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Verification of Feeding Tube Placement, AACN Practice Alert, Lecture notes of Human Biology

Small bowel secretions typically have higher pH values (≥6) than gastric juice; thus, observing for pH changes is useful in determining when a ...

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1 of 4 Revised 12/2009
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VERIFICATION OF FEEDING TUBE PLACEMENT
(blindly inserted)
Expected Practice:
Use a variety of bedside methods to predict tube location during the insertion procedure:
o Observe for signs of respiratory distress.
o Use capnography if available.
o Measure pH of aspirate from tube if pH-strips are available.
o Observe visual characteristics of aspirate from the tube.
o Recognize that auscultatory (air bolus) and water bubbling methods are unreliable. [Level B]
Obtain radiographic confirmation of correct placement of any blindly inserted tube prior to its initial
use for feedings or medication administration.
o The radiograph should visualize the entire course of the feeding tube in the gastrointestinal tract and
should be read by a radiologist to avoid errors in interpretation. Mark and document the tube’s exit site
from the nose or mouth immediately after radiographic confirmation of correct tube placement. [Level
A]
Check tube location at 4-hour intervals after feedings are started:
o Observe for a change in length of the external portion of the feeding tube (as determined by movement
of the marked portion of the tube).
o Review routine chest and abdominal x-ray reports to look for notations about tube location.
o Observe changes in volume of aspirate from feeding tube.
o If pH strips are available, measure pH of feeding tube aspirates if feedings are interrupted for more
than a few hours.
o Observe the appearance of feeding tube aspirates if feedings are interrupted for more than a few
hours.
o Obtain an x-ray to confirm tube position if there is doubt about the tube’s location. [Level B]
Scope and Impact of the Problem:
Although often considered an innocuous procedure, blind placement of a feeding tube can cause serious and even
fatal complications.1;2 3 While styleted small-bore tubes are most often associated with complications, large-bore
unstyleted tubes are not without risk.1;4-6 In a review of over 2,000 feeding tube insertions, investigations found that
nasogastric feeding tubes were malpositioned in 1.3 to 3.2 percent7,8 of all insertions; further, 28 percent of the
malpositions resulted in pneumonia or pneumothorax.7 Although rare, feeding tubes may be malpositioned in the
brain, especially in patients with a traumatic defect.4;11-13 Risk for aspiration is greatly increased when a feeding tube’s
ports end in the esophagus.1;9
Supporting Evidence:
Bedside Methods to Determine Placement During Blind Tube Insertion
Signs of Respiratory Distress
Symptoms such as coughing and dyspnea may occur when feeding tubes are inadvertently positioned in the
airway, especially in patients with an impaired level of consciousness.14-16 The occurrence of these signs
should cause removal of the tube and a new insertion attempt.17
Capnography
A carbon dioxide detector is helpful but is not sufficiently sensitive and specific to preclude the need for a
confirmatory x-ray before initial use of a feeding tube.22;23In addition a concurrently used CO2 sensor failed to
detect 2 of the 4 malpositioned tubes.23 Also, a carbon dioxide sensor cannot determine where a feeding
tube’s tip ends in the gastrointestinal tract (esophagus, stomach, or small bowel).1
pH and Appearance of an Aspirate
Fasting gastric pH is usually 5 or less, even in patients receiving gastric-acid inhibitors.24;17;25 Respiratory
secretions typically have a pH greater than 6.15;26 However, because gastric fluid occasionally has a high pH,
(blindly inserted)
Expected Practice:
Scope and Impact of the Problem:
Supporting Evidence:
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1 of 4 Revised 12/

VERIFICATION OF FEEDING TUBE PLACEMENT

(blindly inserted)

Expected Practice:

Use a variety of bedside methods to predict tube location during the insertion procedure:

o Observe for signs of respiratory distress.

o Use capnography if available.

o Measure pH of aspirate from tube if pH-strips are available.

o Observe visual characteristics of aspirate from the tube.

o Recognize that auscultatory (air bolus) and water bubbling methods are unreliable. [Level B]

Obtain radiographic confirmation of correct placement of any blindly inserted tube prior to its initial

use for feedings or medication administration.

o The radiograph should visualize the entire course of the feeding tube in the gastrointestinal tract and

should be read by a radiologist to avoid errors in interpretation. Mark and document the tube’s exit site

from the nose or mouth immediately after radiographic confirmation of correct tube placement. [Level

A]

Check tube location at 4-hour intervals after feedings are started:

o Observe for a change in length of the external portion of the feeding tube (as determined by movement

of the marked portion of the tube).

