Skip to main content
SpringerLink
Log in

Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements

  • Scientific Review
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

The insertion of a tube through the nose and into the stomach or beyond is a common clinical procedure for feeding and decompression. The safety, accuracy and reliability of tube insertion and methods used to confirm the location of the naso-enteric tube (NET) tip have not been systematically reviewed. The aim of this study is to review and compare these methods and determine their global applicability by end-user engagement.

Methods

A systematic literature review of four major databases was performed to identify all relevant studies. The methods for NET tip localization were then compared for their accuracy with reference to a gold standard method (radiography or endoscopy). The global applicability of the different methods was analysed using a house of quality matrix.

Results

After applying the inclusion and exclusion criteria, 76 articles were selected. Limitations were found to be associated with the 20 different methods described for NET tip localization. The method with the best combined sensitivity and specificity (where n > 1) was ultrasound/sonography, followed by external magnetic guidance, electromagnetic methods and then capnography/capnometry. The top three performance criteria that were considered most important for global applicability were cost per tube/disposable, success rate and cost for non-disposable components.

Conclusion

There is no ideal method for confirming NET tip localisation. While radiography (the gold standard used for comparison) and ultrasound were the most accurate methods, they are costly and not universally available. There remains the need to develop a low-cost, easy-use, accurate and reliable method for NET tip localization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Chernoff R (2006) An overview of tube feeding: from ancient times to the future. Nutr Clin Pract 21(4):408–410

    Article  PubMed  Google Scholar 

  2. Kirby DF, Delegge MH, Fleming CR (1995) American gastroenterological association technical review on tube feeding for enteral nutrition. Gastroenterology 108(4):1282–1301

    Article  CAS  PubMed  Google Scholar 

  3. Hodin R, Bordeianou L (2013) Nasogastric and nasoenteric tubes. UpToDate, Wolters Kluwer Health. Accessed 15 Jan 2014

  4. Williams S, McDavid G (2012) Nasogastric tube errors. Casebook. 3 20:10–13

    Google Scholar 

  5. Koopmann MC, Kudsk KA, Szotkowski MJ et al (2011) A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann Surg 253(2):287–302

    Article  PubMed  Google Scholar 

  6. Axelrod D, Kazmerski K, Iyer K (2006) Pediatric enteral nutrition. JPEN J Parenter Enteral Nutr 30(1 Suppl):S21–S26

    Article  PubMed  Google Scholar 

  7. Genu PR, de Oliverira D, Vasconcellos RJ et al (2004) Inadvertent intracranial placement of a nasogastric tube in a patient with severe craniofacial trauma: a case report. J Oral Maxillofac Surg 62:1435–1438

    Article  PubMed  Google Scholar 

  8. Huffman S, Pieper P, Jarczyk KS et al (2004) Methods to confirm feeding tube placement: application of research in practice. Pediatr Nurs 30(1):10–13

    PubMed  Google Scholar 

  9. Institute ECRI (2006) Confirming feeding tube placement: old habits die hard. Pa Patient Saf Auth 3(4):23–30

    Google Scholar 

  10. Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097

    Article  PubMed Central  PubMed  Google Scholar 

  11. Wells GA, Shea B, O’Connell D et al (2014) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute, Ottawa

    Google Scholar 

  12. Hauser J, Clausig D (1988) The House of Quality. Harvard business review. Harvard College, Boston, p 16

    Google Scholar 

  13. House of Quality (QFD) Tutorial (2007–2010) [Interactive online tutorial]. http://www.qfdonline.com/qfd-tutorials/house-of-quality-tutorial. Accessed 7 Apr 2014

  14. Joanna Briggs Institute (2010) Methods for determining the correct nasogastric tube placement after insertion in adults. Best Pract 14(1):1–4

    Google Scholar 

  15. Roberts S, Echeverria P, Gabriel SA (2007) Devices and techniques for bedside enteral feeding tube placement. Nutr Clin Pract 22(4):412–420

    Article  PubMed  Google Scholar 

  16. Turgay AS, Khorshid L (2010) Effectiveness of the auscultatory and pH methods in predicting feeding tube placement. J Clin Nurs 19(11–12):1553–1559

    Article  PubMed  Google Scholar 

  17. Page S (2012) How to check nasogastric tube placement. Clinical nursing skills and techniques. Accessed 12 Feb 2014

  18. Freij RM, Mullett ST (1997) Inadvertent intracranial insertion of a nasogastric tube in a non-trauma patient. Emerg Med J 14:45–47

