NG tube trouble

[zacarias]

hey all!

i have a question for y'all. yesterday i had a patient who needed an ngt to suction the patient before a bronchoscopy. (apparently a ct showed he had stuff to come out). anyway, this patient is not a nice/fun patient as he's been an alcoholic all his life, and it took me 30 min to convince him to have it done. he said it never worked and well i think he may have been right about this.

first i tried and he wouldn't swallow or lean his head forward (it came out his mouth) so i took it out and and called a senior nurse to do it. she was firm with and made sure he swallowed and kept his head forward and it seemed to work. i was skeptical because the only thing i could aspirate was small amounts of slimy, clear liquid making me concerned it wasn't in the stomach. i didn't hear "swooshing" with the auscultatory method of checking placement either. i called the charge nurse finally and she didn't think it was in the stomach. so, she took it out and reinserted it. still getting the same secretions. she seemed happy but i still was not sure. finally the pulmonary fellow came and thought it was strange no secretions were being suctioned out. him and i were with the patient for like 20 min and he was listening while insufflating air...the doctor thought it might no be in the stomach yet which i suspected..he moved it around. finally we got more secretions but still clear (wouldn't we see some stomach acid?) anyway, finally we took it out since his stomach wasn't distended. the doc thought it might have gotten coiled in the back of his throat but then he thought had finally got it into his stomach. i had measured it and we went it way far, farther than necessary to reach a normal stomach.

thanks for not falling asleep yet. my question is, how do you make sure the ngt makes it to the stomach? it seemed to coil in this guy, come out his mouth. and i got so behind trying to figure out what was going on and only getting slimy, clear stuff and i had two senior nurses help me. is there any secrets you can tell me? one nurse said to put the ngt tube in ice to make it stiff to go down easier. please help!

[jayna, RN]

I have a question, why do you have them tilt their head up Tara, to me that sounds like it would make it harder to swallow and stay in the esophagus??

Also, what does putting the NGT in the fridge do? Make it more stiff?

*************

Tilting the head opens the oesohagus passage .

But NGT in fridge thats a new one to me........Doesn't stiff (COLD) NGT make the upper respiratory constrict?

[EMTPTORN]

greetings,

we now have hospital policy to use nitrazine paper on the initial contents; you are looking for an acid response to confirm the placement. the big hinderence with this is if you don't get any return.

common sense dictates though if you measure and the tube passes to the measured point, you inspect the throat and see it is not coiled, and the pt is not coughing or dyspneic (ie into lungs) then the tube is probably in.

Two variables to ponder that could cause concern is if pt has hx of esophageal varisces or bleeding, or if there is trauma suspected to the face. Then extra measures should be taken to verify placement such as xray.

actually, the above variables could be considered contraindications to placement.

[ceecel.dee, MSN, RN]

I always numb the patients throat with hurricane spray, and the tube with lidocaine jelly and then tilt the head forward until I get it past the nose, and then tilt their head up and have somebody hold a cup of water with a straw for the patient to drink out of and then keep telling them to swallow the water as I advance the tube

Without the gag reflex, now numbed by Cetacaine (I'm assuming that is what you mean by "Hurricane" spray), I would not ask a patient to swallow anything but the tube, for worry of aspiration. I like this method too, just without the water.

[Pete495]

In regards to NGT insertion, I do NOT coil them in my hand prior to inserting them. Think about it. If you coil something, it's more likely to bend more, and get caught up in the throat. I like a brand new stiff NGT, and sometimes if I've tried a couple times to pass an NGT or OGT without success, I'll actually get a new one, and beable to pass it right away because it goes straight where I want it to go. I do use just a little lube though.

On occasion when I have a patient on a vent, I will actually lie them flat, and place the OGT that way. It sounds stupid, but sometimes I think it displaces the ETT anteriorly enough to allow a passage into the esophagus. I only use it as a last resort, but it's worked every time for me so far.

I don't know If I've ever heard gurgles. Those sound like bowel sounds. A swoosh is more of the sound I always here. And as always, if you see bubbling, it's in the lung. Also, if you suspect your OGT Or NGT is in your upper airway, take your ears off you stethoscope to listen to the air coming out the mouth at the end of the NGT.

Pete495

[TaraER-RN]

In regards to the hurricane spray and worry of aspiration, I have never used so much of it to get rid of the gag reflex. I use just one spray, it just seems to help get past the back of the throat and not have it come out the mouth...never have had a problem with it and I always have people gag... The one spray also helps a little with the discomfort later on when the tube is down, I pretty much put it down right after spraying...patients have told me that when they've had them in the past they always feel the tube in the back of their throat after its in...that with the hurricane spray it isn't as noticeable.

[UK2USA]

We often put our NG tubes in the freezer to stiffen them. It does make them slighlty easier to pass. We always litmus test our aspirates for a positive placement.

[duckboy20]

I find that using hurricane spray like mentioned above and keeping the tube relatively stiff is the best way to insert the tube. The hurricane spray will not get rid of the gag reflex, especially in small quantities, so there is no risk of aspiration if you chose to have the patient swallow water to help. If in doubt, the only definitive way to see if you are down the right tube without aspirating stomach contents is to get the x-ray.

[zacarias, ASN, RN]

*************

Tilting the head opens the oesohagus passage .

?

Tilting the head up (extension) would actually favor the tube in the trachea.

[kc ccurn]

Tilting the head up (extension) would actually favor the tube in the trachea.

I agree, chin to chest as much as possible to help make entering the esophagus easier. Once you get the tube past the nasopharyngeal curve you, the pt's usually automaticaly start to swallow and you can advance the tube pretty quickly.