o Review routine chest and abdominal x-ray reports to look for notations about tube location.

o Observe changes in volume of aspirate from feeding tube.

o If pH strips are available, measure pH of feeding tube aspirates if feedings are interrupted for more

than a few hours.

o Observe the appearance of feeding tube aspirates if feedings are interrupted for more than a few

hours.

o Obtain an x-ray to confirm tube position if there is doubt about the tube’s location. [Level B]

Scope and Impact of the Problem:

Although often considered an innocuous procedure, blind placement of a feeding tube can cause serious and even

fatal complications.1;2^3 While styleted small-bore tubes are most often associated with complications, large-bore

unstyleted tubes are not without risk.

1;4-

In a review of over 2,000 feeding tube insertions, investigations found that

nasogastric feeding tubes were malpositioned in 1.3 to 3.2 percent

7,

of all insertions; further, 28 percent of the

malpositions resulted in pneumonia or pneumothorax.

7

Although rare, feeding tubes may be malpositioned in the

brain, especially in patients with a traumatic defect.

4;11-

Risk for aspiration is greatly increased when a feeding tube’s

ports end in the esophagus.

1;

Supporting Evidence:

Bedside Methods to Determine Placement During Blind Tube Insertion

Signs of Respiratory Distress

• Symptoms such as coughing and dyspnea may occur when feeding tubes are inadvertently positioned in the

airway, especially in patients with an impaired level of consciousness.

14-

The occurrence of these signs

should cause removal of the tube and a new insertion attempt.

17

Capnography

• A carbon dioxide detector is helpful but is not sufficiently sensitive and specific to preclude the need for a

confirmatory x-ray before initial use of a feeding tube.22;23^ In addition a concurrently used CO 2 sensor failed to

detect 2 of the 4 malpositioned tubes.^23 Also, a carbon dioxide sensor cannot determine where a feeding

tube’s tip ends in the gastrointestinal tract (esophagus, stomach, or small bowel).^1

pH and Appearance of an Aspirate

• Fasting gastric pH is usually 5 or less, even in patients receiving gastric-acid inhibitors.

24;17;

Respiratory

secretions typically have a pH greater than 6.

15;

However, because gastric fluid occasionally has a high pH,

(blindly inserted)

Expected Practice:

Scope and Impact of the Problem:

Supporting Evidence:

2 of 4 Revised 12/

the pH method is not sufficiently reliable to rule out the need for an x-ray to distinguish between gastric and

respiratory tube placement. 26

  • Small bowel secretions typically have higher pH values (≥6) than gastric juice; thus, observing for pH changes

is useful in determining when a feeding tube has advanced from the stomach into the small bowel.

24;25;

Using this method, it is often possible to limit the needed number of confirmatory x-rays to one.

  • The pH method has no benefit in detecting placement of a feeding tube in the esophagus. Fluid withdrawn

from the esophagus can be swallowed alkaline saliva or refluxed acidic gastric juice. 28

  • In summary, while the pH method is helpful, it is not sufficiently accurate to eliminate the need for a

confirmatory x-ray prior to first-time use of a feeding tube.

  • Aspirate appearance is not sufficient to eliminate the need for a confirmatory radiograph prior to first-time use

of a feeding tube; there is confusion in differentiating between gastric and respiratory secretions. 15;37;6;16;30-

Listening over Epigastrium for Air Insufflated Through Tube.

  • The auscultatory method is not reliable in distinguishing between respiratory and gastric placement or between

gastric and small bowel placement.

  • There are numerous anecdotal reports of blindly-inserted tube entering the respiratory tract undetected by the

auscultatory method, causing clinicians to assume that the tubes were correctly positioned in the

stomach.

6;15;16;36;38-

In a number of these cases, feedings or medications were administered and led to poor

patient outcomes.

6;16;35;36;40;42-

Radiographic Confirmation

  • A properly obtained and interpreted radiograph is recommended to confirm correct placement of any blindly

inserted tube before its initial use for feedings or medication administration. 1;9;30;45;46^47 Because radiographs

may be misinterpreted,42;44;48^ it is best to have a radiologist read the film to approve use of the tube for

feedings.

1

  • Marking and documenting the tube’s exit site at the time of radiographic confirmation of correct placement will

be helpful in subsequent monitoring of the tube’s location during its use for feedings.

49

Checking Tube Location at Regular Intervals After Feedings are started

Feeding tube dislocation during feedings is a frequent problem. 49-51^ Most often, it occurs when the tube is partially

pulled out during movement or by an agitated patient.

