal tube, lubricate it liberally, and insert it through the
patient’s mouth and into the esophagus. A well-lubricated
nasogastric tube can then be inserted through the second en-
dotracheal tube, which can then be removed over the proxi-
mal end of the nasogastric tube. Some clinicians use scissors
to cut down the entire length of one side of the endotracheal
tube to facilitate later removal; even when one side is cut, it
maintains most of its rigidity.
• Nasogastric placement may be facilitated manually through
the oropharynx with three fingers, if necessary. However,
unless the patient is unconscious or paralyzed, a bite block
should be in place for this maneuver to prevent the clini-
cian from being bitten.
• In difficult cases, a laryngoscope may be helpful for guiding
or confirming proper placement.
• Fluoroscopic or endoscopic assistance may also be necessary.
is passed. Ask the patient to speak after placement. If he or she
is unable to speak, the tube is in the trachea and should be with-
drawn. (Be aware that cases have been reported in which the pa-
tient could talk despite tracheal placement of a small-bore feed-
ing tube.) Otherwise, the position of the tip should be confirmed
by a chest radiograph (the most accurate method of confirming
placement). In addition, there are two traditional methods for
confirming proper nasogastric placement: checking for absence
of rhythmic airflow and auscultating for gastric bubbling when
air is injected into the stomach. As it turns out, both of these
techniques have been found to be inaccurate, and therefore they
are not recommended. Even if the tip of the tube is located in
the esophagus, duodenum, jejunum, pleural space, or respiratory
tract, a bubbling sound may be heard. If proper location is misdi-
agnosed, the instillation of feeds or air has been reported to result
in a pneumonia or pneumothorax with a high chance of an ad-
aspiration (to check for gastric contents) and by ultrasonography.  
Note: If gastric juices are aspirated, correct placement has been
demonstrated. To confirm gastric juices, we recommend pH indi-
cator strips with 0.5 gradations or paper with a range of 0 to 6 or 1
to 11. It is important that the resulting color change on any indi-
cator strip or paper is easily distinguishable, particularly between
the pH 5 and 6 range. The old type of litmus paper should not be
used. Rakel and colleagues (1994) reviewed several studies and
found that gastric fluid should have a pH of 0 to 4. If the pH is
less than 4, there is a 95% chance the tube is in the stomach and
nonrespiratory placement is almost guaranteed. If the patient is
 217 –––– NASOGASTRIC AND NASOENTERIC TUBE INSERTION AND REMOVAL 1451

1. Check if on acid-inhibiting medication

2. Check for signs of tube displacement
and measure tube length Aspirate obtained (0.5–1 mL)
3. Reposition or repass tube if required
4. Aspirate using 50-mL syringe and gentle

Aspirate not obtained

DO NOT FEED
1. If possible, turn adult onto side
Aspirate obtained (0.5–1 mL)
2. Inject 10–20 mL air into the tube using
syringe
3. Wait for 15–30 minutes
4. Try aspirating again

Aspirate not obtained

DO NOT FEED Aspirate obtained (0.5–1 mL)

1. Advance tube by 10–20 cm Test on pH strip or paper
2. Try aspirating again

Aspirate not obtained pH 6 or above pH 5.5 or below

DO NOT FEED
pH 6 or above
1. Leave for up to 1 hour
2. Try aspirating again
Fig. 217.8  Algorithm to confirm
pH 5.5 or below the correct position of nasogastric
feeding tubes in adults. (From the
DO NOT FEED National Patient Safety Agency [NPSA].
Reducing the harm caused by misplaced
1. Call for advice
nasogastric feeding tubes: Interim advice
2. Consider replacement/repassing of tube Proceed to feed
for healthcare staff—February 2005:
and/or checking position by x-ray How to confirm the correct position
of nasogastric feeding tubes in infants,
CAUTION: If there is ANY query about position and/or the clarity of the color change on the pH strip, children and adults. www.nrls.npsa.nhs
particularly between ranges 5 and 6, then feeding should not commence. .uk/resources/?EntryId45=59794.)

