Nasoenteric Feeding: Tube Insertion

22 July 2017

Equipment
• Syringe
• Water
• pH strip
• Surgical tape
• Tape measure
• Glass of water and drinking straw (if patient is alert and gag reflex present)
• Feeding tube
• Water soluble lubricant
• Non-sterile disposable gloves

Recommended Practice
NOTE:
• Insertion of nasoenteric tubes must be carried out by a trained health professional. Check local policy
guidelines.
• No evidence suggests that either litmus paper tests or insufflations of air into the stomach are accurate
indicators of tube position.
• X -ray is the current gold standard method of checking tube placement but it is not realistic for all tube
placements. A pH check of stomach aspirate is considered and widely accepted as the most reliable test
after x- ray.

PREPARATION OF PATIENT:
• Check patient’s medical and nursing records for potential complications/precautions
• Explain the procedure, reassure patient and implement interventions (e.g. nebulized and atomized
lidocaine) to facilitate patient comfort during the procedure.
• Assist patient to a semi-upright position in the bed or chair, with their head supported with a pillow. Head
should not be tilted backwards or forwards.
• Perform hand hygiene, and put on non-sterile gloves.
PROCEDURE:
• Measure the distance to insert tube, from the tip of the patient's nostril to the tip of the ear lobe, and to
the tip of the xiphoid process.
• Lubricate tip of the tube.
• Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Do the same with
the other nostril.
• Gently insert the tube into the nostril in an upward and backward direction. If an obstruction is felt,
withdraw the tube and try again in a slightly different direction or use the other nostril. Otherwise,

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encourage patient to sip water through a straw, advancing the tube downwards and backwards when the
patient swallows. Do not use force, and discontinue procedure if signs of distress are present.
• Secure the tube in place using hypoallergenic tape or nasal bridle (refer to ‘Recommended Practice’ and
‘Evidence Summary’ on Nasoenteric Tube Feeding: Monitoring and Care)
• Apply a pH test of aspiration to verify the position of the tube: Aspirate 0.5 to 1 ml of aspiration and apply
it to pH indicator strip. If the pH is less than 5.5, that indicates the position of tube is correct.
• NOTE: Verification of tube position should not only be performed following initial insertion but also when
the following signs are present: episodes of vomiting, retching, or coughing spasms, when there is
suggestion of tube displacement (e.g. loose tape or portion of tube appears longer), or in the presence of
any new or unexplained respiratory symptoms or reduction in oxygen saturation.

• If no gastric contents are aspirated, inject 10 to 20 ml of air and wait 15 to 30 minutes and aspirate
again.
• If no aspiration, or the pH value is more than 5.5, report to medical officer and seek advice.
FOLLOWING TUBE INSERTION:
• Ensure the tube is securely anchored.
• Perform a baseline external tube measurement (nares to tube end) and document.
• Document size and length of tube.

References
Nutrition, fluid balance and blood transfusion. In: Dougherty L and Lister S, editors. The Royal Marsden
Hospital Manual of Clinical Nursing Procedures. 8th edition. West Sussex: John Wiley & Sons; 2011.
P. 371-460.

Occupational Health and Safety Considerations

The author declares no conflicts of interest in accordance with International Committee of Medical Journal Editors (ICMJE) standards.
How to cite: The Joanna Briggs Institute. Recommended Practice. Nasoenteric Feeding: Tube Insertion. The Joanna Briggs Institute EBP Database,
JBI@Ovid. 2017; JBI1808.
Note: The information contained in this Recommended Practice must only be used by people who have the appropriate expertise in the
field to which the information relates. The applicability of any information must be established before relying on it. While care has been
taken to ensure that this Recommended Practice summarizes available research and expert consensus, any loss, damage, cost or
expense or liability suffered or incurred as a result of reliance on this information (whether arising in contract, negligence, or otherwise)
is, to the extent permitted by law, excluded.
Copyright © 2017 The Joanna Briggs Institute licensed for use by the corporate member during the term
of membership.

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Nasoenteric Feeding: Tube Insertion
22 July 2017

Author
Dr Susan Slade, BScApp (Physio), Grad Dip Manip Ther, M Musc Ther, PhD

Question
What is the best available evidence regarding the method of inserting nasoenteric feeding tube and ways
to verify its position following insertion?

Clinical Bottom Line

Nasoenteric feeding tubes are widely used for enteral feeding in hospitalized patients who are critically ill
and unable to take food orally due to medical conditions. A nasoenteric feeding tube is inserted through
the patient’s nose with the tip positioned in the patient’s stomach (nasogastric tube) or intestine
(nasoduodenal or nasojejunal tube).1 Inadvertent insertion of the tube into the wrong site is quite
common, which highlights the importance of verifying the position of the tube following insertion.

• Clinical practice guidelines recommend that people requiring enteral tube feeding should have their tube
inserted by healthcare professionals with relevant skills and training.2 (Level 5)
• A randomized clinical trial investigated caloric delivery, costs, and complications associated with
fluoroscopically and blindly placed feeding tubes. The trial concluded that critically ill patients who are
intubated endotracheally or with tracheostomy should have nasoenteric feeding tubes placed with the
guidance of fluoroscopy.3 (Level 1)
• For nasogastric enteral feeding, a fine bore nasogastric tube is preferred over a wide bore or Ryles tube.
The fine bore is more comfortable for patient and minimizes the risk of developing rhinitis, pharyngitis or
esophageal erosion. When inserting a nasogastric tube, the patient should be positioned in a semi-upright
position in a bed or chair, with the head straight and supported by a pillow. If the patient is unable to sit
up, the procedure can be carried out with the patient lying on their side.4 (Level 5)
• Nebulized and atomized lidocaine can be administered prior to tube insertion to minimize pain and/or
discomfort associated with the procedure.5 (Level 1)
• Inadvertent insertion of the tube into the wrong site, such as the tracheopulmonary system or the brain,
is associated with significant morbidity and can cause serious and life-threatening conditions. These can
include (but not limited to) pneumothorax6,7, severe irritation and coughing7, trauma to the brain7,8, and
death from feeding into the lung.7 (Level 4, Level 5, Level 4)
• An alert from the National Patient Safety Agency on reducing the harm caused by misplaced nasogastric
feeding tubes reported that:9 (Level 5)

• Nasogastric tube position should be verified by assessing the pH of aspirate ( < 5.5) or by X-ray.
• For pH testing, readings between pH 5 and 6 should be checked by a second competent person.
• X-ray images should only be interpreted and tube position confirmed by someone assessed as
competent to do so.
• Verification of tube position should be performed:
• following initial insertion
• following episodes of vomiting, retching or coughing spasms
• when there is suggestion of tube displacement (for example, loose tape or portion of visible tube
appears longer)
• in the presence of any new or unexplained respiratory symptoms or reduction in oxygen saturation

• ‘Whoosh’ tests, acid/alkaline tests using litmus paper, or interpretation of the appearance of aspirate
should not be used to confirm nasogastric tube position as they are not reliable.

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• A systematic review, and meta-analysis, evaluated methods for determining nasogastric tube
placement.10 (Level 1)

• Colorimetric capnometry: Three trials evaluated the diagnostic accuracy of colorimetric capnometry to
differentiate between respiratory and gastrointestinal placement of feeding tubes. All trials reported high
sensitivity and specificity in detecting airway intubation and high agreement with the reference standard
(radiology).
• Capnography: Three trials determined the sensitivity and specificity of capnography in correctly
differentiating between respiratory and gastrointestinal tube placement. Capnographs successfully
identified tubes that were placed in the bronchus, esophagus and the oral cavity.
• Biochemical parameters of feeding tube aspirates: Nine trials investigated biochemical parameters (pH,
bilirubin, pepsin and trypsin) in differentiating gastric from respiratory and intestinal placement of feeding
tubes, with pH alone and in combination with other parameters successfully identifying tube location.
• There were nine trials that investigated the effectiveness of using various methods to differentiate
between respiratory and gastrointestinal feeding tube placement. In a limited number of small trials, spring
gauge pressure manometer, magnetic detection and sonography were shown to be effective. Auscultation
and visual inspection of aspirates were found to be unreliable indicators of correct tube placement.

