PROCEDURE FOR INSERTING AN ORAL/NASAL
SMALL BOWEL FEEDING TUBE IN CCTC

  1. Select Patient and Contraindications
  2. Obtain Order
  3. Collect Supplies
  4. Prepare for Insertion
  5. Adjust Bed
  6. Measure Placement
  7. Prepare Feeding Tube
  8. Begin Insertion
  9. Advance to Stomach
  1. Confirm Gastric Placement
  2. Position Patient for Entry into Small Bowel
  3. Administer Prokinetic
  4. Introduce Air
  5. Advance Tube to Small Bowel
  6. Auscultate
  7. Secure Tube
  8. Confirm Placement Prior to Feeding
  9. Remove Guidewire
  10. Document

PROCEDURE

RATIONALE FOR PROCEDURE

Overview of Safety Protocol: Prevention of Iatrogenic Pneumothoraces

The procedure for the insertion of any feeding tube in CCTC (gastric or small bowel) requires a TWO step process.  Try to coordinate Step One to other routine Xray's if the timing is appropriate to reduce the number of Xrays.

The goal of Step One is to rule out airway placement and confirm esophageal insertion before additional feeding tube is inserted.   Step One confirmation is completed by CHEST Xray.  The feeding tube tip must be below the level of the carina and there must be confirmation that the feeding tube has not followed either the right or left main stem bronchus.

Optimally, the tip of the feeding tube should be inserted no greater than 5 cm below the carina (to reduce the risk for distal airway advancement and potential pneumothorax in the event of inadvertent airway placement).

Step One must be confirmed before the tube can be advanced to the stomach or small bowel.  Examine the feeding tube distance marking following completion of the Step One Xray.  If the feeding tube tip distance is optimal on chest Xray, document the insertion distance on the Kardex to inform future insertions (e.g., from the right nare optimal Step One distance is 35 cm).  If the Step One chest Xray demonstrates that the feeding tube tip was greater than or less than optimal, modify the recommended distance before documenting to the Kardex.

Step Two confirmation is completed by ABDOMINAL Xray following advancement of the feeding tube to the stomach or small bowel.  This must be completed before a patient can be fed.

Optimizing Small Bowel Placement:

To reduce the chance of coiling of the feeding tube within the stomach and to optimize tube placement within the small bowel (ideally to the jejunum), limit the amount of tubing that is initially advanced during Step Two to 80-90 cm. 

After the abdmonial Xray is taken, leave the patient on the Xray plate while the Xray is examined.  If the feeding tube tip has successfully entered the duodenum, advance the remaining tube (or until resistance is met).  Repeat the abdmoinal Xray after advancement and ensure that the final image is uploaded to Power Chart as placement confirmation.

If the feeding tube is coiled in the stomach at 80-90 cm, do not advance the tube any further.  Remove the wire and attempt gastric feeding (advancing more tube leads to large loops of coiled feeding tube).

Goal for Step One Placement:

Optimal Step One Proximal Right Main Bronchus

Image 1: Chest Xray successfully rules out airway placement. You can use the ruler (red arrow) to measure the distance of the tip from the carina. Step back to view the darkened area of the trachea and branching of the left and right bronchi. The tip of the feeding tube must be below the level of the carina and it should not follow either airway.    If the tube is more than 5 cm below the carina, it has been advanced more than needed to rule out airway placement.

Image 2: This tube is in the right mainstem bronchus.  The proximal location has successfully identified airway placement, without the harm associated with a more distal advancement.

The tip is less than 5 cm beyond the level of the carina which is optimal. Reattempt insertion after removing the feeding tube completely.  Use this same distance for the next attempt.

Carina and Distance
Image 1b: The carina is identified by the top blue arrow. The green line shows the distance from carina to feeding tube tip.

Menu Bar

Image 3: To determine the distance from the tip of the carina, you can click on the ruler from the Centricity menu bar. Drag the line between the carina and the tip of the feeding tube.  In Power Chart the line length will be displayed as 50 mm (maximum distance from carina = 5 cm). In PAX display you can use the cm markers identified by the red arrow in Image 1.

