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:
