Version May 2024
INTRODUCTION — Nasogastric and nasoenteric tubes are flexible double or single lumen tubes that are passed proximally from the nose distally into the stomach or small bowel. Enteric tubes that will be removed within a short period of time can also be passed through the mouth (orogastric). This topic will review the indications, contraindications, placement, management, and complications of nasogastric and nasoenteric tubes in the adult inpatient.
INDICATIONS — Nasogastric tubes are indicated for the following reasons:
●Treatment of ileus or bowel obstruction – Gastrointestinal decompression using nasogastric tubes is important for the treatment of patients with bowel obstruction or prolonged ileus. Nasogastric decompression improves patient comfort, minimizes or prevents recurrent vomiting, and serves as a means to monitor the progress or resolution of these conditions. (See "Postoperative ileus" and "Management of small bowel obstruction in adults".)
●Administration of medications – A nasogastric tube may be needed to administer medications, or oral contrast for computed tomography, to patients who cannot swallow or who are neurologically impaired.
●Enteral nutrition – Nasogastric and nasoenteric tubes are used to deliver enteral nutrition into the stomach (gastric feeding) or into the small intestine (postpyloric). (See 'Enteral nutrition' below.)
●Stomach lavage – Lavage may be needed to remove blood or clots to facilitate endoscopy. (See 'Gastric lavage' below.)
Contraindications — Nasogastric intubation is contraindicated in patients with esophageal stricture because of the risk for esophageal perforation, and in patients with basilar skull fracture or facial fracture due to the potential for intracranial misplacement [1,2].
Nasogastric tubes should also be avoided in patients with esophageal varices because tube placement may trigger variceal bleeding, which can be life-threatening. In patients with a bleeding diathesis, minimal trauma to the pharynx, esophagus, or stomach from nasogastric tubes can also lead to severe bleeding, and, thus, tubes are avoided whenever possible.
TYPES OF TUBES — Nasogastric tubes are made of polyvinyl chloride (PVC), polyurethane, or silicone and come in numerous sizes. A variety of tubes are available for gastrointestinal decompression or the administration of medications or enteral formula (table 1). Nasogastric tubes made of PVC (eg, Salem Sump) are relatively stiff and therefore more irritating long-term and are used primarily for gastrointestinal decompression. The most commonly placed nasogastric tube size in adults is 16 Fr, although larger and smaller sizes are available.
The Salem Sump tube is the most commonly used tube for gastrointestinal decompression. The tube has two lumens. The larger lumen is connected to intermittent wall suction for aspiration of gastric contents, or, alternatively, it can be used for irrigation, delivery of medications, or enteral feeding. The smaller lumen vents to atmosphere (equalizes the pressure in the stomach once the gastric contents have been emptied), thus preventing the distal holes from adhering to and damaging the stomach mucosa.
Nasoenteric tubes are more flexible, have a smaller diameter (3.5 to 12 Fr), vary in length (15 to 170 cm), and may be weighted or non-weighted. Although nasogastric tubes can be used as enteric feeding tubes, a feeding tube cannot be used for gastric decompression because its soft walls tend to collapse when suction is applied.
AREAS OF CONTROVERSY
Prophylactic placement — We do not recommend routine prophylactic use of nasogastric tubes for gastric decompression following abdominal/gastrointestinal surgery. When selectively applied, only approximately 10 percent of postoperative patients require nasogastric decompression. If the patient develops a prolonged postoperative ileus or early postoperative small bowel obstruction, then a nasogastric tube is indicated. (See 'Indications' above.)
Postoperative nasogastric decompression after major abdominal or thoracic surgery has been used extensively since its initial introduction by Levin [3]. It was thought that such decompression might reduce postoperative ileus, pulmonary complications, and anastomotic leakage after gastrointestinal and thoracic surgery [4]. However, data do not support this belief and most clinicians argue against prophylactic use of nasogastric tubes following surgery.
Numerous systematic reviews and meta-analyses have shown a lack of benefit from prophylactic nasogastric tube decompression in the postoperative setting, including in a wide range of abdominal and thoracic surgeries (eg, biliary, gastroduodenal, colorectal, gynecologic, trauma, esophageal, and vascular surgery) [4-11]. A meta-analysis of randomized trials and nonrandomized studies published prior to 1995 found that, although vomiting and distension were more common when nasogastric tubes were not routinely used, other parameters were improved [12]. Management of postoperative nausea and vomiting has become more effective with the introduction of antiemetic agents that do not cause drowsiness and respiratory depression (eg, ondansetron). The management of postoperative nausea and vomiting is discussed elsewhere. (See "Overview of post-anesthetic care for adult patients", section on 'Postoperative nausea and vomiting'.)
In light of these data, allowing a nasogastric tube to remain following recovery of anesthesia should only be considered in cases where placement may be difficult or associated with added risks, such as in patients with hiatal hernia, prior stomach or bariatric surgery, esophagectomy patients, or in patients who may not be able to cooperate postoperatively.
Gastric lavage — Nasogastric tubes have traditionally been used to evaluate patients with hematochezia, especially when no concomitant hematemesis is present. It was thought that nasogastric intubation and lavage would distinguish upper from lower gastrointestinal bleeding by confirming a gastric source for blood per rectum. However, the use of nasogastric aspiration and lavage alone has a low sensitivity for predicting an upper gastrointestinal bleeding source. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Approach to acute upper gastrointestinal bleeding in adults", section on 'Nasogastric lavage'.)
Although commonly used in the past, gastric lavage is no longer routinely used in the treatment of poisoning. The specific indications for gastric lavage in these patients are discussed elsewhere. (See "Gastrointestinal decontamination of the poisoned patient", section on 'Gastric lavage'.)
Enteral nutrition — Nasogastric sump-type tubes are often initially inserted for gastrointestinal decompression and then used to deliver medications or enteral nutrition when decompression is no longer needed. Although less prone to clogging, use of a sump-type nasogastric tube in this manner should be limited to a short period of time and the tube replaced with a softer, specifically designed enteral feeding tube to minimize potential complications. Whether to administer feedings into the stomach or postpyloric into the small intestine is discussed in detail elsewhere. (See "Enteral feeding: Gastric versus post-pyloric".)
At what point a nasogastric or nasoenteric tube should be discontinued in favor of percutaneous or surgical gastrostomy tubes for enteral nutrition is unclear [13]. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults".)
TUBE PLACEMENT — Most nasogastric tubes are placed at the bedside in an alert patient. Placement is usually straightforward; however, some patients who have unusual anatomy (eg, gastric bypass, hiatal hernia repair) may require nasogastric tube placement with fluoroscopic or endoscopic guidance [14].
Prior to nasogastric tube placement, the appropriate length can be estimated using several means; however, no single method has been found to be foolproof [15]. A common technique is to use the distance from the tip of the nose to the tip of the ear to the tip of the xiphoid as the initial length of nasogastric tube for insertion. Investigators have found that this method can underestimate or overestimate the length of nasogastric tube needed for proper placement [15,16]. Other measurements such as tip of nose-tip of ear-umbilicus, sternal notch-tip of the xiphoid, tip of nose-umbilicus, body length, and crown-rump length and various formulas using these measurements have also been correlated to the internal esophagogastric length, but these methods are unnecessarily cumbersome. We advise initially placing the nasogastric tube no deeper than the tip of nose-tip of ear-xiphoid distance and stress that all placements should be followed by a plain abdominal radiograph to exclude kinking of the tube and to evaluate for correct placement. If the tube is in the esophagus, it should be advanced into the stomach to ensure adequate stomach decompression. If the tube is beyond the pylorus, it should be pulled back to minimize the potential for electrolyte abnormalities. (See 'Confirmation of placement' below.)
Placement for decompression
Alert patient — In alert adult patients, a soft 14- to 16-Fr Salem sump nasogastric tube provides an adequate diameter for gastrointestinal decompression. The tube, which is coiled in its packaging, should be straightened by pulling on each end prior to placement, and lubricated. Several small randomized trials have found that instillation of local anesthetic spray (eg, preservative free 4% lidocaine spray) helps control gagging and will ease some of the discomfort associated with tube placement [17]. The spray can be intermittently repeated to help lessen discomfort associated with the ongoing presence of the tube. (See 'Management' below.)
