ThisnformationsheetfirstpublishedastheJoannaBriggsIntituteMethodsfordeterminingthecorrectnasogastrictubeplacementafterinsertionadults.

Best Practice: evidenceinformation-basedsheetshealthprofessionals2010;14(1):1.-4

Evidence-based information sheets for health professionals

Methods for determining the correct nasogastric tube placement after insertion in adults

RecommendationsInformation Source requiresskillsandexpertiseasplacement

isItrecommendedtouse errorscouleadtopotentiallymajorcapnographyorcolorimetric ThisBestPracticeinformationsheethas complications4,6-7 .capnometryforidentificationof

Researchershavereportedthatinadults,feedingtubeplacementin

beenderivedfromasystematrevicewpublishedin2009inJBILibraryof 8

mechanicallyventilatedadultpatients. tubeplacementerrorsvaryfrom1.3-50%.(Grade A) SystematRevicewsThefull.textofhe Assessmentoftubepositionisanimportan

2

systematrevircewportisavailablefrom

Springgaupressuremanometer theJoannaBriggsIntitutecarecomponenttominimizetherisksofNG

tuberlatedcomplicatiandprovidensformightbeusedtodifferentiateGIfrom(http://www.joannabriggs.edu.au).respiratoryplacementofeeding optimalpatientsafetyandcomfort.

Avarietyofbedsidemethodshavebeentubesinon-mechanicaventilatedlypatients(GradeB) Background usedeitherindividuallyorcombinatioto

assessNGtubeplacementTheseinclude. Magnet-systemtrackingmightbe

Nasogastric(NG)tubesarefrequentlyused

observingforcoughandchoking,intheclinicalsettingforthemanagementof

usedtodeterminegastrointestinal auscultofairtioninsufflatedthroughthefeedingtubeplacement(GradeB).

patientswhorequiredecompressionofthe

gastrointestinal(GI)tract,diagnosisand tube,aspirationofluid,visualinspectionof Sonographymightbeusedfor assessment,nutritionalsupportand theaspirates,testingofaspiratesforpHor

verifyweightedngNGtubes-tip 3 concentrationsofbilirubin,pepsinortrypsinmedicationdmiistrationTheinsertion.

(WNGTs)placement(GradeB). andmanagementofNGubesareobservingforbubblingwhenthetipofthetubeisheldunderwater,testingheability

Visualinspectionofaspirateand proceduresprimarilyundertakenbynurses,howeverthereisawidevariationin tospeak,theuseofmagneticdetection,auscultationareunreliableindicators springgaugepressuremanometer,ofcorrectplacementandshouldnot practice. capnography,colorimetriccapnometryorbereliedupon(Grade. B) TheuseofNGtubesisassociawitedh radiography.

respiratory(pulmonaryaspiration),gastrointestinal(diarrhoea,constipation,nauseaandvomiting),tuberlated Objectives(nasopharyngeulceration,trauma/nasalThepurpofsethisBestPracticeulcers,tubeocclusion,tubedisplacement/InformatSheetionspresentthebestdislodgement,tuberlatedperforation),andavailableevidthatncesupportdecisionsmetabolic(dehydration,electrolytepertainingtomethodsfordeterminingthe

4-6alterations)complicationsInseroft.ionhecorrectnasogastric(NG)tubeplacement

NGtubeisacomplexprocedureand afterinsertion.

Grades of RecommendationTheseGradesofRecommendhationvebeenbasedontheJBI-developed2006

Grades of Effectiveness1

Grade A StrongsupportthatmeritsapplicationGrade B ModeratesupportthatwarrantsconiderationofapplicationGrade C Notsupported

JBI Methods for determining the correct nasogastric tube placement

after insertion in adults Best Practice 14(1) 2010 | 1

Quality of the research Capnographyversus Other methods toTwentytrials-sixwereincludedthe colorimetriccapnometryindifferentiate between

2 verifyingtubeplacementrespiratory andsystematrevicew.

Methods to differentiate AtrialcomparedtheuseofaportableGI tube placementcapnographwithdisposablecolorimetricrespiratory from GI CO indicatordetectinginadvertent2 Springgaugepressurerespiraintoryubationamong130placement mechanicallyventilatedadultpatients(195manometer

gastubeinsertions)rictheintensivecareOnestudyinvestigatedthediagnostic

unitTheresults.demonstratedsensitivity:Sensitivityandspecificityof accuracyofspringgaugepressure

1.00(95%CI0.93-1specificity:.00),1.00colorimetriccapnometryor manometertodifferentiateGIfrom

(95%CI0.97-1PPV:.00),1.00,NPV:1.00,capnographyindifferentiating respiratoryplacementofeedingtubesinrespiratoryfromGItube positlikelihoodveratio:283.(95%35CI 46non-mechanicaventipatientsllyated.17.81-4508andnegat.75)liveklihoodplacement.

