Tl;dr: Failed OGT placement in an intubated patient is common. Try using an 8.0 ETT as an introducer into the esophagus to prevent coiling in the mouth / upper esophagus.

 

Placement of an OGT or NGT can often be challenging in an intubated patient since we can’t ask them to swallow during the procedure. Further, OGT decompression is important in the post-intubation period as it decreases the rates of ventilator-associated pneumonia and increases venous return (via decreased gastric distension).

After a failed attempt at OGT placement, consider using an 8.0 Fr endotracheal tube as an introducer into the esophagus. This technique will prevent early coiling in the mouth or esophagus, thus increasing the likelihood of placement into the stomach. The procedure is as follows:

  1. Obtain an 8.0 ET tube and advance blindly into the oropharynx in a downward fashion (similar to placement of an OGT). Advance slightly deeper to the ETT you recently placed in the trachea. Stop and restart if you meet resistance.
  2. Advance a lubricated NGT through the ETT introducer to the appropriate distance.
  3. Confirm placement with an XR.
  4. The hub on the ETT introducer can easily be removed over the NGT. You may have to cut the ET tube introducer in order to fully remove it.

See the link below for a youtube video on how to pull this off. Shout out to Megha who used this maneuver in cardiac today!

 

Sources:

Willete, P.  Trick of the Trade: Rapid Insertion of Orogastric Tube. ALiEM.com. Available at: https://www.aliem.com/2017/02/trick-rapid-insertion-orogastric-tube/. Accessed Aug 2018.