The patient should be seated with the head tilted toward the chest. The tube is introduced into one of the nares and advanced horizontally (picture 1). If any resistance is met, the contralateral nostril should be used. When the tube reaches the posterior nasopharynx, the patient may feel like gagging. It is helpful to take advantage of the patient's swallowing mechanism to help passage of the tube into the esophagus and then into the stomach. The patient can be asked to swallow as the tube is being advanced, but it may be more helpful to provide the patient with a cup of water to drink using a straw. If the patient gags excessively or cannot speak, the tube may have entered the trachea. In this case, the tube should be immediately withdrawn and placement re-attempted.
Once the tube is in the stomach and its location is confirmed, further manipulation of the tube is performed depending upon the intended purpose. In general, tubes for decompression are positioned in the gastric fundus and connected to low intermittent wall suction, which decreases the risk of injury to the gastric mucosa. If the nasogastric tube has a venting side-port (eg, Salem Sump), it may be practical to use continuous suction initially to rapidly evacuate accumulated fluid from the stomach, but as the amount of drainage lessens, the tube should be placed to intermittent suction. Although the vent port of these tubes should theoretically prevent mucosal injury, the vent port frequently malfunctions or gets capped inadvertently, essentially converting the tube from a dual lumen to a single lumen tube.
Tubes intended for feeding can be positioned into the antrum, duodenum (postpyloric), or jejunum. (See "Enteral feeding: Gastric versus post-pyloric".)
Intubated patient — When an intubated patient requires a nasogastric tube, we suggest avoiding blind nasogastric tube placement due to the risk of inadvertently placing the tube into the lung, which can occur even with an inflated endotracheal cuff [18]. The best approach is to use a laryngoscope to advance the nasogastric tube into the esophagus under direct vision. However, experienced clinicians, such as anesthesiologists who regularly deal with intubated patients, often use an alternative technique of placing a finger inside the patient's mouth to guide the tip of the nasogastric tube into the esophagus. If resistance is felt or the tube begins to coil, a laryngoscopic is then used. Regardless of how the tube is placed, its position should be verified before instilling anything into the tube. (See 'Confirmation of placement' below.)
A trial that included 216 anesthetized, intubated adult patients compared nasogastric tube placement using the conventional methods with modified techniques, such as a guidewire, neck flexion with lateral pressure, or the reverse Sellick's maneuver (ie, upward traction of the thyroid cartilage to elevate the larynx anteriorly) [19]. In this study, assisted methods were more reliable than conventional techniques for providing successful, quick nasogastric tube insertion on the first attempt. A separate study of 195 intubated patients compared nasogastric tube placement using conventional methods, placement of a slightly frozen tube, or placement of a tube using the reverse Sellick's maneuver [20]. The reverse Sellick's maneuver provided effective placement in 95.2 percent of the patients. Freezing the tube improved successful insertion over traditional insertion (84.6 versus 69.2 percent). We suspect that the combination of the nasogastric tube freezing plus the reverse Sellick maneuver might further increase success rates.
There seems to be some interest in the experimental esophageal guidewire-assisted technique, which was evaluated in a separate trial that randomly assigned 480 patients to the experimental technique or a conventional control technique of nasogastric tube placement with head flexion and lateral neck pressure [21]. The guidewire-assisted technique consisted of esophageal guidewire placement with manual forward displacement of the larynx. The first-attempt success rate was significantly improved for the guidewire-assisted technique (99 versus 57 percent) compared with the control group. However, the technique used in the control group (head flexion and lateral neck pressure) may not be the most reliable blind technique. Also, there remains concern over the cost of the guidewire and the potential that it could perforate the pharynx or esophagus.
Placement for feeding — Soft, small-caliber tubes are commonly used for feeding to minimize patient discomfort. To place an enteral tube, the stylet (for tubes smaller than 12 Fr) is placed into the enteral feeding tube and the tube is lubricated. As with nasogastric tubes, the tube is placed into one of the nares and advancement of the tip is aided by having the patient swallow. Once the position of the tube is confirmed clinically, the stylet is removed carefully, and radiography obtained to confirm the position of the tip.