Thereferencestandardusewasratio:0.01(95%CI0.00-0The.15)authors.

concludedacolorimetricdevicewasas radiographyFindingsdemons.thrthateTheresultsofthereviewndicathethat springgaugepressuremanometeris100%accurateascapnographyfordetectingCOuseofcapnographyorcolorimetric 2 sensitiveandspcificinidentifyingtubecapnometryisaneffectivemethodin duringplacementofNGubes. location.differenbetweiatingrespiratoryandGISensitivityandspecificityoftubeplacementforadultpatientsA.

Auscultationbiochemicalmeasurementsin

colorimetricdevicewasfoundinonestudy Astudyconducttoedterminethetobeasaccurateascapnographyfor differenbetweeniating sensitivityandspecificofusingtydetectingCO2duringtheplacementofNG respiratoryandGItube auscultationofinsufflatedairtubesThepool.resultsdforsensitivity,placement differenbetweeniatinggastricandspecificpositandivey,negatliveklihood respiratoryplacemeportntthresultsdratioswere0.99,1.00,129.and620.05 Fourstudiesmadeuseofavarietyofcut-ofthreepatienmisplacedwithtubesrespectively. offpointsbaedonthebiochemical determinedbyX-rayTheresults.indicatemeasurementparametersofeedingtube

thauscultationisnotreliablemethodtoColorimetriccapnometryaspiratesfordifferentiatingrespiratoryfrom

GIplacementofeedingtubesOnetrial.differentiategastricandspiratory

Threetrialsevaluatedthediagnostic placement.usedpHaloneNosensitivity.and

accuracyofthecolorimetriccapnometryto

differentiatebetwespiratoryandGIspecificitydatawerereporintedhisstudy

anditwasconcludedbytheauthorsthat Visualinspectionofaspiratesplacementin156feedingtubesAllthree.

anacidicpHvalue(preferably4orless) Onestudyinvestigatedtheuseofvisual

trialsreportedhighsensitivityand obtainedfromnewlyinsertfeedinginspectionofeedingtubeaspiratesinspecificityofthecolorimetriccapnometryin identifyingfeedingtubelocationinthedetectingairwayintubationandhigh

tubewasreasonableindicatorofgastric

respiratoryGItracwasItconcluded.versusrespiratoryplacementTwostudies.

agreementwithreferencestandard thatobservationofthevisualcharacteristradiologicaltechnique.

usedacombinationofpHandbilirubin.

Onestudyconcludedthatthecut-ofoffpH ofeedingtubeaspiratesisoflittvalinue

Capnography>5andbilirubin5andbilirubindeterminthesednsitivityandspecificityof6,pepsin

2 | JBI Methods for determining the correct nasogastric tube placement after insertion in adults Best Practice 14(1) 2010

Methods to differentiate Other methods to Visualinspectionofaspiratebetween gastric and determine the gastric Thediagnosticaccuracyofvisualinspectiintestinal placement placement of NG tubes

ofaspirwastesinvestigatedtrial(n=365observandtions)thefindings

SensitivityandspecificityofSonographyindicathatedhelocationofonly50%ofthefeedingtubeswerecorrectlyidentifie

biochemicalmeasurementsinOnestudyinvestigatedtheaccuracyof usingthismethodSpecific.ofthmethodistytodetectpositionofthemisplacfeeding

differentiatinggastfromic sonographyforverifyweingghtedNG-tip

intestinalplacement tubes(WNGTs)placementin33ICU tubeswasreporttobe0d.48.AuscultationpatientsOfthe35WNGTs,.34were

Ninestudiesmadeuseofavarietyofcut-visualizedbysonographyintheGItract,offpointsdifferentiatinggastfromic andallwereconfirmedbyraiographyThediagnosticaccuracyofauscultatiofor intestinalplacementofeedingtubes. (Sensitivity:0.97;95%CI0.83-1.00)determining.feedingtubelocationwasWhendeterminingtheeffectivenessof investigatedtwostudiesInonestudy.theseparameters,studieseitherevaluatedMagneticdetection involving78nasoenteraltubeplacementinasingletest(pHorbilirubin)ora 46patientsthesensitivitywas0.98and

Threestudiesinvolvingatotalof34healthycombination(pHandbilirubin;pH,pepsin specificiwas0.06,theypositivepredicti

volunteersand134patienvestigatedtsandtrypsSistudiesxn).usedpHalone, valuewas0.80andnegativepredictive

theaccuracyofmagneticdetectingdevicestwoacombinationofpHandbilirubin,and valuewas0.50Inastudy.involving134oneacombinationofpH,pepsinand

ormagnet-trackingsystemtodetermine

patien365dtsobservations,thetrypsinOnestudy.alsoreportthed

gastrointfeestinaldingtubeplacement.

Thereferencestandardusewaseitherauscultationmethodwasabletoidentifyeffectivenessofusingbilirubinalonethe accuratthlocationelyof84%ofalltubes.verificationoftubeplacementThereis.

radiography,fluoroscopyesophageal

manometryThesensitiv.ofusingtySensitivitywas0.45,specificitywas

insufficievidentodeterminecethe reporttobe0d.85,LR+was3.(95%1CImagneticdetectiontodeterminefeeding

optimalcut-pHoffvaluetodifferentiate 1.6-2and.9),LRwas-0.(95%6CI0.4-1.1tubelocatwithinontheGItractishighwith

betweengastrandicntestinalplacements.avalueof1.00intwostudiesThethird.

