Nasogastric tube positioning

Last revised by Dr Vikas Shah on 30 Apr 2022

Assessment of nasogastric (NG) tube positioning is a key competency of all doctors as unidentified malpositioning may have dire consequences, including death. 

Radiographic features

Plain radiograph

A correctly placed nasogastric tube should 10:

  • descend in the midline, following the path of the esophagus and avoiding the contours of the bronchi
  • clearly bisect the carina or bronchi
  • cross the diaphragm in the midline
  • have its tip visible below the left hemidiaphragm

Ideally, the tip should be at least 10 cm beyond the gastro-esophageal junction 1.

Malpositioning may include tip position:

  • remaining in the esophagus
  • traversing either bronchus or more distally into the lung
  • coiled in the upper airway
  • intracranial insertion, possible in both patients with and without skull base trauma or surgery 2
  • spinal canal insertion is very rare, occurring after skull base surgery in one case report 8,9

In some circumstances fluoroscopic nasojejunal tube insertion is necessary.

Ultrasound

Point-of-care ultrasonography may be used to guide the nasogastric tube in real time with the probe placed sequentially in the following locations 7:

  • anterolateral neck
    • cervical esophagus typically visualized to the left, posterolateral to the trachea
    • an intraluminal curvilinear echogenic interface represents esophageal placement of the tube
  • epigastrium
    • with a longitudinal view of the gastroesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualization
    • oblique and sagittal scan planes to view the tube coursing through the gastric fundus and terminating in the antrum, confirming correct placement

Complications

Overall, complications occur in 1-3% of cases, with fatal sequelae in ~0.3% of cases. Complications include 1-6,8,9:

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Cases and figures

  • Case 1: appropriate NGT position
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  • Case 2: NG coiled in upper airway
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  • Case 3: NG in distal esophagus
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  • Case 4: NG in right lung
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  • Case 5: NGT coiled in nose
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  • Case 6: appropriate position
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  • Case 7: down both bronchi
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  • Case 8: misplaced nasogastric tube
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  • Case 9: right lower lobe
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  • Case 10: left lower lobe with pneumothorax
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  • Case 11: curved back in the mid esophagus
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  • Case 12: iatrogenic bronchopleural fistula from a Dobhoff tube
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  • Case 13: malposition of nasogastric tube causing right PTX
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  • Case 14: in the left lower lobe bronchus
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  • Case 15: in distal esophagus
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  • Case 16: nasogastric tube in a gastric pull-up
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  • Case 17: nasogastric tube in both bronchi
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  • Case 18: kinked in stomach
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  • Case 19 : right lower lobe
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  • Case 20: misplaced into the left lung
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  • Case 21: Malpositioned NG tube
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  • Case 22: MRI
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