If the tube is found to be malpositioned, it is important that the stylet is not replaced because doing so can lead to gastrointestinal perforation. Rather, the tube should be removed from the patient, the integrity of the tube verified, the stylet replaced, and the tube reintroduced and positioned. (See 'Complications' below.)
Confirmation of placement
Radiographic confirmation — We always radiographically confirm the position of tubes that will be used to administer tube feeding formula or medications. Although malposition of nasogastric or nasoenteric tubes most commonly involves curling of the tube within the esophagus, placement into the bronchial tree can occur and may lead to disastrous consequences (image 1). (See 'Complications' below.)
Various guidelines agree that the placement of all nasogastric and nasoenteric tubes should ideally be documented with a radiograph of the lower chest/upper abdomen [22,23]. However, confirming the placement of nasogastric tubes used only for gastrointestinal decompression (Salem Sump type) is probably not necessary provided the patient does not have any respiratory complaints or difficulties, and the position of the tube is adequately confirmed by clinical means. (See 'Clinical confirmation tubes used only for decompression' below.)
When obtaining radiographs, it is important to inform the radiologist that the study is being done to specifically to assess nasogastric tube placement. Absence of explicit request regarding tube placement leads to a higher rate of misinterpreted radiographs and unhelpful reports that fail to mention the tube location [24]. The entire course of the tube within the gastrointestinal tract should be seen. Confirmation of proper nasogastric tube placement on plain chest radiograph is made by noting that the tube is centrally located distal to the carina (ie, does not deviate laterally) and continues inferiorly, crossing the diaphragm in a central position into the gastric region below the level of the diaphragm.
While radiography is essential for assuring safe nasogastric tube use, there are some limitations. In one review of 1934 radiographs performed to evaluate nasogastric tube positioning after placement in 891 patients, gastric placement was confirmed in 85 percent, but only 73 percent were deemed safely positioned to allow feeding without repositioning and further radiographic confirmation [25]. Subsequent radiography delayed feeding and drug treatment by over two hours in 51 percent of placements, and 33 percent of patients required more than three radiographs during their enteral episode. These results led the authors to argue in favor of other methods (eg, endoscopy, fluoroscopy, ultrasonography) to guide and confirm tube placement. However, there are issues with these methods, as illustrated in one systematic review that included 10 studies describing ultrasound guidance for nasogastric tube placement (545 participants and 560 tube insertions), in which ultrasound did not have sufficient accuracy as a single test to confirm gastric tube placement [26]. A planned metaanalysis was not performed due to a high level of heterogeneity of methods, including differences of echo window, the combination of ultrasound with other confirmation methods (eg, saline flush visualization by ultrasound), and ultrasound during the insertion of the tube. Other methods such as real-time video-guided placement are even less well studied [27].
Thus, we still advocate routine radiography for patients who require enteral feeding. These images should confirm that the tip of a decompressive nasogastric tube should be positioned into the most dependent portion of the stomach and should not be seen to cross the midline (ie, postpyloric position). If the tip of a Salem Sump type nasogastric tube is found to be postpyloric, it should be withdrawn into the stomach. It should not be allowed to remain in a postpyloric location because these stiff tubes have the potential to damage the duodenal mucosa. Whenever possible, we prefer to place feeding tubes in a postpyloric position to minimize risk of aspiration related to distention of the stomach with feeding. However, the postpyloric placement of feeding tubes does not eliminate the risk of aspiration. (See "Enteral feeding: Gastric versus post-pyloric".)
Clinical confirmation tubes used only for decompression — Once a Salem Sump tube has been positioned, the main lumen is aspirated. Gastric contents are usually obvious based on appearance and volume. Placement into stomach will provide enteric-looking contents that are typically bilious (ie, green in color). Placement within the lung will not provide an aspirate. If an insufficient amount of fluid returns, the tube should be readjusted and the test repeated [28].
