Placement of Nasogastric Tube Explain the procedure of nasogastric (NG) intubation, as well as its benefits, risks, complications, and alternatives, to the patient or the patient's representative. Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards (see the images below), and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect. Aspiration of viscous lidocaine into a syringe. Instillation of viscous lidocaine 2%. Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump NG tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube (see the image below). Estimation of nasogastric tube length from nostril to stomach. Apart from the nose-to-ear-to-xiphisternum (NEX) method, several other methods for determining the length of the tube have been described. Among the various options, a formula based on gender, weight, and nose-to-umbilicus measurement while lying flat was found to be safer and more accurate in a study by Santos et al. [7] Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the NG tube (see the image below). Nasogastric tube lubrication with water-based lubricant. Gently insert the NG tube along the floor of the nose, and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow (see the image below). Continue to advance the NG tube until the distance of the previously estimated length is reached. Patient flexing his neck and drinking water while a nasogastric tube is inserted. Source