    Article  CAS  Google Scholar 

  19. Sparks DA, Chase DM, Coughlin LM et al (2011) Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review. JPEN J Parenter Enteral Nutr 35(5):625–629

    Article  PubMed  Google Scholar 

  20. Kearns PJ, Donna C (2001) A controlled comparison of traditional feeding tube verification methods to a bedside, electromagnetic technique. JPEN J Parenter Enteral Nutr 25(4):210–215

    Article  CAS  PubMed  Google Scholar 

  21. Welch SK, Hanlon MD, Waits M et al (1994) Comparison of four bedside indicators used to predict duodenal feeding tube placement with radiography. JPEN J Parenter Enteral Nutr 18(6):525–530

    Article  CAS  PubMed  Google Scholar 

  22. Gharpure V, Meert KL, Sarnaik AP et al (2000) Indicators of postpyloric feeding tube placement in children. Crit Care Med 28(8):2962–2966

    Article  CAS  PubMed  Google Scholar 

  23. Metheny NA, Schnelker R, McGinnis J et al (2005) Indicators of tubesite during feedings. J Neurosci Nurs 37(6):320–325

    Article  PubMed  Google Scholar 

  24. Westhus N (2004) Methods to test feeding tube placement in children. MCN Am J Matern Child Nurs 29(5):282–287 quiz 290–1

    Article  PubMed  Google Scholar 

  25. Metheny N, Reed L, Berglund et al (1994) Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Nurs Res 43(5):282–287

    Article  CAS  PubMed  Google Scholar 

  26. Botoman VA, Kirtland SH, Moss RL (1994) A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition. JPEN J Parenter Enteral Nutr 18(2):154–158

    Article  CAS  PubMed  Google Scholar 

  27. Dimand RJ, Veereman-Wauters G, Braner DA (1997) Bedside placement of pH-guided transpyloric small bowel feeding tubes in critically ill infants and small children. JPEN J Parenter Enteral Nutr 21(2):112–114

    Article  CAS  PubMed  Google Scholar 

  28. Gatt M, MacFie J (2009) Bedside postpyloric feeding tube placement: a pilot series to validate this novel technique. Crit Care Med 37(2):523–527

    Article  PubMed  Google Scholar 

  29. Taylor SJ, Clemente R (2005) Confirmation of nasogastric tube position by pH testing. J Hum Nutr Diet 18(5):371–375

    Article  CAS  PubMed  Google Scholar 

  30. Gilbertson HR, Rogers EJ, Ukoumunne OC (2011) Determination of a practical pH cutoff level for reliable confirmation of nasogastric tube placement. JPEN J Parenter Enteral Nutr 35(4):540–544

    Article  PubMed  Google Scholar 

  31. Stock A, Gilbertson H, Babl FE (2008) Confirming nasogastric tube position in the emergency department: pH testing is reliable. Pediatr Emerg Care 24(12):805–809

    Article  PubMed  Google Scholar 

  32. Phang JS, Marsh WA, Barlows TG et al (2004) Determining feeding tube location by gastric and intestinal pH values. Nutr Clin Pract 19(6):640–644

    Article  PubMed  Google Scholar 

  33. Ireton-Jones CS, Cheney J, Young R et al (1993) Does the use of an enteral feeding tube with a pH-sensitive tip facilitate enteral nutrition? J Burn Care Rehabil 14(2 Pt 1):215–217

    Article  CAS  PubMed  Google Scholar 

  34. Metheny N, Williams P, Wiersema L et al (1989) Effectiveness of pH measurements in predicting feeding tube placement. Nurs Res 38(5):280–285

    Article  CAS  PubMed  Google Scholar 

  35. Berry S, Orr M, Schoettker P et al (1994) Intestinal placement of pH-sensing nasointestinal feeding tubes. JPEN J Parenter Enteral Nutr 18(1):67–70

    Article  CAS  PubMed  Google Scholar 

  36. Ellett ML, Croffie JM, Perkins SM (2005) Gastric tube placement in young children. Clin Nurs Res 14(3):238–253

    Article  PubMed  Google Scholar 

  37. Elpern EH, Killeen K, Talla E et al (2007) Capnometry and air insufflation for assessing initial placement of gastric tubes. Am J Crit Care 16(6):544–549 quiz 550