Once gastric contents are returned, the tube can be tested by flushing with 20 to 30 cc of warm water with a large syringe (eg, Toomey), and the water immediately suctioned back into the syringe. If most (approximately 70 percent) of the water can be retrieved, the tube is likely in the proper position. It is important to realize that auscultating over the epigastrium during air injection into any tube is not an accurate way to evaluate tube position since the tube may be in too far, or not in far enough. Nursing staff should be informed that the tube placement has only been confirmed clinically, and instructions should be given not to administer any medicines or feeds through the tube without radiological confirmation of placement. If there is any question about the position of the tube, a radiograph should be obtained. (See 'Radiographic confirmation' above.)
While some have advocated using pH testing of the aspirate [29-31], this is also not likely to be helpful and may provide confusing information given the ubiquitous use of proton pump inhibitors. Testing may potentially be improved using a novel 6400 ester-impregnated pH strip. In a study of 376 gastric samples in adult patients in 10 hospitals in the United Kingdom, the ester strips detected 70.2 percent of the gastric samples compared with only 49.2 percent using the standard strip [32]. If these data can be replicated in future research, the use of such strips could change clinical management. However, these strips are still in the experimental stage.
Capnography is an alternative method for verifying nasogastric tube position in mechanically ventilated patients [33,34]. In a systematic review, calorimetric capnography (semiquantitative CO2 monitoring) was a reliable predictor of misplacement of the nasogastric tube into the airway, with a pooled sensitivity and specificity of 0.96 (95% CI 0.88, 0.99) and 0.99 (95% CI 0.96, 1.0), respectively [33]. (See "Carbon dioxide monitoring (capnography)".)
Tube fixation — Once the nasogastric tube is in its proper position, it should be taped securely to the nose, but care should be taken not to push the tube up against the nares because pressure ulceration or necrosis can occur [35]. The nasogastric or nasoenteric tube can then be secured to the patient's gown with a safety pin. (See 'Nasal alar ulceration or necrosis' below.)
Various commercial tapes can be used for this purpose. A retrospective comparison of three types of tape (pink tape, clear tape, "butterfly") in 264 taping episodes reported an advantage for pink tape with a significantly increased time until failure of the securing method (100 versus 56 and 30 hours, respectively) [36]. Duodenal tubes stayed secured significantly longer than sump-type tubes for all taping methods (86 versus 41 hours). The results were independent of patient alertness, confusion, mobility, or use of restraints.
Other, more aggressive methods of securing nasogastric or nasoenteric tubes have been described, and these can be used when the risk of losing the tube justifies the intervention. For example, placing a suture through the membranous nasal septum and securing it to the tube has been described as an alternative to adhesive tapes. However, significant soft tissue damage can occur with chronic tension on the columella [37]. Bridles that pinch the membranous septum provide an anchoring point and are commercially available as an alternative to suturing, but their safety has not been prospectively evaluated, and routine use is not recommended. In patients with distorted anatomy such as due to facial trauma or head and neck surgery, a fine bore suction catheter can be looped around the nasal septum to secure the nasogastric tube in place (figure 1) [38].
MANAGEMENT — The function of nasogastric and nasoenteric tubes should be checked frequently by irrigating the tube with water every four to eight hours.
The drainage from nasogastric tubes placed for gastrointestinal decompression should be documented to help judge the progression or resolution of obstruction/ileus and the need for supplemental intravenous fluid. Fluid and electrolyte replacement for nasogastric losses depends upon the volume and nature of the loss. (See "Maintenance and replacement fluid therapy in adults".)
The measurement of gastric residual volume, while administering enteral nutrition, does not appear to be necessary and is not feasible when the small flexible tubes are used. However, if a larger-bore nasogastric tube is being used, gastric residuals should be periodically checked in order to avoid problems related to gastric overdistension [39]. (See "Nutrition support in intubated critically ill adult patients: Enteral nutrition", section on 'Monitoring and management of complications'.)
Many patients experience oropharyngeal discomfort, which usually resolves in 24 to 48 hours. Local anesthetic spray applied to the oropharynx may alleviate some of the gag reflex and discomfort associated with the presence of a tube [17]. New onset of gagging or respiratory difficulties in a patient with a nasogastric tube should raise the concern of migration into the oropharynx and indicates the need to reevaluate the position of the tube. Any tube that does not appear to be functioning properly should be evaluated and may need to be removed, and replaced if still needed.
