Editing NGT insertion

== Types of tube ==

* Terminology highly variable
* At Austin they seem to refer     to two different types of tube, with slightly unclear differences between     them
** Ryles tube for NGT      suction/drainage
** Levin tube for      feeding/medications

== Contraindications ==

* Basal skull fracture
* Oesophageal stricture
* Oesophageal varices     (relative)
* Bleeding diathesis

== Technique ==

* Local anaesthetic spray     (proven to reduce gagging and discomfort)
* Size to fit: nose to pinna to     sternal angle to xiphisternum
** If, for some reason, this      was not or cannot be measured, the mean distance is 56cm
* Lubrication and insertion     flat along nasal canal
* At 15cm (approaching     trache-oesophageal junction):
** Suck water through straw
** Flex chin towards sternum
** Turn head to either left or      right
* Insert to appropriate depth     (10cm below GOJ)
* For extreme safety, stop     entry at 30cm and CXR to confirm oesophageal placement (if midline on CXR,     continue)
* Secure
* CXR

== Specific situations ==

* Tubes for decompression     should be placed in the fundus
* Tubes for feeding should be     placed in antrum, duodenum or jejunum
* Anaesthetised patients
** If inserting blind, use a      finger in mouth to direct posteriorly, combined with reverse Sellick's      manoeuvre, and using a frozen tube (actually proven to help)
** Laryngoscope if any      difficulties
* Feeding tubes
** Stylet placed and tube      lubricated
** Standard insertion
** Remove stylet and image
** If need to push further,      have to fully withdraw then reinsert with stylet from the start again

== Confirmatory tests: ==

* Soft (not reliable)
** Easy placement to desired      length
** Absence of cough
** Visual inspection of tube      aspirate
** Positive epigastric      auscultation (only 80% sensitive)
* Medium
** pH (mean 3.90 in stomach,      7.73 in lung, 7.35 in intestine) - but can be erroneously acidic in      pulmonary infection
** Bilirubin - high in      intestine, medium in stomach, very low in lung
*** pH <5 and bili < 5 is       98% specific for stomach
*** pH >5 and bili <5 is       100% specific for respiratory
*** pH > 5 and bili > 5       88% specific for intestine
** Capnography
* Hard
** Radiography

== Complications of placement ==

* Respiratory placement
** Pneumothorax
** Pleural effusion
** Bronchoaspiration from      enteral nutrition
* Oesophageal
* Pharyngeal injury
* Intracranial perforation
** Majority basal skull      fractures, mainly due to cribriform plate fracture

== Complications after placement ==

* Oesophagitis/GORD (due to     compromised lower oesophageal sphincter)
* Knotting - need gastroscopy     to remove
* Gastritis/mucosal pressure     necrosis
* Nasal alar ulceration or     necrosis - frequent retaping, especially once discomfort occurs
* Tube obstruction
** Mostly caused by concomitant      administration of medication and enteral feeds
* Clogging
**

== Management ==

* Don't fully spigot - always     aspirate regularly to prevent overdistension of stomach



[[Category:UGIS operations]]
[[Category:Intern education]]