    PubMed  Google Scholar 

  38. Metheny N, McSweeney Wehrle MA et al (1990) Effectiveness of the auscultatory method in predicting feeding tube location. Nurs Res 39(5):262–267

    Article  CAS  PubMed  Google Scholar 

  39. Neumann MJ, Meyer CT, DUtton JL et al (1995) Hold that X-ray: aspirate pH and auscultation prove enteral tube placement. J Clin Gastroenterol 20(4):293–295

    Article  CAS  PubMed  Google Scholar 

  40. Hernandez-Socorro CR, Marin J, Ruiz-Santana S et al (1996) Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients. Crit Care Med 24(10):1690–1694

    Article  CAS  PubMed  Google Scholar 

  41. Gilbert RT, Burns SM (2012) Increasing the safety of blind gastric tube placement in pediatric patients: the design and testing of a procedure using a carbon dioxide detection device. J Pediatr Nurs 27(5):528–532

    Article  PubMed  Google Scholar 

  42. Sekino M, Yoshitoomi O, Nakamura T et al (2012) A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients. Anaesth Intensive Care 40(1):154–158

    PubMed  Google Scholar 

  43. Holzinger U, Brunner R, Miehsler W et al (2011) Jejunal tube placement in critically ill patients: a prospective, randomized trial comparing the endoscopic technique with the electromagnetically visualized method. Crit Care Med 39(1):73–77

    Article  PubMed  Google Scholar 

  44. Holzinger U, Kitzerberger W, Madl C, et al (2009) Prospective randomised comparison study of two methods of jejunal placement of enteral feeding tubes in critically ill patients: endoscopic versus electromagnetic visualised method. In European society of intensive care medicine. Springer, New York

  45. Elpern EH, Killeen K, Talla E et al (2007) Capnometry and air insufflation for assessing initial placement of gastric tubes. Am J Crit Care 16(6):544–549

    PubMed  Google Scholar 

  46. Meyer P, Henry M, Maury E et al (2009) Colorimetric capnography to ensure correct nasogastric tube position. J Crit Care 24(2):231–235

    Article  PubMed  Google Scholar 

  47. Thomas BW, Falcone RE (1998) Confirmation of nasogastric tube placement by colorimetric indicator detection of carbon dioxide: a preliminary report. J Am Coll Nutr 17(2):195–197

    Article  CAS  PubMed  Google Scholar 

  48. Burns SM, Carpenter R, Truwit JD (2001) Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurements. Crit Care Med 29(5):936–939

    Article  CAS  PubMed  Google Scholar 

  49. Ellett ML, Woodruff KA, Stewart DL (2007) The use of carbon dioxide monitoring to determine orogastric tube placement in premature infants: a pilot study. Gastroenterol Nurs 30(6):414–417

    Article  PubMed  Google Scholar 

  50. Munera-Seeley V, Ochoa JB, Brown N et al (2008) Use of a colorimetric carbon dioxide sensor for nasoenteric feeding tube placement in critical care patients compared with clinical methods and radiography. Nutr Clin Pract 23(3):318–321

    Article  PubMed  Google Scholar 

  51. Araujo-Preza CE, Melhado ME, Gutierrez FJ et al (2002) Use of capnometry to verify feeding tube placement. Crit Care Med 30(10):2255–2259

    Article  PubMed  Google Scholar 

  52. Keidan I, Gallagher TJ (2000) Electrocardiogram-guided placement of enteral feeding tubes. Crit Care Med 28(7):2631–2633

    Article  CAS  PubMed  Google Scholar 

  53. Levy H, Hayes J, Boivin M et al (2004) Transpyloric feeding tube placement in critically ill patients using electromyogram and erythromycin infusion. Chest 125(2):587–591

    Article  PubMed  Google Scholar 

  54. Kline AM, Sorce L, Sullivan C et al (2011) Use of a noninvasive electromagnetic device to place transpyloric feeding tubes in critically ill children. Am J Crit Care 20(6):453–459

    Article  PubMed  Google Scholar 

  55. Powers J, Luebbehusen M, Spitzer T et al (2011) Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement. JPEN J Parenter Enteral Nutr 35(4):535–539

    Article  PubMed  Google Scholar 

  56. Dolan AM, O’Hanlon C, O’Rourke J (2012) An evaluation of the Cortrak enteral access system in our intensive care. Ir Med J 105(5):153–154