Observing for Change in External Tube Length.

  • Observing for a change in length of the external portion of the feeding tube (as determined by movement of the

marked portion of the tube) may be helpful in detecting tube dislocation.

49-

Reviewing Routine Chest and Abdominal X-ray Reports.

  • Reviewing routine chest and abdominal x-ray reports to determine if the radiologist has referred to feeding tube

location can be quite helpful.

49

Observing For Changes in Volume of Feeding Tube Aspirates.

  • Observing the volume of fluid withdrawn from a tube at 4-hour intervals during continuous feedings or prior to

each intermittent feeding may be helpful.

49

A sharp increase in residual volume may indicate displacement of a

small-bowel tube into the stomach.

  • Consistent inability to withdraw more than a few drops of fluid from the feeding tube may signal upward

displacement into the esophagus.

28

  • It is often difficult to withdraw fluid from small-bore feeding tubes.

52

To avoid this problem, a proven method

53

calls for injecting 20-30 ml boluses of air into the tube with a large syringe (30 ml to 60 ml) and then slowly

applying negative pressure to the plunger to withdraw fluid; it may be necessary to repeat the procedure

several times.

Testing pH of Feeding and Observe the Appearance of Tube Aspirate if Feedings are Off for Several Hours.

  • While feedings should never be interrupted solely for the purpose of pH testing, or observing the appearance

of feeding tube aspirates they are sometimes interrupted in preparation for tests or procedures. If the latter

occurs, pH testing may be useful in distinguishing between gastric and small bowel tube positions.

26;

The pH

method is of minimal benefit during continuous feedings because enteral formula buffers the pH of gastric

secretions. 26 Observing the appearance of feeding aspirates may be useful in distinguishing between gastric

and small bowel positions.^37 As indicated above, fasting gastric juice is usually grassy-green or clear and

colorless, while small bowel juice is often bile-stained. 37

Listening Over Epigastrium for Air Insufflated Through the Tube.

  • The auscultatory method cannot distinguish between esophageal, gastric, or small bowel tube placement.

Obtain an x-ray to determine tube location if in doubt.

  • When multiple bedside methods suggest that tube displacement has occurred, it is prudent to consider

obtaining an x-ray to determine tube location.

4 of 4 Revised 12/

premature infants: a pilot study. Gastroenterol Nurs. 2007;30:414-7.