Acut-ofoffapH

Methods for determining the correct nasogastric tube placement after insertion

Nasogastric

tube insertion

Feeding tube in Feeding tube in Gastrintestinal Weighted-tipmechanically non-mechanically nasogastric tubesfeeding tubeventilated patients ventilated patients (WNGTs)

(Grade B) (Grade B) (Grade B) (Grade B)

Use capnography Use spring gauge Use magnet-pressure Use sonographyor colorimetric tracking system tomanometer to to verify weighted-capnometry for determinedifferentiate GI tip NG tubesidentification of gastrointestinalfrom respiratory placementtube placement tube placementplacement

(Grade A) (Grade B) (Grade B) (Grade B)

Acknowledgements 8. Burns SM, Carpenter R, Truwit JD. Report on thedevelopment of a procedure to prevent placementThisBestPracticeinformationsheetwas of feeding tubes into the lungs using end-tidal CO

developedbyTheJoannaBriggsIntitutemeasurements.. Crit Care Med 2001;29:936-9.

15. Phang JS, Marsh WA, Barlows III TG, Schwartz HI.Determining feeding tube location by gastric andintestinal pH values. Nutr Clin Pract 2004;19:640-4.

16. Pearson A, Wiechula R, Court A, Lockwood C.

References1. The Joanna Briggs Institute. Levels of Evidence

and Grades of Recommendations.

http://www.joannabriggs.edu.au/pubs/approach.ph

p

2. Chau Janita Pak-Chun, Thompson DR, Fernandez R, Griffiths R, Lo Hoi-Shan. Methodsfor determining the correct nasogastric tube placement after insertion: a meta-analysis. JBI Library of Systematic Reviews 2009;7(16):679-787.

3. Phillips NM. Nasogastric tubes: an historicalcontext. Medsurg Nurs 2006;15:84-8.

4. Sanaka M, Kishida S, Yoritaka A, Sasamura Y, Yamamoto T, Kuyama Y. Acute upper airway obstruction induced by an indwelling long intestinal tube: attention to the nasogastric tube syndrome. J Clin Gastroenterol 2004;38:913.

5. Leder SB, Suiter DM. Effect of nasogastric tubes on incidence of aspiration. Arch PhysMed Rehabil 2008;89:648-51.

6. Wu PY, Kang TJ, Hui CK, Hung MH, Sun WZ, Chan WH. Fatal massive hemorrhage caused by

nasogastric tube misplacement in a patient with

mediastinitis. J Formos Med Assoc 2006;105:80-5.

7. Weinberg L, Skewes D.Pneumothorax from

intrapleural placement of

a nasogastric tube.

Anaesth Intensive Care

2006;34:276-9.

9. Metheny NA,

Smith L,

Stewart

BJ.

Develop

ment of a

reliable

and valid

bedside

test for

bilirubin

and its

utility for

improving

prediction

of feeding

tube

location.

Nurs Res

2000;49:

302-9.

10. Burns SM, Carpenter R, Blevins C, Bragg

S, Marshall M, Browne L, Perkins M, BagbyR, Blackstone K, JonathonD. Detectionof inadvertent airwayintubation during gastric tube insertion:capnography versus a colorimetric carbon dioxide detector. Am J CritCare

2006;15:188-95.

11.Howes

DW,Shelley ES,PickettW.Colorimetriccarbondioxidedetector todetermineaccidentaltrachealfeeding tubeplacement.Can JAnaesth

2005;52:428-32.

12. Metheny NA, Stewart BJ, Smith L, Yan H, Diebold M,Clouse RE. pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement. J Parenter Enteral Nutr 1997;21:279-85.

13. Metheny NA, Stewart BJ, Smith L, YanH, Diebold M, Clouse RE. pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. NursRes 1999;48:189-97.

14. Metheny NA, Schnelker R, McGinnis J, Zimmerman G, Duke C, Merritt B, Banotai M, Oliver DA. Indicators of tubesite during feedings. J Neurosci Nurs 2005;37:320-5.

The JBI model of evidence-based healthcare.Int J of Evid Based Healthc 2005; 3(8):207-215.

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Theproceduresdescribedin BestPracticemust onlybe used bypeoplewho haveappropriate expertisein the fieldto whichtheprocedurerelates.Theapplicability of anyinformatio

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Evidence-based Practice ThisBest Practiceinformationsheetpresentsthebestavailableevideonce evidence,thistopicImplications.forpracticeare

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professwiutionallthisliseevidencewithconsiderationoftheircontext,their

judgem

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clients

preferenceandthclinicalirjudg

ement16.

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on these procedures(whether arising incontract, negligence orotherwise) is, to theextent permitted by

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4 | JBI Methodsfor

determinin

g the correc

t nas

ogastric

tube placement

after insert

ion in adults Best Practice 14(1) 2010