How to estimate the optimal length for Step One:

1. Look at the Kardex to see if the optimal distance has been recorded from a previous attempt

2. Measure from the tip of the nose to ear to xyphoid process and SUBSTRACT 10 cm from the measured length.

3. Oral route: look at the distance marking for the endotracheal tube and ADD 5 cm.

4. Nasal route: look at the distance marking for the oral endotracheal tube and ADD 10 cm.

Following the initial Xray, look at the distance marking for the feeding tube and compare it to the Chest Xray. There can be a lack of precision in the estimation of the optimal insertion distance, especially on the first attempt. If the first Chest Xray reveals that the tube was advanced further (or not far enough) than needed to rule out lung placement, use the Chest Xray and ruler (shown above in Image 3) to identify the optimal insertion distance for future attempts.

Use this information to recommend the distance for future insertions by adjusting the insertion distance. Record the recommended distance for Step One on the Kardex to inform future insertions. When documented the optimal insertion distance on the Kardex, be sure to identify whether this was an oral or nasal insertion.

Two Examples of Step One Insertion depth that is greater than the Goal:

Step One Too Far
Step One Too Far

Image 4: Although this Step One Xray rules out airway placement, this tube was advanced further than desired. The tip was in the stomach. If this tube had entered the airway, lung trauma would have been likely. Document the modified insertion distance on the Kardex to inform future insertions.

Image 5: Although the Step One Xray successfully identified right airway placement prior to further advancement, this tube was advanced too far (with greater risk for harm).

Document the modified insertion distance on the Kardex to inform future insertions.

 

Step Two includes the advancement of the feeding tube, aided by the prior administration of a prokinetic, right sided positioning and administration of air (do not perform any steps that are contraindicated, just perform the ones that are acceptable in this patient).

An abdominal Xray is required following the final advancement, even if the tube was intially observed in the stomach.  Feeding tubes can coil and loop back on themselves and end up with the tip in the esophagus. The only way to ensure that the tube has not kinked backward is via the Abdominal Xray.

Example of Optimal Small Bowel Placement:

Jejunal Placement
Image 6 (above): The feeding tube tip enters the duodenum toward the right. Note that the tube takes a downward turn if it enters the duodenum. The tube continues through the ~ 10 cm of duodenum and turns downward to the left of the sternum as the tube likely enters the jejunum.

Other Examples:

kink at duodenum Barely Duodenal
Image 7 (above): This feeding tube appears to have entered the duodenum but the tip looks to be kinked. Continued advancement of large amounts of tubing can lead to problems seen in Image 10 Image 8 (above): This feeding tube appears to have "turned the corner" into a downward direction that would suggest it is in the very beginning of the duodenum. The hard part is done! Advancing the tube further before removal of the guidewire will usually result in the optimal placement seen in Image 6.
Reason Extra Loops

Image 9 (above): This Xray reveals the reason why an xray should be performed after a tube is advanced. This tube has curled back from the stomach and is heading back up the esophagus instead of toward the duodenum.   Feeding here would lead to aspiration. This tube should be pulled all the way back out. Attempts to pull back a few cm will only result in less loop; the tip direction will remain backwards.

Tubes can kink/fold within the bowel and take a backward journey as well.

Image 10 (above): The tip of this tube is curling upward from the point where the duodenum is expected...this is curling in the stomach (a tube that enters the duodenum heads downward). Because the tube did not enter the duodenum and a signifcant length was added, there is a lot of surplus feeding tube in place.

Several cm of tubing should be withdrawn before the guidewire is removed. Leaving the loop of tubing can lead to knotting.

PROCEDURE FOR INSERTION OF GASTRIC AND SMALL BOWEL FEEING TUBES

 1.

Select Patient

Attempts should be made to insert all feeding tubes into the small bowel during initial placement, using this procedure.

Exception: For patients previously tolerating gastric feeding and requiring frequent feeding tube reinsertions gastric placement is acceptable.

A minimum of two xrays is required for safe placement of all feeding tubes. If initial attempts to place a feeding tube into the small bowel results in gastric placement, initiate feeding via the gastric route, assess for tolerance and re-evaluate the need for small bowel placement.

