Nasogastric tube check, easy or not?

To cite: Koo S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015214075 DESCRIPTION Our patient required nasogastric tube (NGT) feeding for poor nutritional intake. He was alert when NGT insertion occurred. This required two attempts due to coughing. On the second attempt, coughing was present throughout but settled gradually. NGT insertion may be tricky in the awake patient, especially if neurological deficits are present. Optimisation of position by sitting the patient upright and inserting the NGT horizontally and posteriorly should be undertaken. A correct insertion attempt should feel smooth, with minimal or no resistance. More importantly, the patient should not be distressed if the NGT has correctly entered the oesophagus. NGT malpositioning is suggested if coughing, respiratory distress or tachypnoea persists when the NGT has been inserted to the desired length. If this occurs, as with our patient, consider reinserting the NGT. Chest X-ray was performed to check NGT position as no aspirate for pH check was obtainable (figure 1). At one glance, the NGT tip is visible below the right diaphragm, however, scrutiny may suggest otherwise. National Patient Safety Agency guidance suggests a four-step approach to confirm NGT position, the tube: (1) avoids the contours of bronchi; (2) bisects the carina; (3) crosses the diaphragm in the midline and (4) its tip is visible below the left hemidiaphragm. Following this approach would reveal that the NGT has entered the right main bronchus and its tip is abutting the inferior portion of the dome of the diaphragm. It has not crossed the diaphragm at the midline. Start feeding in this case would result in a disastrous outcome.