Nasogastric tube positioning

Dr Daniel J Bell and Dr Ian Bickle et al.

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 subdiaphragmatic 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 canal insertion is 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 used 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 canal
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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  • 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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  • Case 15: in distal esophagus
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