Confirmation of nasogastric tube placement.

I have read the AACN Practice Alert titled "Verification of Feeding Tube Placement" (1) as well as the recent article by Metheny about preventing aspiration in patients with feeding tubes ("Preventing Respiratory Complications of Tube Feedings: Evidence-Based Practice," July 2006: 360-369). My interpretation of these sources is that we should have an initial x-ray to confirm placement of any nasogastric tube prior to administering medication, feedings, and fluids.

Some of my colleagues look at these sources and infer a distinction between a small-bore "feeding" tube and a large-bore nasogastric tube (eg, Salem Sump). In making this distinction, they feel that x-ray confirmation is not necessary for large-bore nasogastric tubes; I don't see that, however. I also notice that the AACN Procedure Manual for Critical Care does not clearly recommend x-ray confirmation for placement of these large-bore tubes. (2) To me, the danger in such an approach is that large-bore tubes are sometimes used for feeding and administration of medications as well as for drainage. This fact leaves several questions unanswered. Should we trust nonradiologic confirmation techniques? Also, what exceptions should we make for Salem Sump tubes when confirming placement?

Kathleen Kunis, RN, MS, CCRN

Petaluma, Calif

REFERENCES

(1.) American Association of Critical-Care Nurses Practice Alert. Verification of Feeding Tube Placement. May 2005.

(2.) Wiegand DJL-M, Carlson KK, eds. AACN Procedure Manual for Critical Care. 5th ed. St. Louis, Mo: Elsevier Saunders; 2005:902.

Norma Metheny replies:

You have raised an important question. The Practice Alert issued by AACN in 2005 recommends radiographic confirmation of correct tube placement prior to initial use in all critically ill patients receiving feedings or medications via blindly inserted tubes. (1) Although it is not explicitly stated, this recommendation refers to all blindly inserted tubes regardless of size or type. The common assumption that bedside assessments work better for large-bore tubes than for small-bore tubes is largely false. A gurgling sound can be heard over the epigastrium when air is injected through a tube, regardless of its size and port configuration (of course, this "auscultatory method" is not reliable). It is easier to obtain an aspirate from a large-bore tube to test its pH and observe its appearance; however, these methods (though far better than the auscultatory method) are not as accurate as radiography.

Whereas clinicians rightly worry about inadvertent respiratory placement of a blindly inserted tube, they also should consider whether the tube is properly positioned in the patient's gastrointestinal tract. Many institutions now require x-ray confirmation that the ports of a nasogastric tube are in the stomach (rather than the esophagus) before the infusion of bowel preparation solutions, medications, or feedings to avoid inadvertent aspiration. (2) As reported in the July 2006 issue of the American Journal of Critical Care, a patient suffered a massive aspiration following the rapid administration of several liters of a bowel preparation solution via an 18 French sump tube that ended in the distal esophagus; the tube was assumed to be properly positioned based on the auscultatory method. (3) There are multiple other reports (4-7) of patients being harmed by substances administered through erroneously positioned large-bore tubes. In all of these situations, nonradiological assessments indicated "correct" placement.

In my view, the cost of an x-ray to confirm correct placement of a blindly inserted tube of any size prior to its initial use to administer formula or medications to critically ill patients is money well spent.

REFERENCES

(1.) American Association of Critical-Care Nurses Practice Alert. Verification of Feeding Tube Placement. May 2005.

(2.) Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract. 2006;21(1):40-55.

(3.) Metheny NA. Preventing respiratory complications of tube feedings: evidence-based practice. Am J Crit Care. 2006;15(4):360-369.

(4.) Godambe SA, Mack JW, Chung DS, Lindeman R, Lillehei CW, Colin AA. latrogenic pleuropulmonary charcoal instillation in a teenager. Pediatr Pulmonol. 2003;35(6):490-493.

(5.) Muthuswamy PP, Patel K, Rajendran R. "Isocal pneumonia" with respiratory failure. Chest. 1982;81(3):390.

(6.) Torrington KG, Bowman MA. Fatal hydrothorax empyema complicating a malpositioned nasogastric tube. Chest. 1981;79(2):240-242.

(7.) Chang JL, Melnick B, Bedger RC, Bleyaert AL. inadvertent endobronchial intubation with nasogastric tube. Arch Otolaryngol. 1982; 108(8):528-529.