on antacids, histamine type 2 inhibitors, or proton pump inhibi-
tors, the pH is between 0 and 6 approximately 70% to 80% of the
time. Fluid aspirated from the duodenum averaged a pH of 6.5.
Fluid aspirated from tracheobronchial secretions ranged from pH
6.74 to 8.79. In other words, suspect that fluid from the respira-
tory tract has been aspirated when the pH is greater than 6.
Neumann and colleagues (1995) concluded that when the
pH of the nasogastric tube aspirate is less than 4.0, radiographs
are not needed to confirm tube placement. In 2005, the National
Patient Safety Agency in the United Kingdom recommended the
use of a pH value of less than 5.5 for tube placement confirma-
tion; they concluded a pH value of less than 4.0 (as recommend-
ed by Neumann and associates) is too low to evaluate patients
practically. If the pH is greater than 5.5, a chest radiograph, still
the gold standard, is required to confirm tube placement (Fig.
217.8). However, chest radiography adds cost and prolongs wait-
ing time before use (it can take up to 8 hours to receive notifica-
tion from the radiologist). It also increases radiation exposure.
There are also case reports of inaccurate confirmations by radio-
graphs, with the tube located in the midline after perforating the
esophagus, subclavian vein, or atrium of the heart.
Recently, bedside sonographic examination performed by
experienced clinicians has been reported to be a sensitive
method for confirming position. It is faster than conventional
radiography and can easily be taught to nonradiologists.Re-
gardless of how, confirmation must be done on all nasogastric
or nasoenteric tubes used for instillation or feeding purposes
before starting to avoid massive aspiration. The distal tips of
feeding tubes should be allowed to migrate to the duodenum
before enteral feeding is initiated.  
12. Secure the tube to the patient’s nose after confirmation of
proper placement. First, apply alcohol to the dorsum of the
nose. If available, tincture of benzoin may then be applied after
the alcohol dries. Next, obtain a 5-inch piece of 1-inch-wide
hypoallergenic tape. Make a 3-inch cut lengthwise in the mid-
dle, thereby forming two narrow strips of tape at one end of
the 5-inch piece (Fig. 217.9). The two narrow strips of tape
should be applied in a spiral down and around the nasogastric
tube, going away from the patient’s nose. Attempt to tape the
tube so that it will rest in the middle of the nostril to minimize
direct contact of the tube with the skin of the nose and avoid
pressure necrosis. Recently, several commercial products (e.g.,
NG Secure, NG Strip) have been developed for this special
purpose.
13. Also secure the nasogastric tube to the patient’s gown. Place a
slipknot over the tube with a rubber band, and then pin it to the
patient’s gown. This should reduce the risk of the nasogastric
tube being tugged out of position. The Salem sump tube vent,
or blue pigtail, must remain above the patient’s waistline at all
times to prevent gravity from siphoning fluid. Inadvertent si-
phoning of gastric contents could block the sump vent. When
suction is discontinued during ambulation, the pigtail should be
attached to the connector of the main lumen to close the system
and avoid the spillage of gastric fluids.

Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
1452 HOSPITALIST
Fig. 217.9  Secure the tube with a 5-inch piece of 1-inch-wide hypoal-
lergenic tape, partially cut lengthwise. Apply to the dorsum of the nose and
spiral the cut portions down the tube away from the nose.
14. For removal, again place the patient in the sitting (Fowler or
semi-Fowler) position and cover his or her neck and chest with
towels, surgical Chux, or other drapes. Disconnect the nasogas-
tric tube from the patient, from his or her nose, and from suc-
tion. Hand the patient an emesis basin and some tissues. Fold
over the proximal end of the tube to prevent leakage and hold it
tightly. Ask the patient to flex the neck, breathe in, and hold his
or her breath. Place a drape around the tube and withdraw the
tube from the patient’s nose through the drape. The patient can
then resume breathing. Discard the tube and the drape. 
Complications
The most common complication is discomfort for the patient. The
traumatic insertion of a nasogastric tube can cause epistaxis, but this
is often avoided by using careful technique and a decongestant. Epi-
staxis can be massive and require packing. It can even compromise
the airway. Gagging can occur with insertion and induce vomiting
with aspiration of gastric contents. This can cause an aspiration
pneumonitis or pneumonia with a mortality rate as high as 30%.
Patients with an altered mental status from severe trauma or other
causes should have their airway secured with an endotracheal tube
before placement of a nasogastric tube. Long-term use of a naso-
gastric tube also predisposes patients to aspiration because of tube-
induced hypersalivation, depressed cough reflex, or physiologic or
mechanical impairment of the glottis. Aspiration is also quite com-
mon with nasoenteric feedings in debilitated patients for the same
reasons, hence the value of gastrostomy tubes (see Chapter 92, “Per-
cutaneous Endoscopic Gastrostomy Placement and Replacement”).
Another common complication is misplacement into the respi-
ratory tree, which is estimated to occur in 15% of cases. This should
be recognized rapidly in the conscious patient when it causes him or
her to cough, choke, or develop respiratory distress or an inability
to talk. The vocal cords may also be traumatized. In a patient with
decreased consciousness, tracheal intubation can go undetected, cre-
ating multiple complications such as atelectasis, pulmonary edema,
pneumonia, or lung abscess.
Nasogastric tube syndrome is a reported life-threatening compli-
cation with laryngeal and upper airway obstruction and vocal cord
Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
abduction paralysis. This syndrome results from postcricoid ulcer-
ation and its effect on the posterior cricoarytenoid muscles, and can
be prevented by early recognition and by checking the patient every
day when making rounds. It is treated with emergent tracheostomy,
immediate removal of the nasogastric tube, and administration of
systemic antibiotics.
Penetration of a nasogastric tube into the pleural space is a rare
but reported complication, with further possible complications
including lung abscess, pneumothorax, isocalothorax, empyema,
and sepsis. Intravascular penetration of the internal jugular and sub-
clavian vessels has also been reported.
Perforation of the esophagus is a very serious reported complica-
tion that often results in mediastinitis, with a mortality rate of up
to 30%. This may occur when the esophagus has been damaged by
chemical burns or esophageal cancer, or if strictures are present, or
with insertion after esophageal surgery. Prompt recognition of this
complication, surgical repair, and parenteral antibiotics can signifi-
cantly reduce the mortality rate. Bleeding from esophageal varices is
not usually caused by nasogastric intubation. Duodenal perforation
is very rare but has also been reported. Tube knotting, coiling, kink-
ing, obstruction, and rupture can occur.
With long-term use, sinusitis, erosion of nasal tissue, or even a
tracheoesophageal fistula can occur. Tracheoesophageal fistulas are
usually associated with simultaneous use of an endotracheal tube.
Sinusitis can cause a fever of unknown origin in patients.
If the tube is forced against resistance, cribriform plate fracture
may result, with subsequent intracranial intubation. Individuals
with midfacial or maxillofacial trauma or a basilar skull fracture have
a significantly increased risk of inadvertent intracranial intubation.
The risk of this complication can be reduced by using the orogastric
route or by initially introducing a nasotracheal tube or a soft rubber
nasal airway, through which a smaller-diameter nasogastric tube can
then be passed. This technique decreases the danger of penetrating
the cranium, reduces discomfort during insertion, decreases epistaxis,
and decreases the frequency of the nasogastric tube kinking into the
mouth. The long-term use of nasoenteric tube feeding may result in
diarrhea, infection, electrolyte imbalance, and malnutrition. 
Postprocedure Management
The nares should be assessed for skin irritation, erosion, or necrosis by
health providers at regular intervals. The patient should be asked if
he or she has any pain or pressure in the nose, throat, or sinuses. Any
old or detached tape should be replaced after cleaning the skin of the
nose with alcohol and applying tincture of benzoin. On a regular basis,
the nursing team should record the patency of the tube, the level of
graduated marks on the tube, any symptoms or patient complaints, the
volume and nature of anything infused, and any residual volume. If it
becomes difficult to aspirate from the tube, it should be flushed with
30 mL water. If patency is still uncertain, it should be repositioned by
advancing 1 inch or withdrawing 1 inch. The same maneuver should
then be tried again to confirm patency. Because the use of acidic sub-
stances for flushing can cause whole-protein formulas to coagulate and
clog the tube, this practice should be discouraged. The tube should
be flushed before and after each intermittent feeding, after medica-
tion administration, or every 4 to 6 hours in case of continuous infu-
sion. When the volume of residual is higher than 300 to 400 mL or
there is significant gastric distention, the clinician should be notified
and any infusions held. Infusions should be held for several hours and
the residual rechecked before restarting. For the infusion of medica-
tions, liquid forms should be used if possible. If pills are used, they
should be crushed to a fine powder and mixed with water. If the result
is sticky or highly concentrated, dilute it further with water. When the
tube is clogged, it can be irrigated with warm water or, if unsuccess-
ful, a pancreatic enzyme solution injected. Reinsertion of a device, for
example a stylet or guidewire, into a nasoenteric tube should never be
tried because it can result in gastrointestinal tract injury. If there are
unusual gastrointestinal symptoms like nausea, cramping, abdominal
 217 –––– NASOGASTRIC AND NASOENTERIC TUBE INSERTION AND REMOVAL 1453