• A systematic review, and meta-analysis, evaluated the diagnostic accuracy of end-tidal carbon dioxide
detection in detecting inadvertent airway intubation.11 (Level 1)

• The use of colorimetric capnometry or capnography had a sensitivity ranging from 0.88 to 1.00,
specificity 0.95 to 1.00, positive likelihood ratio 15.22 to 283.35, and negative likelihood ratio 0.01 to 0.25.
A summary receiver operator characteristics (SROC) curve showed an area under the curve of 0.9959.
• The reviewers concluded that “there is evidence to support the use of capnography or colorimetric
capnometry for the identification of nasogastric feeding tube placement in mechanically ventilated
patients”.11,p.513

• A systematic review reported evidence that demonstrated colorimetric capnography to be a valid method
for verifying nasogastric tube placement in mechanically ventilated adult patients.12 (Level 1)
• A systematic review evaluated the diagnostic performance of biochemical tests used to determine
placement of nasogastric tubes after insertion in adults. It did not provide substantive evidence for the
development of recommendations for biochemical markers for predicting nasogastric tube placements.
However, this review did indicate that bilirubin measurement demonstrated high sensitivity for
differentiating gastric and intestinal tube placement. This review also f reported increased prediction
accuracy by combining low pH and bilirubin; or a combination of pepsin and trypsin.13 (Level 1)
• A systematic review was conducted to evaluate the methods used to confirm the tip location of a
nasoenteric tube and to compare the methods for reliability, accuracy, cost-effectiveness and
generalizability. The authors reported that none of the 20 current methods are 100% reliable. The “house
of quality” approach demonstrates global applicability and radiography and ultrasound imaging are the
most accurate.14 (Level 1)

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Characteristics of the Evidence
This summary is based on a structured search of the literature and selected evidence-based health care
databases. Evidence in this summary is from:

• A clinical practice guideline.2

• A randomized clinical trial that included 30 participants.3
• An expert opinion paper.4,7
• A systematic review that included 212 participants.5
• Case reports.6,8
• An alert from the National Patient Safety Agency.9
• A systematic review that included 26 trials.10
• A systematic review that included nine trials.11
• A systematic review that included five diagnostic studies.12
• A systematic review that included 10 diagnostic.13
• A systematic review that included 76 articles.14

Best Practice Recommendations

• Insertion of nasoenteric tube should only be undertaken by a competent health professional (Grade A)
• Proper positioning of patient should be observed, and use of lidocaine be considered to minimize pain
caused by insertion (Grade A)
• Fluoroscopy should be considered where possible when inserting a nasoenteric feeding tube in critically
ill patients. (Grade B)
• Nasogastric tube position should be verified by assessing the pH of aspirate ( < 5.5) or by X-ray. (Grade
A)
• For pH testing, readings between pH 5 and 6 should be checked by a second competent person. (Grade
A)
• X-ray images should only be interpreted and tube position confirmed by someone assessed as
competent to do so. (Grade A)
• Verification of tube position should be performed following initial insertion and when there is any
suggestion of possible tube displacement. (Grade A)
• Capnography or colorimetric capnometry may be used for the detection of inadvertent airway intubation
of a nasogastric tube in mechanically ventilated patients. (Grade B) [Note: this should not replace final
confirmation of tube position by assessing the pH of aspirate or by X-ray]
• There is limited evidence that other methods to verify nasogastric tube position, such as biochemical
parameters (e.g. bilirubin, pepsin and trypsin), spring gauge pressure manometer, magnetic detection and
sonography may be effective. (Grade B) [Note: these should not replace final confirmation of tube position
by assessing the pH of aspirate or by X-ray]
• Auscultation and visual inspection of aspirates are not recommended to assess nasogastric tube
positon. (Grade B)

