Feeding Tubes (Nasogastric, Nasoduodenal, and Nasojejunal)
Dhyanesh A. Patel, MD
Keith L. Obstein, MD, MPH, FASGE, FACG, AGAF
Nasoenteral feeding is an effective means of providing temporary nutrition for the majority of patients who are unable to eat due to medical or psychological comorbidities. Multiple studies in different patient populations have shown that use of enteral nutrition when compared to parenteral nutrition is associated with decreased infectious complications, cost, and hospital length of stay.1,2,3 Bedside nasoenteric tube placement is the most common technique used in the hospital setting and can be placed by a nurse, midlevel provider, or physician. Large bore tubes (14 to 18 French) can also be used for suctioning and should primarily be reserved for nasogastric (NG) placement, while small-bore tubes (8 to 12 French) can be used for nasoduodenal or nasojejunal feeding. Postpyloric feeding may be preferred in patients who are critically ill, as it has been shown to reduce the rate of pneumonia by 30% when compared to gastric feeding.4,5 Furthermore, early enteral nutrition should be considered within 24 to 48 hours in critically ill patients (if there is no contraindication)—as, when compared to withholding or delayed enteral nutrition, it has been shown to reduce mortality (RR = 0.70; 95% CI, 0.49-1.00; P = .05) and infectious morbidity (RR = 0.74; 95% CI, 0.58-0.93; P = .01).5 In patients with severe acute pancreatitis, NG feeding has been recently shown to be noninferior to nasojejunal feeding, and thus the choice of access should be based on institutional resources (i.e., the ease and feasibility of placing small bowel enteral access devices).6 Furthermore, feeding tolerance with either gastric or postpyloric nasoenteral access should be continually assessed to reduce the risk of adverse events.
1. Patient is unwilling or unable to maintain adequate nutrition with oral feeding alone
2. Consider postpyloric feeding (nasoduodenal or nasojejunal) in patients with:
a. Critical illness
b. Abnormal gastric motility
c. History of pulmonary aspiration
d. History of significant gastroesophageal reflux
a. Gastrointestinal tract mechanical obstruction (esophageal, gastric, pyloric, small bowel, or colonic). If foregut obstruction, can consider placement past the obstruction if feasible
b. Severe maxillofacial trauma and/or basilar skull fracture (avoid transnasal tube placement)
a. Short bowel syndrome
c. Severe uncontrolled coagulopathy
d. Large esophageal varices (avoid large bore tube placement)
e. Recent esophageal surgery or perforation (carbon dioxide [CO2] should be used in these cases for insufflation)
1. Be careful when placing nasoenteral tubes in patients with altered mental status, depressed sensorium, or endotracheal tubes who are unable to swallow on request; as the risk of inadvertent placement into the trachea is reported to be 1.3% (with potential risk of bronchopulmonary injury).7 Below are potential methods to reduce this risk:
a. Clinical clues are helpful, but lack adequate sensitivity:
i. Observe patient for cough, hoarseness, or cyanosis
ii. Can consider placing the external end of the tube under water to observe for air bubbles
b. Consider placement using radiographic guidance or direct visualization:
i. Fluoroscopic guidance
ii. Endoscopic guidance
iii. Two-step radiographic guidance: Pass the tube to 30 cm from the nares and obtain a portable chest radiograph and advance the tube only if it is midline
2. Always read the package insert for the feeding tube to be used and examine the tube for defects prior to placement. Review the schematic on the package of the tube for its dimensions.
3. Assess patient for any history of nasal or sinus surgeries and use the most patent nostril. If able, ask the patient to breathe with closure of each individual nostril and ask the patient for preference of which nostril to use.
4. Patient positioning is important and, if able, upright or left lateral positions are helpful in reducing risk of aspiration compared to the supine position.
5. Give nothing by mouth for at least 4 hours and preferably for 6 hours (unless NG access is urgently indicated in patients with severe nausea/vomiting in whom, access is needed for decompression of the gastrointestinal tract).
6. Always review the indications, procedure, risks, benefits, and alternatives with patient (if able) prior to placement of nasoenteral access. Document informed consent based on institutional practice.
7. Always wear gloves and protective eyewear (universal precautions).
1. Choose the diameter of the tube based on the indication. If the patient needs decompression of the gastrointestinal tract, use a large bore tube (14 to 18 French, Fig. 7.1). If the primary indication is enteral feeding or postpyloric placement, use a small-bore tube (8 to 12 French, Fig. 7.2). For adults, 10 French outer diameter provides a good balance between patient comfort and reducing the likelihood of clogging. If the patient is unable to swallow on request or has an endotracheal tube, choose the feeding tube with a tip that is equal to or greater than 5 mm in width.
2. In patients that need both gastric decompression and jejunal feeding, a combined nasojejunal feeding tube with gastric decompression tube can be used.
3. Choose weighted or unweighted feeding tube based on availability. It should be noted that contrary to expectation, unweighted enteral tubes are more likely to pass spontaneously from the stomach to the duodenum to achieve postpyloric placement.8
4. Tubes coated with hydromer water-activated lubricant in the lumen and on the tip should be submerged in water and flushed with a 20-mL syringe of water to activate the hydromer lubricant.
TABLE 7.1 Approximate Distance From Nasal Opening to Varying Locations of the Foregut in an Average Adult Without Any Significant Looping of the Tube
Nasogastric Tube Placement
1. Using the NG tube, measure and mark the distance from the entrance to the patient’s nose to the level just below the diaphragm. Table 7.1 shows the approximate distance from nasal opening to varying locations of the foregut in an average adult without any significant looping of the tube.
2. Place lubricating jelly or 2% lidocaine jelly (can also act as a local anesthetic) into the chosen nostril and also on the NG tube. If available, cetacaine (benzocaine or tetracaine) spray can also be sprayed in the posterior oropharynx for local anesthesia if no contraindications, but it can be rarely associated with a small risk (0.035%) for acquired methemoglobinemia.9
3. With the patient in the appropriate position (preferably sitting upright with head flexed forward), carefully place the NG tube into the nostril, directing it straight back toward the occiput.
4. Once the tip reaches the posterior pharyngeal wall, slight resistance may be felt. Do not advance the tube if significant resistance is felt, which may suggest malposition of the tube, obstruction within the nose, or potential pressure of the tube against the cribriform plate.
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