What Xray To Order For Ng Tube Placement – The purpose of this post is to highlight the need for protocols to promptly identify misplaced nasogastric tubes (NGTs) on position control chest x-rays (CXR). Such protocols should be in place in each department to prevent “never events” such as endobronchial NGT feeding.
“Never events” are serious, preventable patient safety events that should not occur if preventive measures are in place . A single case of misplaced endobronchial NGT feeding has resulted in at least 21 deaths in the UK since 2005, including 12 due to X-ray misinterpretation . In the UK, guidance on the use of X-rays to validate NG tube placement is well established . In addition, the Royal College of Radiologists (RCR) specifies that radiological examinations must be reported in a timely manner . We are investigating…
What Xray To Order For Ng Tube Placement
A prospective review was conducted between May and July 2013. All CXRs taken to confirm NGT status during business hours (Monday to Friday 9am to 5pm) are identified. A 2-month review identified 57 CXRs taken for NGT status check. Only 33 (61%) of these were reported, with an average reporting time of 39 hours. 12 NGTs (21%) were not correctly placed, and of these, 11 were reported at 24 hours after placement. Misplaced tubes are identified at the following locations (see Figure 2 and Figure 3):…
Confirming Ng Tube Position
Procedures should be in place to ensure that chest x-rays taken during daytime business hours are reported to confirm inappropriate nasogastric placement before the patient leaves the radiology department. This will prevent inappropriately placed tubes being used to feed the ward. Check the NGT radios for reporting from the radiologist on duty the next morning. Care should be taken to develop the skills of the radiographer so that they can evaluate the x-rays of a misplaced NGT and alert the medical team accordingly. hopefully…
National Patient Safety Agency. When Events Annual Report 2010/11. http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=83471&type=full&servicetype=attached National Patient Safety Agency. Patient Safety Alert NPSA/2011/PSA002. To reduce harm from misplacement of nasogastric feeding tubes in adults, children and infants. http://www.nrls.npsa.nhs.uk/easysiteweb/getresource.axd?assetid=129696 Royal College of Radiologists. Standards for communication of critical, urgent and unexpected significant radiological findings. Second edition. http://www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=375 If you wish to re-use this article or all of it please use the link below which will take you to the Copyright Release RightsLink service- center . You’ll be able to get quick pricing and instant permission to reuse content in many different ways.
Our patient required nasogastric tube (NGT) feeding with no nutritional deficiencies. He was conscious while inserting the NGT. Two attempts were necessary for this cough. On the second try, the cough was full but subsided. NGT insertion can be difficult in an awake patient, especially if there are neurological deficits. Position should be optimized by keeping the patient upright and inserting the NGT horizontally and posteriorly. A proper insertion attempt should feel smooth, with minimal or no resistance. More importantly, the patient should not suffer if the NGT has entered the esophagus correctly. NGT malposition is suggested if cough, respiratory distress or tachypnea persists if the NGT is inserted to the desired length. If this occurs, as in our patient, consider NGT reinsertion.
Chest X-ray was taken to check NGT status because no aspirate could be obtained for pH testing (Figure 1). At first glance, the NGT tip is visible under the right diaphragm, however, examination may suggest otherwise. National Patient Safety Agency guidelines suggest a four-step approach to confirm NGT status, tubes: (1) avoid bronchial contours; (2) divides the carina; (3) crosses the diaphragm in the midline and (4) its tip is visible below the left hemidiaphragm. 1 Following this approach reveals that the NGT entered the right main bronchus and its tip entered the lower part of the dome. diaphragm It did not cross the diaphragm in the middle line. Starting to eat in this situation will lead to disastrous results. The ability to safely assess nasogastric (NG) tube placement is a key skill that medical students need to develop. Assessment of NG tube placement requires a systematic approach and a willingness to seek senior assistance if unsure prioritizing patient safety. Incorrect placement of the NG tube can lead to life-threatening complications (such as aspiration pneumonia).
