Nasogastric intubation is one of the common procedures performed
in Emergency Departments in the United States.1 Its use
as a conduit into the stomach was first popularized in the early
twentieth century mainly through the efforts of Levin. Since then,
clinicians have studied its use and have proposed methods to improve
the ease with which the tube is inserted as well as ways to diminish
the incidence of potentially lethal complications. A nasogastric
tube is often placed in patients who have a bowel obstruction, intractable
nausea and vomiting, intoxication, significant trauma, and upper gastrointestinal
bleeding. The procedure is rapid, simple, and straightforward.
The nasal cavity is lined by the very vascular nasal mucosa.
The medial wall of the nasal cavity is composed of the septum. The
lateral wall of the nasal cavity is covered by the turbinates. The
posterior nasal cavities are continuous with the nasopharynx that
develops into the posterior oropharynx as you move caudally (Figure
47-1). The oropharynx continues inferiorly as the esophagus that
enters the stomach below the diaphragm.2
Basic anatomy of the path of the nasogastric tube.
The placement of a nasogastric tube in children is often difficult.
Their large tonsils and adenoids may hinder the passage of the nasogastric
tube. These tissues are soft, easily injured, and may bleed as the
nasogastric tube is passed. The tongue, large by comparison with
adults, may push into the oropharynx and impede passage of the nasogastric
tube. Their nostrils and nasal passage are quite small and limit
the size of nasogastric tube that may be passed.
Nasogastric intubation may be performed for diagnostic or therapeutic
indications. A nasogastric tube may be inserted to instill air into
the stomach to assess for an intraperitoneal perforation. It is used
to evaluate the presence, rapidity, and volume of an upper gastrointestinal
hemorrhage. Gastric fluid and contents may be aspirated for laboratory
analysis. It may also be placed to visualize the stomach on chest
radiography to assess for a diaphragmatic hernia. A nasogastric
tube is placed in patients for medication administration, relief
of a bowel obstruction, treatment of recurrent vomiting, and to
perform gastric lavage. They are placed preoperatively, postintubation,
prior to a diagnostic peritoneal lavage, or prior to a pericardiocentesis
to decompress the stomach.
Absolute contraindications do not exist for nasogastric tube
placement. The relative contraindications are geared toward predicting
which patients are more likely to experience complications and which
patients are likely to have misplaced tubes. Insertion of a nasogastric
tube should be avoided, unless necessary, in the patient with midface
trauma. Intubation through the nasal cavity can result in the nasogastric
tube being misdirected blindly into the respiratory tract or the
rare perforation through the thin cribriform plate of the ethmoid
bone and into the brain. Patients with facial trauma are best ...