Contraindications to ORAL or NASAL tube placement by nurse:

  • Esophageal varices (contact GI)
  • Esophageal surgery, e.g., esophagectomy (contact surgical team)
  • Recent ear nose and throat or gastric surgery (contact surgical team)
  • Recent GI bleeding (contact GI or surgical team)

 

Contraindications to NASAL tube placement:

  • Nasal fractures
  • Anterior basal skull fracture
  • Sinusitis
  • Epistaxis
  • If INR > 2.0, review with physician to consider appropriateness of correcting INR to facilitate nasal insertion. If INR is prolonged and there is no contraindication to oral tube placement (above), use oral route for tube insertion (nurse may insert orally).

 1.

A feeding tube that sits in the small bowel results in improved tolerance of feeds and better absorption of nutrients. It may decrease the risk of aspiration in some patients. Bedside placement of small bowel feeding tubes (SBFT) may facilitate earlier feeding (1, 2, 3).

Tube placement may induce bleeding in patients with coagulopathies or varicosities.

Esophageal or gastric incisions may be perforated by tube advancement.

Anterior basal skull fractures may provide a communication between the nasal cavity and meninges that can increase the risk for meningitis. In severe facial and basal skull trauma, feeding tubes could be inadvertently advanced into the cranial cavity (rare), and are associated with sinusitis that could lead to meningitis.

 2.

Obtain Order

Rule out contraindications to feeding tube insertion and check for allergies/sensitivity to erythromycin. Rule out significant QT prolongation (contraindication to erythromycin).

Obtain an order to:

  • Insert a small bowel feeding tube
  • For prokinetic if desired:
    • Metoclopramide 10mg IV 10 minutes before advancement from the stomach to small bowel

or

    • Erythromycin 500 mg in 100 ml IV over 30 minutes (central administration) or 60 minutes (peripheral administation)

Erythromycin is usually the most effective agent and may be the most appropriate option if small bowel placement is critical.

Maxeran may be effective, and has the advantage of shorted wait time following administration to advancement.

.

 2.

Erythromycin has been shown to stimulate gastric motility and facilitate gastric emptying (3) and metoclopramide has been reported to be a successful prokinetic agent for feeding tube advancement (4). Metoclopramide has been changed to the first line agent (previously erythromycin) due to antimicrobial stewardship program. .              

Contraindications to administering erythromycin include allergy or sensitivity. Caution should be used in patients with hepatic insufficiency.  Although both erythromycin and metoclopramide may cause prolongation of the QT interval, the risk for prolongation with a single dose is relatively low. Both drugs are containdicated if significant preexisting prolongation is present. QT is prolonged if the distance from the beginning of the QRS to the end of the T wave is > 50% of the R to R interval (or the QTc is prolonged to > 450-500).



 3.

Collect Supplies  

Feeding tube

60cc syringe

Water for flushing feeding tube

Lubricant

Stethoscope

Tape for securing feeding tube

Gloves

PPE- non-sterile gloves, assess risk for gown and facemask with shield if required

 3.

 4.

Prepare for Insertion

Explain procedure to patient and family.

Hand Hygiene and put on non-sterile gloves.

ALL feeding tube insertions require a minimum of 2 Xrays.

 

 4.

Preparation reduces anxiety and provide an opportunity to answer questions.

This is a clean procedure.

LHSC Hand Hygiene Policy

LHSC Routine Practices

LHSC Donning and Doffing Policy

 5.

Adjust Bed

Patient should be in supine, upright position with HOB ~45 degrees as tolerated (unless contraindicated).

 5.

To facilitate the initial advancement into the stomach.

6.

Measure Placement for First Step Advancement

Remove or withdraw the existing nasogastric or oral tube.

How to estimate the optimal length for Step One:

1. Look at the Kardex to see if the optimal distance has been recorded from a previous attempt

2. Measure from the tip of the nose to ear to xyphoid process and SUBSTRACT 10 cm from the measured length.

3. Oral route: look at the distance marking for the endotracheal tube and ADD 5 cm.

4. Nasal route: look at the distance marking for the oral endotracheal tube and ADD 10 cm.

 

When optimally placed, the feeding tube should be advanced between 2.5 and 5 cm from the carina. Insertion to 30-35 cm is usually optimal for most patients.