Nasogastric tubes should be removed when the indication for placement no longer exists. For example, in patients with a small bowel obstruction, a decrease in nasogastric output and the passage of flatus suggest a resolution of the obstruction and that the tube can be safely removed. A trial of nasogastric drainage to gravity or nasogastric tube clamping are advocated by some as interim maneuvers prior to nasogastric tube removal to minimize the need for tube reinsertion. In contrast, others argue that clamping should not be performed, because it increases the risk of aspiration by allowing gastric distention in the presence of an impaired esophageal sphincter. There is little evidence to justify or discredit this practice. If a clamping trial is used, one should check the gastric residuals at least every four hours. (See 'Pulmonary' below.)
Nasogastric tube removal is generally uneventful (picture 2). If resistance is met upon attempted removal of a nasogastric or nasoenteric tube, removal should be abandoned and radiographs obtained. Nasogastric or nasoenteric tube knotting can occur [40]. (See 'Complications' below.)
COMPLICATIONS
Gastrointestinal — In the gastrointestinal tract, malposition, coiling, or knotting of tubes can occur anywhere along the course of the tube, including pharynx, pyriform sinus, esophagus, stomach, and duodenum [41]. Pharyngeal and pyriform sinus misplacement can be recognized in a patient who complains of significant gagging or emesis. In patients who may not be able to complain, a laryngoscopic examination easily reveals the misplacement. Fluoroscopy or endoscopy may be needed to safely remove a knotted tube.
The presence of a nasogastric or nasoenteric tube impairs the normal function of the lower esophageal sphincter, making the patient more susceptible to reflux of gastric contents that may lead to esophagitis, esophageal stricture, gastrointestinal bleeding, or pulmonary aspiration. The development of new-onset epigastric or chest pain suggestive of acid reflux may indicate the development of esophagitis, and, ideally, the tube should be removed [42]. For patients who continue to require the tube, suppression of gastric acid secretion may be indicated. The treatment of gastroesophageal reflux is discussed in detail elsewhere. (See "Medical management of gastroesophageal reflux disease in adults".)
Nasogastric tubes can cause gastritis or gastric bleeding due to chronic irritation or pressure necrosis due to suctioning of the gastrointestinal mucosa [43]. This is usually recognized when the aspirated gastric contents become guaiac positive or grossly bloody. Patients with bloody gastric drainage require further evaluation, and, whenever possible, the nasogastric tube should be removed. (See "Acute hemorrhagic erosive gastropathy and reactive gastropathy".)
Esophageal bezoar has been reported as a consequence of improper nasogastric tube placement [44].
Pulmonary — The risk for pulmonary complications is increased in patients with nasogastric tubes. Avoidance of prophylactic postoperative nasogastric decompression decreases pulmonary complications and has other beneficial effects. (See 'Prophylactic placement' above.)
A systematic review identified 28 trials in which patients were randomly assigned to no nasogastric tube or selective nasogastric tube placement [4]. Among 19 of these trials looking at pulmonary complications, a subanalysis identified a trend toward decreased pulmonary complications in those patients who did not have a nasogastric tube, but the difference was not significant. However, an updated meta-analysis that included four additional trials did find an increased risk of pulmonary complications (odds ratio 1.45, 95% CI 1.1-1.92) [5]. Pulmonary complications were increased in patients with a nasogastric tube undergoing upper gastrointestinal surgery but not in patients undergoing colorectal surgery.
Intubation of the lung and inadvertent administration of medications, radiocontrast media, or enteral formula through the malpositioned tube (image 1) can lead to pneumonia. Pulmonary abscess may result [45]. Tracheal perforation and pneumothorax have also been reported. Proper placement and positioning of these tubes and radiographic confirmation of position for any tube used for the administration of medications or enteral nutrition can help prevent these complications. (See 'Tube placement' above.)
Nasal alar ulceration or necrosis — As mentioned above, improperly securing the tube or placement of too large a tube in an unconscious patient who cannot convey his/her discomfort can lead to pressure ulcers and even alar necrosis [46]. Frequent retaping of the tube to decrease pressure on any particular point may help to prevent this complication. Other methods of tube fixation may be needed. (See 'Tube fixation' above.)
