Comparing insertion characteristics on nasogastric tube placement by using GlideScope™ visualization vs. MacIntosh laryngoscope assistance in anaesthetized and intubated patients

Role of Endotracheal Tube Cuff Deflation in Facilitating Passage of Nasogastric Tube

Background

Nasogastric tube insertion is a routinely performed technique in anesthetized and intubated patients. However, failure leads to repeated insertion attempts causing injury, which makes the situation cumbersome. Therefore, we introduce a simple technique of deflating endotracheal tube cuff for nasogastric tube insertion in such patients.

Methods

Eighty adult patients scheduled for elective abdominal surgeries were randomly allocated into two groups, Group A (nasogastric tube insertion without endotracheal cuff deflation) and Group B (nasogastric tube insertion with endotracheal tube cuff deflation) along with lateral pressure application at cricoid in both groups. The number of attempts required, overall success rate, the time taken, rescue maneuvers, and incidence of complications were compared between the groups.

Results

In Group B, the total success rate for nasogastric tube placement was significantly higher than in Group A (80% vs 55%, p=0.016). Group B had a 55% first attempt success rate, but only 25% of patients in Group A had a first attempt success rate (p=0.014). The overall time for successful nasogastric tube placement was longer in Group A than in Group B (65.4 ± 28.72 seconds vs 43.5 ± 25.37 seconds, p=0.0005). The differences in nasogastric tube kinking and coiling between Group B and Group A were not statistically significant (20% vs 22.5%, 10% vs 27.5%, p = 0.78 and 0.08, respectively). Mucosal bleeding was substantially higher in Group A than in Group B (30% vs 10%, p=0.025, respectively).

Conclusions

This study showed that endotracheal tube deflation significantly increased the first-attempt success rate, overall successful placement of the nasogastric tube in intubated patients, and incidence of complications like mucosal bleeding decreased.

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients: A meta-analysis

BACKGROUND

Several techniques of nasogastric tube (NGT) insertion have been described in the literature with different success rates.

AIM

To systematically search the literature and conduct a meta-analysis comparing the success rates, insertion time and complications associated with different techniques of NGT insertion in anesthetized and intubated patients.

METHODS

An electronic search of the PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google Scholar databases were performed up to October 31, 2019. We included 17 randomized controlled trials with 2500 participants in the meta-analysis.

RESULTS

As compared to the conventional method, successful insertion of the NGT on first attempt was higher with modified techniques such as the reverse Sellick’s maneuver [relative risk (RR) 1.94; 95% confidence interval (CI): 1.62-2.31], use of a frozen NGT (RR 1.55; 95%CI: 1.13-2.13), inserting the NGT with neck flexion and lateral neck pressure (RR 1.64; 95%CI: 1.10-2.45), endotracheal tube-assisted (RR 1.88; 95%CI: 1.52-2.32) and video-assisted placements (RR 1.60; 95%CI: 1.31-1.95). All the modified techniques also led to comparatively higher insertion success rates than the conventional technique.

CONCLUSION

The use of modified techniques of NGT insertion such as the reverse Sellick’s maneuver, neck flexion with lateral neck pressure, frozen NGT, endotracheal tube-guided or video-assisted methods result in a significantly better chance of successful tube insertion at first attempt as compared to the conventional technique. All modified techniques also significantly improve the overall chance of successful NGT placement as compared to the conventional method.

Using Video-Assisted Laryngoscope (GlideScope®) to Insert a Nasogastric Tube and Prevent Pneumothorax From Incorrectly Inserted Nasogastric Tubes

When indicated, nasogastric tubes (NGT) are often inserted blindly, and the positioning is later confirmed using a chest X-ray (CX-ray). This case describes the blind insertion of an NGT in an 85-year-old nonverbal woman with advanced dementia who developed a pneumothorax (PTX) following NGT insertion. The patient had sepsis due to pneumonia and an infected decubitus ulcer. Because the patient had difficulty swallowing, NGT insertion was blindly performed by a house staff resident, and the tube entered the left lung. A portable bedside CX-ray was performed post-insertion and confirmed that the NGT was in the left lung, with left-sided PTX. An immediate CT of the chest revealed a partial collapse of the left lung. The patient was placed on a nonrebreather mask with 80% oxygen, and immediate insertion of a chest tube (12 Fr catheter) resulted in a subcomplete resolution of the PTX on the left side, with remaining apical PTX. Because an NGT was still required to feed the patient, we used a video-assisted laryngoscope (VAL) to assist with the insertion of the NGT the second time and prevent insertion in the incorrect location. We encourage physicians to consider the insertion of NGT under direct observation using VAL.