 

 6.

 



This measurement will indicate when the feeding tube should have reached the stomach.

If patient has a nasogastric or oral gastric tube in place, it should be removed prior to insertion of the feeding tube as it will interfere with the ability to 'corkscrew' the feeding tube into final position (5).

7.

Prepare Feeding Tube

  1. Dip the tip of the feeding tube in water.
  2. Secure stylet tightly into the feeding tube.
  3. Flush the tube with water.
  4. Flush out water with air. 
  5. Add extra lubricant to tip of tube.

 7.

The stylet provides tube stiffness to facilitate advancement. Flushing activates the lubricant for the tube. The water is flushed out to decrease the risk of inducing coughing, especially if the tube enters the airway. Extra lubricant facilitates easier insertion.

8.

Begin Insertion

Connect the empty luer lock syringe to the guidewire end of the feeding tube. Be sure the feeding tube is firmly inserted and the connection is tight. Cap the medication port at the Y connection.

Utilize the oral route if nasal route is contraindicated (e.g., head injury, sinusitis) or if nasal resistance is met bilaterally.

If the patient has an NG/OG tube in place, identify whether gastric drainage will continue following small bowel placement of the feeding tube. If the NG/OG is to remain in place, review the X-ray to ensure the NG/OG tip is well away from the entry to the duodenum. If the NG/OG is low, withdraw until it is in the fundus. If the gastric drainage tube is not being removed, it should be clamped during insertion.

Gently insert the well lubricated tip of the feeding tube into one nare. If the tube cannot be advanced into the nasopharynx, gently manipulate the tip of the nose (upward and/or side to side) and reattempt. If resistance is met, attempt insertion into the other nare.  Do not force the tube. 

If possible, flexion of the chin toward the chest can open up the nasal channels and make the initial insertion easier.

Once the tube is in the pharynx, ask the patient (if able) to swallow and while slowly advancing the tube. If the patient is not intubated and has an intact gag reflex, you may provide a sip of water to aid in swallowing. If the patient continually coughs or his/her oxygen saturation drops during tube advancement, withdraw the tube and reattempt.

When the tube has been advanced to the ~30cm mark, try to aspirate. If you aspirate air, you are likely in the trachea (unless the connection is loose). If you feel a resistance when you draw back on the plunger and it then returns to its original position when released, you are likely in the esophagus (6) .

 8.


If the NG is at the pylorus, it may interfere with the placement of the feeding tube.

Swallowing during advancement of the feeding tube may facilitate movement into the esophagus.

If the patient is intubated with an ETT or NTT, or is trached or extubated without a gag reflex, do not offer water to facilitate swallowing as it may induce coughing or cause aspiration.

Clamping of the OG/NG prevents loss of air during insufflation.

9.

Advance to Esophagus

Advance the tube to predetermined marking. Usually 30-35 cm is sufficient.

 9.

Airway placement should be ruled out before the tube is advanced into the stomach or small bowel. This 2-step X-ray method protects the patient from harm should the tube be inadvertently placed into an airway. By limiting the intial advancement to 35-40 cm, the tube would remain in the airways, instead of perforating lung tissue.

10.

Confirm Placement in the GI tract

Obtain a CHEST X-ray. Have X-ray assessed to RULE OUT airway placement.  Remind resident to evaluate Xray using usual approach and ensure there are no lung complications such as pneumothorax.

DO NOT do an abdominal X-ray for the first view as the goal is to see the large airways.

Use the electronic ruler in the Xray viewer to determine the amount of feeding tube that extends below the carina. The optimal placement is below the carina, but not greater than 5 cm below the carina.

If the placement is within this distance, note the distance marking on the Kardex and identify whether this is the oral or nasal Step One placement.

If the tip of the feeding tube is less than or greater than optimal, adjust the recommended feeding tube insertion distance accordingly before documenting on the Kardex.

