NG/OG tube placement

[Happy-ER-RN]

Is it possible, in a fully conscious pt., to insert an NG/OG tube into their lung and NOT have them gasping for air and becoming hysterical? Has anyone ever misplaced a tube and had the pt. just sit calmly with a tube in their lung? It just seems to me that it should be quite obvious if you are in the wrong place--I have only put one NG in a lung and the pt. pretty much stopped breathing due to laryngospasms until I took it out.

Now, if you did get the tube in the lung and the pt. was sitting quietly and you started dumping fluid in (lavage) wouldn't they immediately start having resp. distress as soon as the fluid hit their lung?

I just don't always trust the listening for air method, I thought I could learn from ya'lls experience...

Thanks.

[GrumpyRN63, ADN, RN]

We ALWAYS confirm NGT placement by CXR before using it !

[BypassThisNurse]

I am comfortable confirming by auscultation. You can also test the pH of any fluid if you believe that it isn't gastric content. I still feel that patient should be fed by Dob Hoff into the jeujenum ... feeding a patient with a NG/OG tube into the stomach is a disaster waiting to happen!

[Virgo_RN, BSN, RN]

Our facility recently implemented a policy regarding NG tubes and I was wondering if it seems reasonable. We are to irrigate with 30 ml of NS every 4 hours to check for placement of the tube. Is this standard practice?

Decisions determine destiny.

The purpose of irrigation is not to check for placement, it is to check for patency.

[chenoaspirit, ASN, RN]

I have placed NG in the lung twice, both times the patient knew. You can also place the other end of the tube in a cup of water, if its in the lung it will bubble. I have NEVER injected any liquid in a NG if it was in the lung. If I had any doubt of its placement, then I wouldnt use it. There was one instance during my initial assessments, I was checking placement of a NG in a patient, I couldnt conclude it was placed. So I called the doc, he argued with me that it was in the right place. I continued to argue because I didnt believe it was. He finally ordered an x-ray, and it was NOT in the right place. So I had to take it out and re-insert it. I would rather have a g-tube or a dobhoff for tube feeds.

[suanna]

Consider your patients with an ETT or even a tracheostomy tube. They have a pretty big piece of plastic in thier trachea and tollerate it fairly well. I would think it is uncommon to have a patient tollerate a lung placed NG without some signs but by no means is it unheard of- even with a neurologicaly intact patient. X-ray is the only sure way to know your placement. Everywhere I've worked or had a family member, X-Ray verification was required before anything went down the tube.

[danissa, LPN, LVN]

I dont do adult NG/OG tubes, never have, only neonates, so I might be going from a different perspective.

A vigorous neonate may require a few tubes to be passed in a day..they wrap their wee fingers round and Yank them out! X-ray for feeding tube position this many times, although the only sure method, is not recommended. Neither is insufflation/auscultation, its not a relaible method. We use ph paper to test a small amount of GA prior to each feed, a score of 6 or less and the acidic reaction means you can feed. A score of seven, with a non vigourous baby, then its at your discretion. We used to use litmus paper, which turns pink at a ph of seven or less, so I personally would feed at this ph, depending upon the baby and his level of activity etc.

If there is no aspirate, sometimes advancing or pulling back the tube, or adjusting position helps.

In a compromised neonate, if the tube is in the wrong place, you would know by the instant "going Off" of the baby.

[nicunursejen]

If you obtain gastric contents from an Og tube, would that not be enough proof you're in the stomach? Why would you need the litmus paper? what other kind of contents would you aspirate if you were in the wrong place?

[geeimjo]

To answer Celebrate5's question (Dec28/07), YES, absolutely, a feeding tube can cause a pneumothorax - witnessed it once - the patient had emphysema, lung tissue so fragile when the feed tube went down - incorrectly - the fragile lung tissue was disrupted and torn by the tube and a pneumothorax ensued. Because the lung tissue was so fragile, the tube met no resistance going down, and the patient was too sick to respond. The patient might have died had the nurse not immediately noticed the patient's immediate respiratory distress and called the doc for a chest tube. Very scary!

[geeimjo]

Reply to NurseJen:

Gastric acid is highly acidic - somewhere between pH 1.0 - 2.0

The gastric content of the stomach usually ranges from 4 - 5, may sometimes be as high as 6.0 (still acidic), whereas the contents of the lungs are neutral - that is, close to 7.0

Per the AACN, the following conditions must be met to measure the pH of gastric content accurately:

- No feedings or medications given orally for one hour prior to test

- No antacids within last hour

- Flush tube with 30-mL air before aspirating contents for pH testing

Why litmus paper? It is sensitive to the pH of solutions - it will indicate the acidity of your aspirate by the colour it changes to. Easy to use and effective.

pH meters and probes are expensive.

The only other (heaven forbid) aspirate you might find would be in, say, a trauma patient with skull base fractures - then you might push the tube into the brain...

[rachelgeorgina]

It's standard practice here to x-ray for confirmation of placement before commencing feeding.

With an ND tube you need to x-ray for confirmation of placement in the stomach before pushing the tube further into the duodenum.

[zacarias, ASN, RN]

One thing I'd like to add:

Checking pH in my opinion is better than the auscultatory method, however, it is still not best practice. pH testing could still give equivocal results. Best practice would be bilirubin testing strips but this is still not readily available to nurses and facilities. No matter what, xray shoud always be done prior to feedings.

[leslie :-D]

i despise ng tubes.

seriously, too dangerous.

leslie