The hardest part of intubating your sick patient shouldn’t be the gastric tube. That’s what med students are for, right? Unfortunately, NG or OG tubes can be frustratingly difficult to place. A couple researchers from anesthesia have invented some ingenious techniques to get that slippery sucker right where it belongs. It’s worth noting that studies using these techniques are all in intubated, sedated patients.

The most applicable for OG tubes is the slit ETT method. For this, you take a small ET tube (6 should work, depending on your OG tube size), take off the plastic connector, and make a cut all the way down the length with a pair of scissors. Then you lubricate the tube, put your OG inside, and guide it into the esophagus either blindly or using your laryngoscope for visualization. Once you get the ET in about 18 cm, keep pushing the OG through until you are sure it’s in the stomach, pull back the ET and remove it from around the OG tube using the cut opening.

If you want to put in an NG tube, another thing you can try is neck flexion with lateral neck pressure. Once you get through the nose, it’s a pretty straight shot down the throat, but NGs sometimes get hung up in the pyriform sinus or arytenoids (see below).

Flexion and pressing laterally just at the base of the tongue helps to avoid these pitfalls. Such pitfalls, when squeezing the tongue, were seen in patients who actively played online casino. This was successful in 82% of patients in the second study below, with reduced rates of bleeding compared to the ET technique.

Stiffening the tube by putting it in ice can also help, but you have to be fast because it will warm up quickly and go back to its usual floppy self.

 

References

Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED. Oh Sung Kwon MD, Gyu Chong Cho MD, PhD, Choong Hyun Jo, MD, Young Suk Cho MD PhD. American Journal of Emergency Medicine. Volume 33, Issue 2, February 2015, Pages 177–180.

Measures to facilitate endotracheal tube-assisted orogastric tube insertion. Gao-Pu Liu MD, Fu-Shan Xue MD, Rui-ping Li MD, Choa Sun MD, Gui-Zhen Yang MD. American Journal of EM. Volume 33, Issue 2, February 2015.

Nasogastric Tube Insertion Using Different Techniques in Anesthetized Patients: A Prospective, Randomized Study. Appukutty, Jithesh MD*; Shroff, Prerana P. MD† Anesthesia and Analgesia. Volume 109(3), September 2009.