IF FEEDING TUBE IS IN THE AIRWAY:

Fully remove the tube and start the procedure again. Pulling the tube back to the nasopharynx may results in the next attempt also following the airway. Double check the distance to ensure that the tube has not been advanced beyond the ideal. Ensure that this and subsequent xrays are examined closely by the resident to ensure there is no pneumothorax.

Pneumothoraxes induced by feeding tubes often cause symptoms upon removal (if the tube was not restricted to the proximal airway).. The physician should be notified of the potential and prepared for potential chest tube placement.

 10.

Identify the carina on the X-ray. Follow the feeding tube. If the feeding tube follows the path of the trachea and continues into the right or left bronchus, airway placement has occurred and the tube should be pulled out and reinserted. GI placement can be identified if the tube has continued past the carina on chest X-ray (without following a bronchus), or if it is below the hemidiaphragm on an abdominal film.

pH has been reported to be a useful method for assessing tube placement, however, it can not be used to confirm placement. Tracheal secretions are alkaline (pH > 7), whereas, gastric secretions are acidic (pH < 5.5) even when an H2 blocker is used. The pH of small bowel fluid is alkaline (due to pancreatic bicarbonate). Although these guides have been suggested to assist with placement, they are not reliable. Gastric secretions may be alkaline if the patient has been swallowing tracheal secretions or if aspirate obtained from the stomach is closed to the duodenum and reflux has occurred.

11.

Position the Patient for Advancement of the Tube into the Small Bowel

1. Following radiographic confirmation that the feeding tube has not migrated into an airway, advance the feeding tube an additional 20 cm into the upper stomach. Do not advanced beyond this point prior to administration of prokinetics, to avoid curling in the stomach.

2. Position the patient on the right side, with head of bed elevated. Maintain this position during administration of prokinetic agent until tube is advanced.

 

 11.

The stomach empties toward the right into the duodenum (5).

 12.

Administer Prokinetic Agent

Once airway placement has been ruled out, administer maxeran or erythromycin.

Maxeran can be given IV direct 10 minutes prior to advancement to the small bowel.

Erythromycin must be diluted into 100 ml and given over 30 minutes (central) or 60 minutes peripheral.

 12.

Peripheral administration of erythromycin can cause phlebitis.

Intravenous erythromycin may have better efficacy as an agent to enhance motility and advance a feeding tube into the small bowel than Maxeran (3).

13.

Introduce Air Into the Stomach

Within 30 minutes following completion of the erythromycin bolus, or 10 minutes following administration of IV maxeran, begin advancing the feeding tube into the small bowel (step 13 and 14).

If the patient has an NG tube connected to suction, clamp the NG. Inject ~ 300 - 500 cc of air into the feeding tube with a 60 cc syringe. Be sure that the NG has been pulled back prior to insertion.

 

 13.

Air insufflation facilitates opening of the pyloric bulb and stimulates gastric motility (3,5). In adults, stomach volume can be anywhere from 1500 to 2000ml (5)Injection of air may be contraindicated if patient had emesis or excessive nasogastric drainage prior to removal of NG.  Check with physician if uncertain.

If OG/NG remains in place, clamp before insufflation with air.

14.

Advance Tube into Small Bowel

Begin advancing tube with a twisting, corkscrew-like motion in 10cm increments. If mild resistance is felt, continue advancing.  If strong resistance is felt, pull back 10cm and re-advance.  When you let go of the tube and it comes back out on its own, the tube was likely coiled upon itself.  Sudden decreases in resistance may also mean the tube is coiled (6,7). Continue advancing until only 10cm of the tube is visible.

 

 14.

The twisting motion turns the tip of the tube, helping it find the bulb of the pylorus (3,5).

15.

Auscultate

While auscultating over the right upper quadrant, inject 20cc of air.  Do the same over the epigastric region and the left upper quadrant. 

Aspirate from a small bowel feeding tube is usually yellow in color and tests alkaline on a pH test strip.

Flush any aspirated fluid with saline to prevent the guidewire from adhering to the tube.

