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Nasogastric tube positioning

Last revised by Daniel MacManus on 1 Mar 2025

Citation, DOI, disclosures and article data

Citation:

Bickle I, MacManus D, Johari A, et al. Nasogastric tube positioning. Reference article, Radiopaedia.org (Accessed on 15 Mar 2025) https://doi.org/10.53347/rID-30966

DOI:

https://doi.org/10.53347/rID-30966

Permalink:

https://radiopaedia.org/articles/30966

rID:

30966

Article created:

11 Sep 2014, Ian Bickle ◉

Disclosures:

At the time the article was created Ian Bickle had no recorded disclosures.

View Ian Bickle's current disclosures

Last revised:

1 Mar 2025, Daniel MacManus

Disclosures:

At the time the article was last revised Daniel MacManus had no financial relationships to ineligible companies to disclose.

View Daniel MacManus's current disclosures

Revisions:

42 times, by 28 contributors - see full revision history and disclosures

Systems:

Gastrointestinal, Interventional

Sections:

Approach

Tags:

ngt

Synonyms:

NG tube position
NGT position
Evaluation of nasogastric tube position

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 oesophagus 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-oesophageal junction ¹.

Malpositioning may include tip position:

remaining in the oesophagus
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 oesophagus typically visualised to the left, posterolateral to the trachea
- an intraluminal curvilinear echogenic interface represents oesophageal placement of the tube
epigastrium
- with a longitudinal view of the gastro-oesophageal junction, the nasogastric tube may be advanced into the stomach under direct visualisation
- 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:

upper airway
- epistaxis from insertion trauma
lower airway
enteral
- GI perforation and mediastinitis or peritonitis
  - may further complicate with intravascular placement
- GI obstruction
- knotting/tangling of the tube
- intramural oesophageal dissection
intracranial and spinal canal
- meningitis
- focal neurological deficits

Quiz questions

References

1. Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg. 2005;4 (5): 429-33. doi:10.1510/icvts.2005.109488 - Pubmed citation
2. Freij RM, Mullett ST. Inadvertent intracranial insertion of a nasogastric tube in a non-trauma patient. (1997) Journal of accident & emergency medicine. 14 (1): 45-7. Pubmed
3. Isik A, Firat D, Peker K, Sayar I, et al. A case report of esophageal perforation: Complication of nasogastric tube placement. (2014) American Journal of Case Reports. 15: 168. doi:10.12659/AJCR.890260 - Pubmed
4. Tai CM, Wang HP, Lee CT, et al. Esophageal obstruction by a tangled nasogastric tube. (2010) Gastrointestinal endoscopy. 72 (5): 1057-8. doi:10.1016/j.gie.2010.03.1131 - Pubmed
5. Hutchinson R, Ahmed AR, Menzies D. A case of intramural oesophageal dissection secondary to nasogastric tube insertion. (2008) Annals of the Royal College of Surgeons of England. 90 (7): W4-7. doi:10.1308/147870808X303128 - Pubmed
6. Duthorn L, Steinberg HS, Hauser H, et al. Accidental Intravascular Placement of a Feeding Tube . (1998) Anesthesiology: The Journal of the American Society of Anesthesiologists. 89 (1): 251.
7. Zatelli M, Vezzali N. 4-Point ultrasonography to confirm the correct position of the nasogastric tube in 114 critically ill patients. (2017) Journal of ultrasound. 20 (1): 53-58. doi:10.1007/s40477-016-0219-0 - Pubmed
8. Hanna AS, Grindle CR, Patel AA, et al. Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. (2012) American journal of otolaryngology. 33 (1): 178-80. doi:10.1016/j.amjoto.2011.04.001 - Pubmed
9. Vahid B. Inadvertent placement of a feeding tube in brainstem and spinal cord. (2007) Internal medicine journal. 37 (8): 577-8. doi:10.1111/j.1445-5994.2007.01410.x - Pubmed
10. NHS Improvement, Resource set - Initial placement checks for nasogastric and orogastric tubes. https://improvement.nhs.uk/documents/193/Resource_set_-_Initial_placement_checks_for_NG_tubes_1.pdf

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