Nasogastric/Nasointestinal Tube Insertion

Definition

Nasogastric tube insertion is the placement of a soft plastic or vinyl tube through the nose, down the esophagus, and into the stomach. It is also called nasogastric intubation. In nasointestinal tube insertion, the tube extends past the stomach and into the small intestine. Nasointestinal tube insertion is also called nasoenteric intubation.

Purpose

Nasogastric tubes are used for diagnostic, therapeutic, preventative, and feeding purposes. Nasointestinal tubes are used for diagnostic, preventative, and feeding purposes. When used for diagnostic purposes, nasogastric and nasointestinal tubes allow access to the contents of the stomach or small intestine. Using suction, a sample of the stomach or intestinal contents can be removed and analyzed. Situations in which it would be desirable to evaluate the contents of the stomach or small intestine include:

• when gastrointestinal bleeding is suspected in the stomach or upper parts of the small intestine

• in suspected poisonings
• when abnormalities in enzyme production or acidity are suspected.

Therapeutic uses of nasogastric tubes include removing the stomach contents after suspected poisoning or after gastric trauma, washing the stomach (gastric lavage) after suspected poisoning, and administering medications in individuals who cannot swallow. Preventative uses include removing air from the stomach (decompression) before and sometimes after abdominal surgery. Nasointestinal tubes are used in a similar way to remove air from the intestine.

By far the most common purpose of nasogastric and nasointestinal tubes is for feeding individuals who cannot or will not swallow. Nasogastric tubes are usually used to counteract short-term feeding problems of not more than two weeks. Common reasons to use a tube for feeding include:

• stroke that has resulted in paralysis of the muscles involved in swallowing
• coma
• cancer of the mouth, throat, or esophagus
• trauma or burns to the mouth, throat, or esophagus
• mental illness such as anorexia or dementia that leads to refusal to eat

Nasointestinal tubes for feeding are preferred when usage will extend beyond two weeks. Tubes for this purpose replace usually have a smaller diameter and are less irritating than nasogastric tubes. With a nasointestinal tube, food is funneled directly into the upper part of the small intestine. These tubes are used whenever there is a reason to bypass the stomach, such as with gastric surgery, trauma to the stomach, or paralysis of the stomach muscles. Nasointestinal tubes are also preferred when there is a good possibility that the individual will aspirate stomach contents.

Precautions

It may not be safe to insert a nasogastric or nasointestinal tube into individuals who have trauma to the jaw, the base of the skull, or the neck. It may also be unsafe to insert a tube of this kind into individuals who have a narrowed nasal passage or a narrowed esophagus (esophageal stricture), who have large esophageal varices, those individuals with uncontrolled bleeding or clotting problems, and individuals having convulsions.

Description

Nasogastric tubes come in several diameters and lengths. The choice of tube depends primarily on the purpose for which it will be used and how long it is expected to remain in place. Insertion of a nasogastric tube can be done at the bedside by a nurse. Conscious patients sit upright during the procedure. The nasal passage is checked for blockage, and some times a nasal decongestant is sprayed into the nose. The tube is lubricated, and then pushed through the nostril (nares). When the tube reaches the back of the throat, the patient is told to swallow, and the tube then slides down the esophagus and into the stomach. The tube is taped in place. Confirmation that the tube is placed correctly is done by attaching a syringe to the exterior end of the tube and drawing up some stomach contents and by listening with a stethoscope over the abdomen for movement sounds as a small amount of air is inserted via a syringe into the tube. Tube placement can also be confirmed by x ray. X-ray confirmation is required for patients who are in a coma or when the tube is inserted under anesthesia.

Placement of a nasointestinal tube is more complicated. Insertion of a nasointestinal tube can be done at the bedside by a physician or nurse, but only with guidance of a fluoroscope or endoscope. The tube is weighted on one end to aid in movement through pylorus, a ring of muscle that separates the bottom of the stomach from the duodenum, or first part of the small intestine. The procedure is similar to insertion of a nasogastric tube, with the exception that the tube must be maneuvered through the pylorus. This increases the difficulty and the chance of complications. Insertion of a nasointestinal tube into an unconscious patient is particularly difficult.

Preparation

Individuals who are unconscious must have an oral airway insertion before a nasogastric or nasointestinal tube can be inserted. When possible, nothing is given by mouth for several hours before the tube is inserted.

Aftercare

Once the tube is in place, care must be taken to prevent it from irritating the nasal passageway. No special care is normally needed after tube removal.

Complications

Complications can occur during insertion and use of either type of tube. Complications related to placing the tube and having it remain in place include:

• nosebleed
• excessive gagging
• passage of the tube into the windpipe (trachea) rather than the esophagus, resulting in choking and difficulty breathing
• damage or irritation to the lining of the nasal passageway, throat, or esophagus
• perforation of the esophagus
• inability to get a nasointestinal tube through the pylorus
• aspiration of stomach contents into the lungs
• irritation of the lining of the stomach
• tube removal by a non-cooperative or confused patient

Other complications are related to the specific use for which the tube is used.

Results

Normally nasogastric and nasointestinal tube insertion allows easy access to the stomach and upper part of the small intestine without complications. Outcomes of treatment depend on the reason the tube was placed.

Health care team roles

Many different healthcare professionals can be involved in tube placement. Tubes may be placed by emergency physicians, gastroenterologists, internists, surgeons, radiologists, and registered nurses. Licensed practical nurses can be responsible for tube care once the tube is in place. Occasionally patients go home with the tube in place. In this case, patient education on how to care for the tube is necessary and is usually done by a nurse.

Resources

BOOKS

Nuzum, Robert. "Gastrointestinal Intubation." In Manual of Gastroenterologic Procedure, edited by D. Drossman. New York: Raven Press, 1993. pp. 10-21.

PERIODICALS

Rushing, Jill. "Inserting a Nasogastric Tube." Nursing 35 (May 2005): 22.

ORGANIZATIONS

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-5920. 〈http://www.gastro.org〉.

OTHER

American Gastrological Association. "American Gastrological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition." November 11, 1994. 〈http://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html〉 (November 2, 2005).

Gabriel, Sabry A. "Placement of Nasoenteral Feeding Tube Using External Magnetic Guidance." Journal of Parenteral and Enteral Nutrition. March/April 2004. 〈http://www.findarticles.com/p/articles/mi_qa3762/is_200403/ai_n9389553/print〉 (November 28, 2005).

Knies, Robert. "Confirming Safe Placement of Nasogastric Tubes." Emergency Nursing World. 2004. 〈http://www.enw.org/Research-NGT.htm.〉 (November 28, 2005).

"Nasogastric Tube Insertion." University of Ottawa Department of Emergency Medicine. 2003. 〈http://www.med.uottawa.ca/procedures/ng.〉 (November 28, 2005).

Aspirate— To breathe foreign material into the lungs, as when stomach contents back up into the mouth and are breathed into the windpipe.

Endoscope— An instrument containing a light and a camera that is inserted into the digestive tract to allow a physician to view the interior of an organ.

Esophageal varices— Stretched veins at the base of the esophagus where it meets the stomach that are likely to burst and cause severe, life-threatening bleeding. Esophageal varices are often associated with heavy alcohol consumption.

Fluoroscope— A special type of x-ray machine that makes it possible to see internal organs in motion.