NG/OG tube placement

Daytonite, BSN, RN · Dec 31, 2005

Yes, if they have a compromised gag reflex, like in a stroke patient. I saw this occur a number of times in the nursing home with post-stroke patients. NG tube was found coiled in the back of the throat mostly with tube feeding dripping willy-nilly into the stomach or the lung, depending on whether the patient was able to detect the presence of the feeding formula and swallow it. Feeding formulas infusing on a slow drip can go right down into these patient's lungs. Some may be able to cough the stuff up and swallow it. In a fully, conscious patient with a proper gag reflex that is not going to happen. They will immediately choke and start coughing.

pugmum · Dec 31, 2005

Yes!

a couple of months ago one of our nurses inserted a NG that was going to be for a tube feeding... aspirated, got back a bunch of fluid that looked like tube feed. The patient kept complaining that things just "didn't feel right". There was no severe distress on the patient's part UNTIL the feed was started, but then lots of coughing and hacking... an xray confirmed the tube was in the lungs, not the stomach.

For some reason, policy was ignored in this case about xraying for tube placement, but getting all that stuff back on aspiration caused the nurse to assume she was in the right place.

the only time I remember inserting an NG where it didn't belong, I knew - pt. choked and went blue... not much doubt then :sniff:

bjtmict · Jan 2, 2006

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.

DidiRN · Jan 2, 2006

I agree and have the same concerns. I do not trust an air bolus for placement all of the time but especially worry when when it is being used for a tube feeding and later gets misplaced. I see this on the unit/floor when someone has a salem sump in initially while on a vent or it was to low wall suction, then it was later used as a feeding tube. I have seen confused patients pull them out, and other nurses will put it back in, check for air bolus, then restart the feeding. ALot of these patients have already flunked their swallowing eval, which makes it all the more worrisome about not seeing gagging/coughing when it is down the wrong pipe. I have heard the air bolus on auscultation then later find out the tube is in the esophagus. I've even heard it with it coiled in the back of the throat. I believe anytime a tube is being used for a feeding and has to be replaced, an XRay should always be ordered to confirm placement before restarting the feeding. I feel a small bore feeding tube should be considered and reinserted if it is being used for feeding, not the larger ones like they had before (with the physician's okay, of course).

Yet where I am, I don't see this in practice. Scares me. Or maybe I'm just too paranoid with these things, I dunno.

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.

nursemaa · Jan 2, 2006

At my facility, our practice council did a lit search about this and the recommendation was to always use xray to confirm placement- air bolus is not a reliable method. So we changed our policy to require an xray every time a tube was placed. After that, aspiration of gastric contents was designated as the method of choice for confirming that the tube was still in place.

zacarias, ASN, RN · Jan 6, 2006

Xray is the definitive method for checking placement on every NG tube. This is done right after insertion, prior to use.

The air insufflation-auscultation method is traditional nursing and still done routinely however the research shows that this method doesn't really prove anything.

Once and NG tube is placed, X-ray has confirmed placement in the stomach, then you can look for migration of the tube. If the tube is in the same spot and taped secure, you can pretty sure it is in the stomach.

Until hightech bilirubin strips or something are available at the bedside, nurses will continue to use the air-auscultation method (it gives nurses something to do anyway....j/k)

FarmgrrlRN · Jan 6, 2006

anybody doing pH testing at your facility? This is new for us and I've only had to do it once so far, worked like a charm. Still do air bolus and aspirate gastric contents (of course); we also measure Q4hrs.

MajorDomo · Jan 6, 2006

At my facility we use the aspiration of gastric content and testing the pH for confirmation of placement using litmus (sp?) paper that we also use to measure the pH of the eye. If any thing out of the ordinary occurs, I get a confirmational x-ray.

As far as the pt reaction to accidental intubation, only one AO pt did not give me any s/s. I reason it was because of the lido jelly injected in to nare and the hurricaine spray adminstered orally prior to insertion of a 14fr salam. When no aspiration of the good green stuff occured, x-ray confirmed it was down the wrong pipe.

I have seen an AO pt nasally intubated with a 7.5 et tube for protection of the airway (all rx) and all he required was a lido neb prior to placement.

Hope this helps

MajorDomo

truthseeker · Jan 10, 2006

Has anyone seen aspiration pneumonia w/ klebsiella and e faecia? Pt had bronchoscopy w lung biopsy/lobectomy and no gag reflex testing was done upon her recovery from anesthesia. An aide gave her a glass of water and pt aspirated, could not cough. W/I 2 days she had pneumonia, ARDS, ARF, pleural effusions bilat on CXR. Aide claimed it was not in chart to withold oral fluid intake.

jmgrn65, RN · Jan 10, 2006

At my facility, our practice council did a lit search about this and the recommendation was to always use xray to confirm placement- air bolus is not a reliable method. So we changed our policy to require an xray every time a tube was placed. After that, aspiration of gastric contents was designated as the method of choice for confirming that the tube was still in place.

This is the same thing my facility had done, evidence practice is how we develop policies. we aspirate for gastric contents and if used for feeding we always get an x-ray.

celebrate5 · Dec 28, 2007

I recently had a patient with a trach die from an unidentified tension pneumothorax. The patient had a recently inserted dobhoff feeding tube and was awaiting x-ray verification of placement. Could the feeding tube have caused the pneumo?