Nasogastric tube positioning

Assessment of nasogastric (NG) tube positioning is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death.

Evaluation of NGT

Plain radiograph

The ideal position should be in the sub-diaphragmatic position in the stomach - identified on a plain chest radiograph as overlying the gastric bubble. Ideally, it should be at least 10 cm beyond the gastro-esophageal junction 1.

Malpositioning may include tip position:

  • remaining in the esophagus
  • traversing either bronchus or more distally into the lung
  • coiled in the upper airway
  • intracranial insertion, possible in both patients with and without skull base trauma or surgery 2
  • spinal cord insertion, very rare, occurring after skull base surgery in one case report 8,9

In some circumstances fluoroscopic nasojejunal tube insertion is necessary.

Ultrasound

Point-of-care ultrasonography may be utilized to guide the nasogastric tube in real time with the probe placed sequentially in the following locations 7:

  • anterolateral neck
    • cervical esophagus typically visualized to the left, posterolateral to the trachea
    • an intraluminal curvilinear echogenic interface represents esophageal placement of the tube
  • epigastrium
    • with a longitudinal view of the gastroesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualization
    • oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement

Complications

Overall, complications occur in 1-3% of cases, with complications leading to death occurring in approximately 0.3% of cases. Complications include 1-6,8,9

  • upper airway
  • lower airway
  • enteral
    • viscus perforation and mediastinitis or peritonitis
      • may further complicate with intravascular placement
    • viscus obstruction
    • knotting/tangling of the tube
    • intramural esophageal dissection
  • intracranial and spinal cord
Chest
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Article information

rID: 30966
Section: Approach
Synonyms or Alternate Spellings:
  • NG tube position
  • NGT position
  • Evaluation of nasogastric tube position

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Cases and figures

  • Case 1: appropriate NGT position
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  • Feeding tube inse...
    Case 2: NG coiled in upper airway
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  • Case 3: NG in distal esophagus
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  • Case 4: NG in right lung
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  • Case 5: NGT coiled in nose
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  • Case 6: appropriate position
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  • Case 7: down both bronchi
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  • Case 8: misplaced nasogastric tube
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  • Case 9: right lower lobe
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  • Case 10: left lower lobe with pneumothorax
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  • Case 11: curved back in the mid esophagus
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  • Case 12: iatrogenic bronchopleural fistula from a Dobhoff tube
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  • Case 13: malposition of nasogastric tube causing right PTX
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  • Case 14: in the left lower lobe bronchus
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