    CAS  PubMed  Google Scholar 

  57. Windle EM, Beddow D, Hall E et al (2010) Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness. J Hum Nutr Diet 23(1):61–68

    Article  CAS  PubMed  Google Scholar 

  58. Mathus-Vliegen EM, Duflou A, Spanier MB et al (2010) Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video). Gastrointest Endosc 71(4):728–736

    Article  PubMed  Google Scholar 

  59. Gabriel SA, Ackermann RJ (2004) Placement of nasoenteral feeding tubes using external magnetic guidance. JPEN J Parenter Enteral Nutr 28(2):119–122

    Article  PubMed  Google Scholar 

  60. Ozdemir B, Frost M, Hayes J et al (2000) Placement of nasoenteral feeding tubes using magnetic guidance: retesting a new technique. J Am Coll Nutr 19(4):446–451

    Article  CAS  PubMed  Google Scholar 

  61. Boivin M, Levy H, Hayes J (2000) A multicenter, prospective study of the placement of transpyloric feeding tubes with assistance of a magnetic device. The magnet-guided enteral feeding tube study group. JPEN J Parenter Enteral Nutr 24(5):304–307

    Article  CAS  PubMed  Google Scholar 

  62. Gabriel SA, Ackermann RJ, Castresana MR (1997) A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med 25(4):641–645

    Article  CAS  PubMed  Google Scholar 

  63. Rulli F, Galata G, Villa M et al (2007) A simple indicator of correct nasogastric suction tube placement in children and adults. Endoscopy 39(Suppl 1):E237–E238

    Article  PubMed  Google Scholar 

  64. Gubler C, Bauerfeind P, Vavricka et al (2006) Bedside sonographic control for positioning enteral feeding tubes: a controlled study in intensive care unit patients. Endoscopy 38(12):1256–1260

    Article  CAS  PubMed  Google Scholar 

  65. Greenberg M, Bejar R, Asser S (1993) Confirmation of transpyloric feeding tube placement by ultrasonography. J Pediatr 122(3):413–415

    Article  CAS  PubMed  Google Scholar 

  66. Kim HM, So BH, Jeong WJ et al (2012) The effectiveness of ultrasonography in verifying the placement of a nasogastric tube in patients with low consciousness at an emergency center. Scand J Trauma Resusc Emerg Med 20:38

    Article  PubMed Central  PubMed  Google Scholar 

  67. Slagt C, Innes R, Bihari D et al (2004) A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study. Intensive Care Med 30(1):103–107

    Article  PubMed  Google Scholar 

  68. Young RJ, Chapman MJ, Fraser R et al (2005) A novel technique for post-pyloric feeding tube placement in critically ill patients: a pilot study. Anaesth Intensive Care 33(2):229–234

    CAS  PubMed  Google Scholar 

  69. Ward MM, McEwen AM, Robbins PM et al (2009) A simple aspiration test to determine the accuracy of oesophageal placement of fine-bore feeding tubes. Intensive Care Med 35(4):722–724

    Article  PubMed  Google Scholar 

  70. Karmally Z, Cyron M, Fowler K, et al (2011) Electromagnetic guided feeding tube insertion: enhancing patient safety. In: Abstract 264, t.S.o.C.C.M. conference, San Diego

  71. Elliot S, Ahmed SM, Mallick A (2010) Electromagnetic sensor guided nasojejunal tube placement in critically ill patients, In: E-poster. European society of intensive care medicine. Springer, New York

  72. Mathus-Vliegan E, Ramali M, Singels L, et al (2009) Feasibility and safety of the placement of nasoduodenal feeding tubes by nurses with the assistance of an electromagnetic guidance system (Cortrak). In: American society for gastrointestinal endoscopy. Amsterdam Academic Medical Center Digestive Disease Week, Amsterdam, Netherlands

  73. Gabriel S, Sabry A, Walter H (1998) Guiding nasoenteral feeding tubes into the distal duodenum with magnets: results from 161 intubations. In: 27th educational and scientific symposium, S.o.C.C. Medicine. San Antonio, Texas, p 89A

  74. Tobin RW, Gonzales AJ, Golden RN et al (2000) Magnetic detection to position human nasogastric tubes. Biomed Instrum Technol 34(6):432–436