If irritation persists and gastric decompression is still needed, replacement of the tube into the opposite nare should allow the affected side to heal with the understanding that the same problem may occur on that side. If gastric decompression is still needed, placement of a gastrostomy tube (percutaneous, surgical) represents a better long-term solution.
Other — There have been case reports of patients experiencing nasal congestion or rhinosinusitis. Avoidance of routine nasogastric intubation during surgery, early removal when they are used, and early placement of gastrostomy tubes for longer-term gastric decompression has likely contributed to a decline in incidence [47-49]. If the patient's symptoms are mild, removal of tube from one nare and repositioning in the other nare may offer relief. More significant symptoms are managed in consultation with an otolaryngologist [50].
In the context of endotracheal intubation, the diagnosis and treatment of nosocomial rhinosinusitis is reviewed elsewhere. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Sinusitis'.)
Perforation — In addition to potential perforation of pulmonary structures or the gastrointestinal tract, nasogastric and nasoenteric tubes can perforate other structures in patients with certain pathologic conditions. Patients with prior esophageal or gastric surgery are at risk for gastrointestinal perforation, and patients with facial trauma are at risk for cribriform plate perforation and intracranial intubation [1,2].
SUMMARY AND RECOMMENDATIONS
●Nasogastric and nasoenteral tubes – Nasogastric and nasoenteric tubes are flexible double or single lumen tubes that are passed proximally from the nose or mouth distally into the stomach or small bowel. In adults, they are used for gastrointestinal decompression in the treatment of small bowel obstruction or prolonged severe ileus, administration of medications or enteral nutrition, and occasionally for gastric lavage. (See 'Introduction' above and 'Indications' above.)
●Nasogastric tube use – We recommend not using prophylactic postoperative nasogastric tubes after gastrointestinal or abdominal surgery (Grade 1B). Although nasogastric or orogastric tubes are placed in the operating room for gastrointestinal decompression during surgery, the majority of these tubes should be removed once the patient is alert and recovered from anesthesia. In the past, routine postoperative gastrointestinal decompression was thought to speed the return of gastrointestinal function following thoracic or abdominal surgery. However, the time to return of bowel function was not significantly changed and could even be delayed. (See 'Prophylactic placement' above.)
●Contraindications – Nasogastric and nasoenteric tube placement is contraindicated in patients with esophageal stricture, and every effort should be made to avoid their use in patients with esophageal varices or a bleeding diathesis. Nasal intubation is contraindicated in patients with basilar skull fracture or facial fracture; these patients should undergo oral tube placement. (See 'Contraindications' above.)
●Types – Nasogastric and nasoenteric tubes are available in multiple sizes and lengths (table 1). Dual lumen sump tubes are most commonly used for gastrointestinal decompression. Although sump tubes can be used for the administration of medications and for enteral nutrition, these tubes are stiff and irritating. Specifically designed, flexible, small-diameter enteral tubes are preferred for long-term nutrition. (See 'Types of tubes' above.)
●Placement – The majority of nasogastric and nasoenteric tubes can be placed at the bedside. For tubes that will be used only for gastrointestinal decompression, initial confirmation of the tube's position by clinical means is usually adequate. However, we always radiographically confirm the position of any tube that will be used to administer tube feeding formula or medications. (See 'Confirmation of placement' above.)
●Routine care – The proper functioning of nasogastric and nasoenteric tubes should be routinely checked every four to eight hours by irrigating the tube. The drainage from tubes placed for gastrointestinal decompression should also be documented to help judge the progression or resolution of obstruction/ileus and requirements for supplemental intravenous fluid. Tubes are removed when the indication for their use is no longer present. (See 'Management' above.)
●Complications – Complications of nasogastric tubes are a consequence of tube placement (eg, perforation, pulmonary abscess), chronic irritation of the gastrointestinal tract (eg, gastritis, ulcer), or altered physiology (eg, reflux) due to the presence of the tube. Other less common complications can also occur. Proper placement and confirmation of positioning should prevent many of these complications. When gastrointestinal reflux, gastritis, or ulcer is identified, the tube should be removed (ideally) and other treatment measures instituted as indicated. (See 'Complications' above.)
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