Confirming Feeding Tube Placement: Old Habits Die Hard
This guide is intended to provide you with a systematic approach to confirm safe NG tube placement in the OSCE setting and should not be relied upon outside of this setting (always follow local guidelines).
When inserting an NG tube for feeding and/or medication, you must secure the tube before using it. Incorrect placement of the NG tube can lead to life-threatening complications (such as aspiration pneumonia).
Gastric contents have a low pH (1.5-3.5) while respiratory tract secretions have a much higher pH. ² This difference makes it possible to determine the safe position of the NG tube using the pH test only if the pH is within a safe range. typically 0 – 5.5).¹
The acceptable pH range to confirm NG tube placement can vary, so always follow your local medical school and/or hospital guidelines. Additionally, some hospitals may require a chest x-ray to confirm safe placement of all NG tubes regardless of NG aspiration results, so always consult your local guidelines.
Newborn Status Post Nasogastric Tube Placement
You may also be interested in our OSCE flashcard collection, which has over 2000 flashcards covering clinical examinations, procedures, communication skills and data interpretation.
If pH testing of the NG aspiration is not possible, a chest x-ray can be used to confirm safe placement of the NG tube.
You can identify key anatomical landmarks on a chest x-ray if you want to safely confirm NG tube placement using this imaging modality.
The esophagus is difficult to see directly on a chest X-ray. It is usually on the left side of the trachea and in the middle of the aortic arch. The normal esophagus passes through the diaphragm and enters the stomach at the gastroesophageal junction (GOJ).
Nasogastric Tubes 1: Insertion Technique And Confirming Position
If none of the above criteria are met and/or you have any doubts about the placement of the NG tube, you should consult a senior colleague or discuss it with the on-call radiologist.
The NG tube can be placed in the left or right main bronchus but still appear in the midline (hence why the single criterion of an NG tube appearing in the midline is not satisfactory evidence to confirm safe placement).
An NG tube can curl on itself, meaning the tip is positioned higher than it should be which can result in reflux and aspiration of NG tube contents. This demonstrates the importance of confirming that you can clearly see the NG tube tip.
This chest x-ray shows an NG tube that has entered the trachea, then the left main bronchus and finally back into the right main bronchus where the tip can be seen.
A Rare Complication Of Nasogastric Tube Insertion
If we evaluate this ray using the criteria for correct NG tube placement, it is clear that this placement cannot be considered safe:
This chest x-ray shows the NG tube entering the trachea, then entering the left main bronchus and then entering the left lung parenchyma and through the visceral pleura. NG tube tip ends in pleural space (with associated pneumothorax). This is an extreme example of misplacement, but it is a good example of why just because the NG tube tip appears near or slightly below the diaphragm does not necessarily confirm that it is in the gastrointestinal tract.
This chest x-ray shows an NG tube that was successfully inserted into the esophagus but at an insufficient length. As a result, although the tip of the NG tube may be inside the stomach cavity, the opening through which the stool is expelled is likely still inside the esophagus. NG tubes that are not inserted long enough can result in esophageal reflux and possible aspiration of the feed. This NG tube should be inserted further and reevaluated with repeated x-rays to ensure placement is appropriate.
Sometimes the NG tube tip is very difficult to visualize and extra wires and/or lines can make the image more difficult to interpret, as the example below shows.
Tubes And Catheters
If the tip of the NG tube is not clearly visible, you should discuss this with an on-call radiologist who can advise:
We have given an example of how you might present your findings after reviewing the position of the NG tube on a chest x-ray.
“This is an AP chest radiograph of an adult [male/female]. The chest x-ray view is adequate and the NG tube can be seen bisecting the carina and remaining at the level of the diaphragm in the midline. The tip of the nasogastric tube is visible below the left hemidiaphragm and the gastro-oesophageal junction than 10 cm Based on these findings, I think the NG tube is safely placed.