  1. Kindopp AS, Drover JW, Heyland DK. Capnography confirms correct feeding tube placement in intensive care unit patients. Can J Anaesth. 2001;48:705-10.
  2. Munera-Seeley V, Ochoa JB, Brown N, et al. 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. 2008;23:318-21.
  3. Phang JS, Marsh WA, Barlows TG, III, Schwartz HI. Determining feeding tube location by gastric and intestinal pH values. Nutr Clin Pract. 2004 Dec; 19:640-4.
  4. Griffith DP, McNally AT, Battey CH, et al. Intravenous erythromycin facilitates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study. Crit Care Med. 2003;31:39-44.
  5. Metheny NA, Reed L, Wiersema L, McSweeney M, Wehrle MA, Clark J. Effectiveness of pH measurements in predicting feeding tube placement: An update. Nurs Res. 1993;42:324-31.
  6. Gharpure V, Meert KL, Sarnaik AP, Metheny NA. Indicators of postpyloric feeding tube placement in children. Crit Care Med. 2000;28:2962-6.
  7. Metheny NA, Clouse RE, Clark JM, Reed L, Wehrle MA, Wiersema L. Techniques & procedures. pH testing of feeding- tube aspirates to determine placement. Nutr Clin Pract. 1994;9:185-90.
  8. Kaufman JP, Hughes WB, Kerstein MD. Pneumothorax after nasoenteral feeding tube placement. Am Surg. 2001;67:772-3.
  9. Kawati R, Rubertsson S. Malpositioning of fine bore feeding tube: a serious complication. Acta Anaesthesiol Scand. 2005;49:58-61.
  10. Balogh GJ, Adler SJ, VanderWoude J, et al. Pneumothorax as a complication of feeding tube placement. AJR Am J Roentgenol. 1983; 141:1275-7.
  11. Nakao MA, Killam D, Wilson R. Pneumothorax secondary to inadvertent nasotracheal placement of a nasoenteric tube past a cuffed endotracheal tube. Crit Care Med. 1983;11:210-1.
  12. Theodore AC, Frank JA, Ende J, Snider GL, Beer DJ. Errant placement of nasoenteric tubes. A hazard in obtunded patients. Chest. 1984;86:931-3.
  13. Hand RW, Kempster M, Levy JH, Rogol PR, Spirn P. Inadvertent transbronchial insertion of narrow-bore feeding tubes into the pleural space. JAMA. 1984;251:2396-7.
  14. Lipman TO, Kessler T, Arabian A. Nasopulmonary intubation with feeding tubes: case reports and review of the literature. JPEN J Parenter Enteral Nutr. 1985;9:618-20.
  15. Torrington KG, Bowman MA. Fatal hydrothorax and empyema complicating a malpositioned nasogastric tube. Chest. 1981;79:240-2.
  16. Metheny N, Reed L, Berglund B, Wehrle MA. Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Nurs Res. 1994 Sep-Oct; 43:282-7.
  17. Metheny N, McSweeney M, Wehrle MA, Wiersema L. Effectiveness of the auscultatory method in predicting feeding tube location.[see comment]. Nurs Res. 1990;39:262-7.
  18. Ng C, Wan S, Lee TW, Yim A. Transbronchial intrapleural intubation with a feeding tube under unusual circumstances. N Z Med J. 2002;115:166-7.
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  20. Kolbitsch C, Pomaroli A, Lorenz I, Gassner M, Luger TJ. Pneumothorax following nasogastric feeding tube insertion in a tracheostomized patient after bilateral lung transplantation. Intensive Care Med. 1997;23:440-2.
  21. Hendry PJ, Akyurekli Y, McIntyre R, Quarrington A, Keon WJ. Bronchopleural complications of nasogastric feeding tubes. Crit Care Med. 1986;14:892-4.
  22. Miller KS, Tomlinson JR, Sahn SA. Pleuropulmonary complications of enteral tube feedings. Two reports, review of the literature, and recommendations. Chest. 1985;88:230-3.
  23. Lo JO, Wu V, Reh D, Nadig S, Wax MK. Diagnosis and management of a misplaced nasogastric tube into the pulmonary pleura. Arch Otolaryngol Head Neck Surg. 2008;134:547-50.
    1. Swain FR, Martinez F, Gripp M, Razdan R, Gagliardi J. Traumatic complications from placement of thoracic catheters and tubes. Emerg Radiol. 2005;12:11-8.
    2. Gavi S, Hensley J, Cervo F, Nicastri Z, Fields S. Management of feeding tube complications in the long-term care resident. Ann Long Term Care. 2008 Apr; 16:28-32.
    3. Seguin P, Le B, V, Aguillon D, et al. [Testing nasogastric tube placement: evaluation of three different methods in intensive care unit]. Ann Fr Anesth Reanim. 2005;24:594-9. French.
    4. Scheiner JD, Noto RB, McCarten KM. Importance of radiology clerkships in teaching medical students life-threatening abnormalities on conventional chest radiographs. Acad Radiol. 2002;9:217-20.
    5. Metheny NA, Schnelker R, McGinnis J et al. Indicators of tubesite during feedings. J Neurosc Nurs.2005;37:320-5.
    6. Metheny NA, Spies M, Eisenberg P. Frequency of nasoenteral tube displacement and associated risk factors. Res Nurs Health. 1986;9:241-7.
    7. Ellett MLC, Maahs J, Forsee S. Prevalence of feeding tube placement errors & associated risk factors in children. MCN Am J Matern Child Nurs. 1998 Sep-Oct; 23:234-9.
    8. Conner TM, Carver D. The role of gastric pH testing with small- bore feeding tubes: in the intensive care unit. Dimens Crit Care Nurs. 2005 Sep-Oct; 24:210-4.
    9. Metheny N, Reed L, Worseck M, Clark J. How to aspirate fluid from small-bore feeding tubes. Am J Nurs 1993;93:86-8.
    10. Metheny NA, Williams P, Wiersema L, Wehrle MA, Eisenberg P, McSweeney M. Effectiveness of pH measurements in predicting feeding tube placement. Nurs Res. 1989;38:280-5.
    11. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: A randomized clinical trial. Crit Care Med. 2000;28:1742-6.
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Additional reading

  1. JPEN J Parenter Enteral Nutr OnlineFirst, published on January 27, 2009 as doi:10.1177/0148607108330314 ASPEN Enteral Nutrition Practice Recommendations

2. Martindale, RG. MD, PhD; McClave, SA MD; et al; American

College of Critical Care Medicine; the A.S.P.E.N. Board of Directors Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Crit Care Med. 2009: 35; 1-