Taming Naso-Gastric Tube (NGT) Torture

RobbiRN, RN

The dreaded NG tube. Hated by most patients and many practitioners who have to insert them, NG tubes are great candidates for the top spot in the "most detested procedure" column.

Several of my early teachers were coworkers who readily admitted, "I hate doing these. They never go well." Their prophecies were usually self-fulfilling. After a few years of learning from others on the job and experimenting on my own, I arrived at a process that works well with very few complications. I won't pretend to solve every possible complication which can occur, but here are six simple steps I've found to be highly successful for inserting NG tubes in alert, cooperative patients. Some of the things I have found to be most helpful are clear departures from traditional wisdom or established practice.

1. First, calm your own spirit

There's no point in taking your own anxiety and abhorrence for the procedure into the room. Consciously or subconsciously, patients feed off of our energy. Like all the nasty, invasive things we do, NG tube insertions go best if we go into the procedure calm, assertive, and expecting a good outcome.

2. The second step is sometimes short changed, but it is the most important: the pre-talk

Doctors often hit a button on a computer to enter the order and don't even tell the patient he or she is getting a tube, so I'm often the one explaining what is going to happen. I never, never rush through the pre-talk, even if the patient has had an NG tube before (unless it was an amazing experience and he/she is excited to be headed down the NG path again). Customize the pre-talk for each patient, but use simple, non-medical words that create a believable picture of how it will go, projecting success:

"So, John, did the doctor talk to you about your CT results?"

"No."

"Well, you have a small bowel obstruction. Your pain is from all the stuff piling up that can't get through. It's like a stampede when there's a fire in a crowded public building. Everyone panics, and bodies pile up against the door. No one can get out until you peel the people off the back of the pile so you can pull the door open. We slide a tube through one side of your nose, through your throat and on down into your stomach to vacuum the pressure off the back of the pileup. A lot of the time, we can get the door open this way, and everything starts flowing again."

"How big is the tube?"

"It's about this big around." (I circle my index finger creating an opening about the size of a #16 tube, then immediately compare it to much worse things.) "You are actually able to swallow much bigger things. If you overdose, we put a tube about ten times that big down your throat to wash out your stomach. (I make a big circle the size of an Ewald tube, about the size of a penny.) Have ever seen someone swallow a sword? Those things are huge, rigid, and sharp. What we use is a soft, smooth, little plastic tube that bends easily. We'll slide it through your nose into your throat. We'll take a little break there. Then all you have to do is take a swallow of water, and we'll send the tube right down with it."

Take time for questions and clarify as needed. I generally don't bring the supplies in with me for the pre-talk because they focus better and relax more if they aren't staring at the distracting instruments of torture. It only takes a couple of minutes to get what I need, and they have a little more time to process the procedure while I'm gone. I want them willing and determined to succeed when I come back to the room. Come in projecting optimism and expecting the patient is ready to go, but be ready to coach more if needed to keep him/her expecting a good outcome. This must be a cooperative effort in a conscious patient.

3. Third, the setup

Bring in a large emesis basin, a cup of water and a straw, a #14, #16, or #18 tube, lubricant (preferably a 2% lidocaine Urojet, which is okay for internal use - some topical preparations specify for external use only), a towel, an alcohol pad, a figure H Band-Aid and a Toomey Syringe.

There are several techniques often used at this point which I believe are not helpful and may be detrimental. Sprays and nebulizers to numb the throat prior to insertion have no benefit and may suppress the gag reflex. The nose is the painful part of the insertion, not the throat, and a good gag reflex keeps the tube on the right path and out of the trachea. I have found the patient generally does best sitting upright with the face in a neutral position. The traditional "chin to the chest" is a distraction with no benefit in a cooperative patient who can swallow. Think about how you swallow most easily. Try swallowing with your chin tucked to your chest and see how it feels. Also, never ice the tube to make it more rigid. I have found that little or no "pre-curling" of the tube is needed. Excessive pre-curling of the tube makes it more likely to curl into the mouth instead of hugging the back of the throat and sliding into the esophagus.

4. Fourth, slide the tube through the nose to the throat and STOP short of hitting the gag reflex for the first break

Continually explain and talk the patient through this part: "I've got a bucket and towel here for backup. On rare occasions, some people gag or need to spit. It's always good to have a backup plan - just in case." (I lay the towel over his chest and place the emesis basin in his lap, placing the tube in the emesis basin until I'm ready to lubricate it.) "This lidocaine really helps the tube slide through your nose. It will still burn some, but this makes it go much better. Do you breathe better though one side or the other? We want to use the good side because it will be the clearest pathway. Once we get through the nose, the rest is easy. Go ahead and take one swallow of water before we start just wet the pipe. Here's where I need you to be tough. Just let me know when you feel it coming into the back of your throat."

Slowly and gently slide the tube into the nostril, leveling the tube and raising the outer rim of the nostril after inserting about 1-2 cm. Aiming too high pushes the tube up into the turbinates which can cause trauma and bleeding. Don't try to force through significant resistance. Back up slightly and redirect the angle.

Constantly coach and cheer: "This is the worst part, John, and you're doing great. Let me know when you feel it coming into the back of your throat. We're going to stop there for a moment." Patients are great at identifying when we have reached this milestone. They also like the idea that they have earned "a break." Stopping here for about thirty seconds allows me to re-lube the next segment of the tube, reducing friction, pain and potential trauma to the nasal passage.

5. Fifth, swallowing the tube

"You've done the hardest part. Go ahead and take one more swallow of water here just to make sure everything is working right. Okay, John, on the next swallow we're going send the tube with it. We'll go just a few inches to get it past your windpipe and into the path to your stomach. Get a mouthful of water, then swallow when you are ready."

Major point: Getting past the trachea is much easier than getting through the nose. Gag reflexes work well, and this step rarely causes trouble IF we just get past the trachea and stop for another break. Follow the swallow, and go only about 10-12 cm, just enough to get past the trachea. Stop again. If the patient can talk and breathe, the tube is in the esophagus. Many insertions go badly here when the nurse tries to rapidly jam forty to fifty cm of tube on into the stomach all at once. This short break here again is calming and reassuring. They realize that they can still breathe, talk and swallow. I also tell them we are now home free - past the painful nose and the patrol guarding the lungs. The rest is easy. Re-lubricate the next 5 cm of tube heading into the nose and have them swallow a few more times to insert the remainder of the tube.

6. Finally, tiding up the loose ends

If the patient is talking and you can aspirate nasty green liquid (it didn't come from the lungs), the tube is where it belongs. Blowing air into it and listening over the epigastrium is reasonable, but stomach contents are a great confirmation. The more you vacuum out, the more valid the confirmation. I prefer to anchor the tube to the nose with a figure H Band-Aid, with two prongs of the H running up onto the nose (use an alcohol swab to de-grease the nose) and the other two wrapping the tube in opposite directions.

Some of my ideas may be controversial departures from standard practice, but these are things that consistently work well for me in taming the potential torture of NG tube insertions.