• For every stage of management, complete Local Safety Standard for Invasive Procedures (LocSSIP). LocSSIP for insertion of nasogastric/orogastric tube is available on ward
• If not competent in procedure, organise supervision by a clinician experienced in the procedure. 

• To provide a means of temporary nutrition where loss of swallow reflex has occurred or to supplement an inadequate oral diet
• To allow aspiration of stomach contents
• To allow decompression

• Base of skull fracture
• Maxillofacial disorders
• Nasal/pharyngeal obstruction or ulceration
• Choanal atresia
• Tracheoesophageal fistula
• Oesophageal/pharyngeal pouch
• Oesophageal stricture or other abnormalities of the oesophagus
• Oesophageal tumours or have undergone oesophageal surgery
• Oropharyngeal tumours or have undergone oropharyngeal surgery 
• Uncorrected coagulopathy
• Post laryngectomy
• Actively bleeding oesophageal or gastric varices
• Unstable cervical spine injuries (these patients may still require NGT - contact anaesthetist)
• Valid consent not obtained/no best interest decision made

• Nasogastric tube polyurethane (PUR) 8 Fr for enteral feeding (guide wire assisted)
• Ideally nasogastric tube PUR 12/14/16 Fr for aspiration/free drainage of gastric contents (not guide wire assisted) may require clarification on size from clinician 
• Bridle if required, size to match size of tube
• Enteral/purple syringe 50 mL
• pH indicator (CE marked) strips for human aspirate - never use ordinary litmus paper
• Naso-fix adhesive patches or other appropriate dressing to secure tube
• Appropriate PPE
• Appropriate lubricant gel (water soluble) or water
• Receiver/vomit bowl 
• Fresh tap water

• Obtain and record consent - see Consent guidelines

Preparation

• If verbal communication not possible, arrange a signal by which the patient can communicate to nurse/clinician to stop, e.g. by raising his/her hand
• Sit patient in a semi-upright position in bed or chair and support patient’s head with pillows. Do not tilt head forward or backward
• Use Nose-ear-xiphisternum (NEX) measurement to determine length of tube to be inserted  
  
  • extend tip (end which will be inserted into patient) of tube from patient's ear lobe to the bridge of the nose. From the bridge of the nose, extend remainder of tube to the bottom of the xiphisternum. Note the mark on the point of the tube next to the bottom of the xiphisternum (NEX measurement)
• Wash hands and put on appropriate PPE
• Assemble equipment 
• Check nostrils and determine which is more patent/appropriate 
  
  • ask patient to blow his/her nose 
• Check guide wire moves freely in NGT (used for enteral feeding tubes only) 

Insertion

• Insert end of NGT into water for lubrication or add a small amount of lubrication gel to the tip
• Insert rounded tip into the nostril of choice and slide it backwards and inwards along the floor of the nose to the nasopharynx
• if any obstruction is felt, withdraw tube and try again in a slightly different direction
• if patient starts coughing, withdraw slightly and wait for coughing to stop then proceed as above
• if swallowing reflex is present, ask patient to swallow, and/or sip water as the tube passes down into the nasopharynx, to aid passage
• Advance the tube through the nasopharynx, oropharynx and oesophagus until required pre-measured depth reached
  • episodically check oropharynx for curled NGT
  • if patient shows any sign of distress, e.g. gasping or cyanosis, remove tube immediately
• Secure tube to nostril and cheek with adhesive patch

Checking feeding tube position

• Never use the following methods to confirm NGT position: 
  
  • auscultation/whoosh test
  • absence of respiratory distress
• Refer to and complete LocSSIP for insertion of NGT - 'Decision tree for nasogastric tube placement in adults'
• Specialised areas may request X-ray along with pH 
• Do not administer drugs, feed or fluid via the tube until its position has been satisfactorily checked
• Wait at least 1 hr after feeding or medication and flush tube with 5 mL air to displace from gastric lining 
• Aspirate 2 mL of stomach contents with 50 mL syringe and test for acid response using universal indicator test strips for human aspirate - never use ordinary litmus paper
• pH level ≤5.5 will indicate gastric placement - if further clarification required consider chest X-ray 
• If pH 5.0-5.5 recommended a second competent person checks reading/retests to confirm safe pH before X-ray request
  
  • if aspirate cannot be obtained or pH remains >5.5 consult medical staff
    
    • do not feed
    • consider patient's medication which may influence pH
• If no aspirate obtained, attempt re-aspirating after each of the following:
  
  • nurse patient in left lateral position
  • inject 10-20 mL of air using a 50 mL syringe - wait 15-30 min and re-aspirate
  • advance tube 10-20 cm
  • patient who can safely swallow has sipped a coloured drink to determine if it can be aspirated back
  • if still no aspirate do not use NGT. Request chest X-ray
• If correct position confirmed, introduce 10 mL of fresh tap water into tube to activate the internal lubrication and remove the guide wire
• Check pre-measured markings of the NGT at the nostrils remain the same
• Ensure all sections of LocSSIP for insertion of NGT are competed

• If tube has been placed in theatre, ward staff to carry out checks listed in 'Checking feeding tube position' before using tube, see LocSSIP document 

Documentation

• Complete LocSSIP for insertion of NGT
• Record procedure in nursing record and, if undertaken by a doctor, the medical record
  • note size of tube, length passed, and which nostril used

• Once correct position confirmed, NGT can be used immediately
• Emergency feeding regimen – see https://intranet.uhnm.nhs.uk/a-z/Clinicians/medical-and-nursing/nutrition-nurse
• In hours refer to dietician

• If tube placed to decompress and aspirate gastric contents, regular aspiration is required as directed by clinician, at least 4-hrly. (see Surgical Guidelines; Small bowel obstruction, at least 4-hrly). Monitor tube position using initial marking as guide
• If tube displacement suspected, check pH and size marking on tube
• If tube known to have moved, consider repositioning of tube with repeat pH check and possible chest X-ray

• Check tube position against the initial markings, as per original and daily NEX measurement to ensure positioned in the stomach
• Sit patient upright (if clinically appropriate) and aspirate NGT
• If tube displacement confirmed, reposition tube to the correct position/original NEX measurement and document
• If unable to reposition safely, remove old tube and re-pass a new NGT
• Document and inform medical staff of any changes
• If passing a new NGT, complete a new LocSSIP safety checklist or update PDMS accordingly

• Check position by measuring aspirate pH (see Checking feeding tube position above) and record on NGT placement checklist (see LocSSIP document initially, then continue the NGT position checklist)
  
  • after initial insertion and subsequent reinsertions
  • before administering each feed
  • before giving medication
  • after vomiting, retching or coughing (absence of coughing does not rule out misplacement or migration)
  • if evidence of tube displacement (e.g. if tape loose or visible tube appears longer or kinked)
• Check position when chest X-ray taken for another reason
• Check integrity of skin around nostril at frequent intervals for signs of deterioration
  
  • if signs of pressure appear, reposition tube and/or tape, or re-pass NGT via opposite nostril. Datix any pressure damage

Changing nasogastric tube

• When changing NGT, follow manufacturer’s recommendations, PUR tubes can be used for 90 days before replacing
• Pass new NGT via opposite nostril wherever possible