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References
1. The Clinical Resource Efficiency Support Team. Guidelines for the management of enteral tube feeding
in adults. CREST. 2004. [cited 2 Jul 2014]. Available from: http://www.crestni.org.uk/publications/
2. National Institute for Health and Care Excellence (NICE). Nutrition support for adults: oral nutrition
support, enteral tube feeding and parenteral feeding. NICE Clinical Guideline 32. 2006. [cited 2015 Nov
12]. Available from: http://www.nice.org.uk/guidance/cg32/evidence/full-guideline-194889853
3. Huerta G, Puri V. Nasoenteric feeding tubes in critically ill patients (fluoroscopy versus blind). Nutrition.
2000; 16(4):264-67. (Level 1)
4. Best C. Nasogastric tube insertion in adults who require enteral feeding. Nurs Stand. 2007;
21(40):39-43. (Level 5)
5. Kuo, YW. Miaofen , Y. Fetzer, S. Lee, JD. Reducing the pain of nasogastric tube intubation with
nebulized and atomized lidocaine: A systematic review and meta-analysis. J Pain Symptom Manage.
2010;40(4):613-619 (Level 1)
6. Moorthy A. Down the wrong way: an important complication of nasogastric tube placement. J Med
Cases. 2014; 5(12):618-620. (Level 4)
7. Durai R, Venkatraman R, Ng P, Nasogastric tubes. 2. Risks and guidance on avoiding and dealing with
complications. Nurs Times. 2009; 105(17):14-16. (Level 5)
8. Psarras K, lalountas MA, Symeonidis NG, Baltatzis M, Pavlidis ET, Ballas K, et al. Inadvertent insertion
of a nasogastric tube into the brain: case report and review of the literature. Clin Imaging. 2012; 36(5):
587-590. (Level 4)
9. National Patient Safety Agency. Reducing the harm caused by misplaced nasogastric feeding tubes in
adults, children and infants. 2011. Available from: http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
(accessed 12 May 2015). (Level 5)
10. Chau J, Thompson D, Fernandez R, Griffiths R, Lo HS. Methods for determining the correct
nasogastric tube placement after insertion: a meta-analysis. JBISRIR. 2009; 7(16):679-760. (Level 1)
11. Chau JP, Lo SH, Thompson DR, Fernandez R, Griffiths R. Use of end-tidal carbon dioxide detection
to determine correct placement of nasogastric tube: a meta-analysis. Int J Nurs Stud. 2011;
48(4):513-521. (Level 1)
12. Bennetzen LV, Hakonsen SJ, Svenningsen H, Larsen P. Diagnostic accuracy of methods used to
verify nasogastric tube position in mechanically ventilated adult patients: a systematic review. JBISRIR.
2015; 13(1):188-223. (Level 1)
13. Fernandez RS, Chau JP, Thompson DR, Griffiths R, Lo HS. Accuracy of biochemical markers for
predicting nasogastric tube placement in adults--a systematic review of diagnostic studies. Int J Nurs
Stud. 2010; 47(8):1037-1046. (Level 1)
14. Milsom SA, Sweeting JA, Sheahan H, Haemmerle E, Windsor JA. Naso-enteric Tube Placement: A
Review of Methods to Confirm Tip Location, Global Applicability and Requirements. World J Surg. 2015;
39(9):2243-2252. (Level 1)

The author declares no conflicts of interest in accordance with International Committee of Medical Journal Editors (ICMJE) standards.
How to cite: Dr Susan Slade, BScApp (Physio), Grad Dip Manip Ther, M Musc Ther, PhD. Evidence Summary. Nasoenteric Feeding: Tube
Insertion. The Joanna Briggs Institute EBP Database, JBI@Ovid. 2017; JBI243.
For details on the method for development see Munn Z, Lockwood C, Moola S. The development and use of evidence summaries for point of care
information systems: A streamlined rapid review approach. Worldviews Evid Based Nurs. 2015;12(3):131-8.
Note: The information contained in this Evidence Summary must only be used by people who have the appropriate expertise in the field to
which the information relates. The applicability of any information must be established before relying on it. While care has been taken to
ensure that this Evidence Summary summarizes available research and expert consensus, any loss, damage, cost or expense or liability
suffered or incurred as a result of reliance on this information (whether arising in contract, negligence, or otherwise) is, to the extent
permitted by law, excluded.
Copyright © 2017 The Joanna Briggs Institute licensed for use by the corporate member during the term
of membership.