distention, or severe diarrhea, the infusion should be stopped and the Suppliers
clinician notified immediately. The clinician must assess the patient
and the tube at this point. (See contact information available at www.expertconsult.com.)
  
When the nasogastric tube is used for gastric decompres- Feeding tubes
sion or postoperative drainage, clinicians should understand the Bard Medical
mechanics of nasogastric suction. Suction strength is inversely Cook Incorporated
proportional to flow; therefore, the lower the flow rate through CORPAK MedSystems
the suction lumen, the higher the suction strength. In addition, Covidien Kendall Medtronic (Dobhoff)
a suction force of more than 25 mm Hg causes tissue capillary NeoDevices
fragility and may damage the gastric mucosa. One advantage of Nestle Health Science
the double-lumen Salem sump tube over the Levin tube is that Latex-free, zinc oxide tape
it allows constant airflow through the secondary lumen, keeping Hy-Tape International
the necessary suction in the main lumen at a minimum. Therefore Levin, Salem sump, and feeding tubes
the vent lumen must not be clamped or plugged. When the Levin Bard Medical
tube is used, an intermittent suction pump should be connected to Covidien Kendall Medtronic
prevent injury of the gastrointestinal mucosa. The length of time Nasogastric tube guard
the tube can be used depends on the patient’s condition, feeding NG Secure (M.C. Johnson)
needs, and the tube design. With proper care and maintenance, NG Strip (Derma Sciences)
most nasogastric tubes can be used for up to 30 days. For longer use, Topical anesthetic
a percutaneous endoscopic gastrostomy tube should be considered Cetacaine, Cetylite Industries, Inc.
(see Chapter 92, “Percutaneous Endoscopic Gastrostomy Place- Hurricaine Spray, Beutlich Pharmaceuticals
ment and Replacement”). 
Acknowledgment
CPT/Billing Codes The editors recognize the contributions of Julie Graves Moy, MD, and
44500 Introduction of long gastrointestinal tube (e.g., Miller- Ramiro Sanchez, MD, to this chapter in previous editions of this text.
Abbott)
42753 Gastric intubation and aspiration(s) therapeutic, ne-
cessitating physician’s skill (e.g., for gastrointestinal Online Resources
hemorrhage), including lavage if performed National Patient Safety Agency (NPSA) UK. Reducing the harm caused by
43754 Gastric intubation and aspiration, diagnostic, single misplaced nasogastric feeding tubes: Interim advice for healthcare staff—Feb-
specimen, for chemical analysis or cytopathology ruary; 2005. www.npsa.nhs.uk/advice.
43755 Gastric intubation and aspiration(s), collection of Thomsen TW, Shaffer RW, Setnik GS. Nasogastric intubation. Videos in
Clinical Medicine. N Engl J Med. 2006. http://content.nejm.org/cgi/video/
multiple fractional specimens with gastric stimula-
354/17/e16/ or www.youtube.com/watch?v=ARHfqRB3t4M.
tion, single or double lumen tube
43756 Duodenal intubation and aspiration; diagnostic,
includes image guidance, single RECOMMENDED READING
43761 Repositioning of a nasogastric or orogastric feeding Fisman DN, Ward ME. Intrapleural placement of a nasogastric tube:
tube, through the duodenum for enteric nutrition an unusual complication of nasotracheal intubation. Can J Anaesth.
1996;43:1252–1256.
 
