📖 Indications for Nasogastric Tubes (NGTs)
- 🥣 Enteral feeding: In patients who cannot swallow safely (e.g., post-stroke dysphagia, head & neck cancer, critical illness).
- 🧪 Gastric aspiration & decompression: In bowel obstruction, ileus, or before anaesthesia in high aspiration risk patients.
- 💊 Drug delivery: For those unable to take oral medications but with functioning GI tract.
- ⚡ Diagnostic use: Sampling gastric contents for bleeding, toxins, or acidity studies.
⚠️ Risks and Complications
- 🫁 Misplacement into the respiratory tract: The most serious complication. If feeding is commenced into the lungs this is a NHS “Never Event.”
- 🩸 Nasal trauma or epistaxis: From rough or repeated insertions.
- 🪢 Coiling or knotting: Rare but possible during insertion.
- 🤢 Discomfort and gagging: Can cause distress or vomiting if not well tolerated.
- 🦠 Infection risk: Prolonged tubes may cause sinusitis or, rarely, oesophageal ulceration.
🔎 Safe Confirmation of Tube Placement
Ensuring correct placement before starting feeds or medications is mandatory. UK national guidance (NPSA, NHS England) sets out the following:
- 🧪 First-line test: Aspirate & pH check
- Aspirate gastric fluid and test with pH paper.
- pH ≤ 4.0 (or ≤ 5.5 in some trust policies) = safe gastric placement.
- If aspirate is not obtained, reposition the patient and retry before escalating.
- 🩻 Second-line test: Chest X-ray
- Only if aspirate cannot be obtained or pH is equivocal.
- The film must be formally reviewed and documented by a trained clinician — never “eyeballed.”
- Routine X-ray for every NG tube is being phased out due to delays, radiation exposure, and risk of misinterpretation.
🚫 Unsafe and Obsolete Methods
- ❌ Whoosh test: Injecting air into the tube and listening over the stomach with a stethoscope is unreliable and must never be used.
- ❌ Bubble test / water immersion: Placing the tube in water to look for bubbles is dangerous and obsolete.
- ❌ Observing patient for cough or distress: Absence of coughing does not exclude tracheobronchial placement.
✅ Key Safety Messages
- Always confirm placement before using an NG tube for feeding or drugs.
- 🧪 Aspirate + pH is the gold standard at the bedside.
- 🩻 X-ray only if aspiration/pH testing is inconclusive, and only interpreted by trained staff.
- 🚫 Never rely on whoosh tests, bubbling, or clinical signs alone.
📌 Conclusion
NG tubes are essential in modern practice for feeding, decompression, and drug delivery. However, their insertion carries potentially fatal risks if not confirmed correctly. Bedside aspirate pH testing is the cornerstone of safety, while X-ray remains a backup when necessary. Old practices such as the “whoosh test” are unsafe and must be abandoned. Clinicians must adhere strictly to local trust protocols and national safety alerts to prevent never events and ensure patient safety.