Note: Neither auscultation or aspirate characteristics provide confirmation of bowel placement. X-ray confirmation is required.

 

 15.

You will hear the air bolus loudest and with a high-pitch over the RUQ if the feeding tube has passed the pylorus.  Sounds to the LUQ will be very quiet (6,7).

16.

Secure the Tube

Secure the feeding tube with tape, being careful not to put pressure on the patient's nares with the tube.  Leave guidewire pending X-ray confirmation.

Identify
the centimeter marking of the tube at the tip of the patient's nose. 
Remove non-sterile gloves and perform hand hygiene.

 16.

Documentation on the Kardex provides a reference to identify if the tube has been pulled out of position. 

 

 

In accordance with the MoHLTC 4 moments of hand hygiene and LHSC infection control policies in an effort to reduce risk of transmission of microorganisms and secretions.

17.

Confirm Placement Prior to Feeding

Obtain an ABDOMINAL X-ray for verification of feeding tube placement. 

If the feeding tube does not enter the small bowel, review with the resident whether gastric feeding would be appropriate. If small bowel placement is desired, the tube can be withdrawn (as long as the guidewire has not been removed) and reinserted. A tube that curls will often follow the same route on a second attempt.

Pull back surplus tubing if there are loops of feeding tube curled in the stomach before guide removal.

Have resident verify X-ray placement and obtain an order "may feed via feeding tube". If the feeding tube has been successfully placed in the small bowel, "nasal small bowel placement" should be identified in the order and documented in the AI record.

 

 17.

Xray confirmation is mandatory prior to administration of medications, flush solutions or feeding. No other method has conclusively confirmed placement. The risk of accidental feeding into a lung is associated with significant morbidity.

18.

Remove Guidewire

Once placement has been verified by the physician, flush the guidewire with saline and gently remove guidewire.


 18.

Do not reinsert guidewire following removal, as the guidewire could puncture the feeding tube wall.

19.

Document Procedure

Document procedure in the AI record. Record feeding tube size and length, final placement marking, technique used and patient response. Document teaching to patient or family.

Record feeding tube size, insertion date and centimeter marking of the tube (at the nare) on the Kardex. 

Note: If tube placement in the small bowel is confirmed, do not check for residuals from the feeding tube. Small bowel feeding may be initiated while gastric drainage is continued.

 19.

To communicate findings and meet documentation standards.

Developed: August 3, 2006
Revised: September 20, 2007
Last Update:  March 8, 2017

Last Reviewed: March 8, 2017
Susan Williams RN BScN CNCC-C, CCTC
Brenda Morgan RN BScN MSc CNCC, CCTC

REFERENCES


1. Powers J, Chance R, Bortenschlager L, et al. Bedside placement of small-bowel feeding tubes in the intensive care unit. Critical Care Nurse. 2003; 23:16-24.

2. Lenart S, Polissar NL. Comparison of 2 methods for postpyloric placement of enteral feeding tubes. American Journal of Critical Care. 2003; 12:357-360.

3. Griffith DP, McNally AT, Battey CH, et al. Intravenous erythromycin facilitates bedside placement of post pyloric feeding tubes in critically ill adults: A double-blind, randomized placebo-controlled study. Critical Care Medicine. 2003; 31:39-44.

4. Booth, CM., Heyland, DK., Paterson, WG. (2002). Gastrointestinal promotility agents in critical care: A systematic review. Crit Care Med. 2002 Jul;30(7):1429-35.

5. Zaloga GP, Roberts PR. Bedside placement of enteral feeding tubes in the intensive care unit. Critical Care Medicine. 1998; 26:987-988.

6. Carroll GC. A Technique that improves the safety of feeding tube insertion. Critical Care Medicine. 2003; 31:1603-1604.

7. Thurlow PM. Techniques, materials and devices: Bedside enteral feeding tube placement in duodenum and jejunum. Journal of Parenteral Enteral Nutrition. 1986; 10:104-105.

8. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients: A prospective study. Chest. 1991; 100:1643-1646.

LHSCHealth Professionals

Last Updated March 8, 2017 | © 2007, LHSC, London Ontario Canada