Grossheim LF. Nasogastric intubation. In: Reichman EF, ed. Emergency Med-
ICD-10-CM Diagnostic Codes icine Procedures. 2nd ed. New York: McGraw-Hill; 2013:387–391.
Marcus EL, Caine Y, Hamdan K, et al. Nasogastric tube syndrome: a life-
A18.32 Tuberculosis, gastrocolic, labs pending threatening laryngeal obstruction in a 72-year-old patient. Age Ageing.
E43 Calorie deficiency, severe 2006;35:538–539.
E46 Malnutrition, protein-calorie Neumann MJ, Meyer CT, Dutton JL, et al. Hold that x-ray: aspirate pH and aus-
R11.2 Vomiting, persistent, unspecified cultation prove enteral tube placement. J Clin Gastroenterol. 1995;20:293–295.
K31.1 Gastric outlet obstruction, acquired or adult Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: re-
K56.0 Ileus, paralytic view of safe practice. Interact Cardiovasc Thorac Surg. 2005;4:429–433.
K56.50 Small intestine obstruction, due to adhesions Rakel BA, Titler M, Goode C, et al. Nasogastric and nasointestinal feeding
K85.90-K85.92 Pancreatitis, NOS or acute tube placement: an integrative review of research. AACN Clin Issues Crit
K86.1 Pancreatitis, chronic Care Nurs. 1994;5:194–206. quiz 218–219.
Samuels LE. Nasogastric and feeding tube placement. In: Roberts JR,
K92.0 Hematemesis or gastrointestinal hemorrhage
Custalow CB, Thomsen TW, eds. Roberts and Hedges’ Clinical Procedures
K92.1 Hematochezia in Emergency Medicine. 6th ed. Philadelphia: Elsevier; 2014:804–830.
K92.2 Gastrointestinal bleeding, unspecified Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors
R11.2 Vomiting, NOS with nausea vs lubricants prior to nasogastric intubation: a randomized, controlled
R11.10 Vomiting, NOS trial. Acad Emerg Med. 1999;6:184–190.
T36-T50 Poisoning by, adverse effect of and underdos- Van Dinter TG, John L, Guileyardo JM, Fordtran JS. Intestinal perforation
ing of drugs or medicaments and biological caused by insertion of nasogastric tube late after gastric bypass. Proc (Bay-
substances lor Univ Med Cent). 2013;26(1):11–15.
Vigneau C, Baudel JL, Guidet B, et al. Sonography as an alternative to ra-
Code first for adverse effects, nature of adverse effect; use additional diography for nasogastric feeding tube location. Intensive Care Med.
codes to specify manifestations of poisoning.  2005;31:1570–1572.

Descargado para Mario Poveda (jpoveda@medicos.cr) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en enero 11, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.