    CAS  PubMed  Google Scholar 

  75. Gabriel SA, McDaniel B, Ashley DW et al (2001) Magnetically guided nasoenteral feeding tubes: a new technique. Am Surg 67(6):544–548

    CAS  PubMed  Google Scholar 

  76. Heiselman DE, Vidovich RR, Milkovich G et al (1993) Nasointestinal tube placement with a pH sensor feeding tube. JPEN J Parenter Enteral Nutr 17(6):562–565

    Article  CAS  PubMed  Google Scholar 

  77. Bercik P, Schlageter V, Mauro M et al (2005) Noninvasive verification of nasogastric tube placement using a magnet-tracking system: a pilot study in healthy subjects. JPEN J Parenter Enteral Nutr 29(4):305–310

    Article  PubMed  Google Scholar 

  78. Harrison AM, Clay B, Grant MJ et al (1997) Nonradiographic assessment of enteral feeding tube position. Crit Care Med 25(12):2055–2059

    Article  CAS  PubMed  Google Scholar 

  79. Metheny NA, Stewart BJ, Smith L et al (1999) pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Nurs Res 48(4):189–197

    Article  CAS  PubMed  Google Scholar 

  80. Metheny NA, Stewart BJ, Smith L et al (1997) pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement. JPEN J Parenter Enteral Nutr 21(5):279–285

    Article  CAS  PubMed  Google Scholar 

  81. Jimenez EJ, Ugo PJ, Trottier SJ (1998) Placement of nasointestinal pH-sensing feeding tube: a prospective evaluation. S.o.C.C. Medicine, San Antonio, p 89

    Google Scholar 

  82. Krafte-Jacobs B, Persinger M, Carver J et al (1996) Rapid placement of transpyloric feeding tubes: a comparison of pH-assisted and standard insertion techniques in children. Pediatrics 98(2 Pt 1):242–248

    CAS  PubMed  Google Scholar 

  83. Berger MM, Werner D, Revelly JP et al (2003) Serum paracetamol concentration: an alternative to X-rays to determine feeding tube location in the critically ill. JPEN J Parenter Enteral Nutr 27(2):151–155

    Article  PubMed  Google Scholar 

  84. Rivera R, Campana J, Hamilton C et al (2011) Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location. JPEN J Parenter Enteral Nutr 35(5):636–642

    Article  PubMed  Google Scholar 

  85. Octobe TW, Hardart GE (2009) Successful placement of postpyloric enteral tubes using electromagnetic guidance in critically ill children. Pediatr Crit Care Med 10(2):196–200

    Article  Google Scholar 

  86. Hemington-Gorse SJ, Sheppard NN, Martin R et al (2011) The use of the Cortrak enteral access system for post-pyloric (PP) feeding tube placement in a burns intensive care unit. Burns 37(2):277–280

    Article  CAS  PubMed  Google Scholar 

  87. Chenaitia H, Brun PM, Querellou E et al (2012) Ultrasound to confirm gastric tube placement in prehospital management. Resuscitation 83(4):447–451

    Article  PubMed  Google Scholar 

  88. Swiech K, Lancaster DR, Sheehan R (1994) Use of a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral feeding tubes. Appl Nurs Res 7(4):183–189

    Article  CAS  PubMed  Google Scholar 

  89. Kenar J, Echard T, Riley S (2010) Use of an electromagnetic placement device for enteral feeding tubes reduces nursing time and financial burden. In: Critical care medicine. Northwestern Memorial Hospital, Chicago

Download references

Author information

Authors and Affiliations

  1. Department of Biomedical Engineering, University of Auckland, Auckland, New Zealand

    S. A. Milsom

  2. Department of Surgery, Faculty of Medical and Health Sciences, Auckland Clinical School, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand

    J. A. Windsor

  3. St John’s College, Cambridge, UK

    H. Sheahan

  4. Department of Health Science, Auckland University of Technology, Auckland, New Zealand

    J. A. Sweeting

  5. Department of Mechanical Engineering, Auckland University of Technology, Auckland, New Zealand

    E. Haemmerle

Authors
  1. S. A. Milsom
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. A. Sweeting
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. H. Sheahan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. E. Haemmerle
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. A. Windsor
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. A. Sweeting.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 118 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Milsom, S.A., Sweeting, J.A., Sheahan, H. et al. Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements. World J Surg 39, 2243–2252 (2015). https://doi.org/10.1007/s00268-015-3077-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-015-3077-6

Keywords

Search

Navigation