
Overview
This module describes how to insert a nasogastric or orogastric tube.
Indications
Diagnostic:
Suspected upper GI bleeding or obstruction
Gastric fluid content aspiration
Administering radiocontrast for imaging
Therapeutic:
Decompression of a distended stomach
Prevention of aspiration during surgery
Nutritional support
Gastrointestinal lavage (washout)
Contraindications
Severe facial trauma
Suspected basal skull fracture
Obstruction of the oesophagus or nose, such as oesophageal strictures or choanal atresia
History of bariatric or recent nasal surgery
Bleeding tendency
Patient information & consent
Always verify your patient’s identity and obtain informed consent before proceeding.
How do I explain this procedure?
“I am going to put a tube through your nose into your stomach so that we can …”
What can my patient expect?
“Placing the tube is uncomfortable and sometimes painful. You may want to vomit, but once it is in place it is not painful.”
What is my patient’s role?
“Please tell me if you have had any surgery on your face, throat or stomach, or a bleeding tendency. Stay very still while I put in the tube, and swallow when I tell you to.”
Preparation
Prepare a trolley with equipment.

Documentation
Patient notes
Equipment
Non-sterile gloves
Linen saver
Nasogastric drainage bag or spigot
- Appropriately sized gastric tubeAppropriately sized gastric tube
Neonates: 5-6 F
Infants: 8 F
Small children: 10 F
Larger children: 12 F
Up to 18 F for adults Lubricant
50 ml catheter tip syringe
Stethoscope
pH (litmus) paper
Tape to secure
Emesis basin
Glass of water and a straw
Suction equipment and connection
Site & Positioning

Sit the patient up at a 45° angle, with their neck flexed forward, so that the tube follows the curvature of the nasopharynx.
To determine the insertion depth of the NG tube, measure along the tube from the tip of the patient’s nose to the earlobe and down to the xiphoid process. Take note of the insertion depth.
Procedure
Follow medical asepsis with non-sterile gloves.
Perform hand hygiene and don non-sterile gloves.
Place the linen saver on the patient’s chest and give them the emesis basin to catch any vomit.
Lubricate the tip of the tube with KY jelly.
Nasogastric insertion: Use the most open nostril. Insert the tube horizontally through the nostril, then aim it downwards towards the opposite ear.
Orogastric insertion: Aim downward and backwards towards the pharynx while advancing the tube.
When the tube reaches the pharynx, flex the patient’s head forward and instruct them to swallow, or sip water if allowed.
Continue advancing until the insertion depth mark is at the nostril.
- SecureSecure
the gastric tube with tape or a tube holder at the nostril and on the cheek. Make sure the tube puts no pressure on the nostril, as it can cause necrosis.
Ensure correct tube placement by obtaining a chest X-ray OR aspirating gastric content with the catheter tip syringe and checking the pH (litmus paper turns pink) OR auscultating epigastrium for bubbles whilst rapidly injecting 20 ml air through the tube with the syringe.
Attach gastric drainage bag or spigot as required.
Discard medical waste safely.
Record completion of the procedure in patient notes.
Troubleshooting
My patient is now struggling to breathe.
Ask the patient to speak. If the patient cannot speak, you have probably gone down the trachea through the vocal cords. Retract the tube and try again.
I feel resistance while I try to insert the tube.
It is normal to feel some resistance as the tube approaches the pharyngeal curvature, but if you cannot gently push past, you may be entering the trachea or coiling the tube in the pharynx. Retract the tube and try again.
The tube is too floppy to insert.
Cool the tube in the fridge before using it. You can bend it into a slight curve to help you slide down into the oesophagus.
My patient gags and panics.
Pause, retract the tube a little, ask the patient to take deep breaths, and continue once they have calmed down, while the patient sips water. Try to time the tube insertion with the sips.
I am unable to advance the tube in a neonate.
The baby might have a congenital abnormality of the nose and oesophagus such as choanal atresia or a tracheo-oesophageal fistula. Abandon the procedure and call a senior.
I’m unsure when to insert an NGT in a neonate.
Babies <34 weeks gestation with feeding problems
Abdominal distention secondary to nasal CPAP, bowel obstruction, necrotising colitis, etc
Babies with respiratory distress
Babies with feeding difficulties
Babies with certain neurological deficiencies
I’m unsure how to insert an NGT in a neonate.
Always use
orogastric insertionorogastric insertionNasogastric insertion increases airway resistance and the work of breathing in small neonates particularly.
for neonates.
To determine the insertion depth of the NG tube, extend the tube from the sternal notch to the xiphoid process, then double its length and add 2 cm.
Test the position of the tube as above, but only use 1 ml of air.
The tube will need to be changed at least three times a week.
When
removing the tuberemoving the tubePinch the tube between thumb and forefinger before removing as this prevents milk from flowing into the baby's lungs.
, wait at least 2 hours following the feed. If not, aspirate prior to removing.
Risks
Local infection (rhinitis, sinusitis, oesophagitis)
Tracheal intubation and trauma to the trachea and lungs
Epistaxis
Hypoxia or respiratory arrest
Oesophageal perforation
Necrosis/erosion of the nasal or gastric tissues
Aspiration and resultant pneumonia due to vomiting or reflux
Vagal response
References
Vetrosky D. Nasogastric Tube Placement. In: Dehn R, Asprey D, eds. Essential Clinical Procedures. 3rd ed. Philadelphia: Elsevier; 2013.
Mynhardt K. How to Insert a Nasogastric Tube. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 331-332.
Henning P. Insertion of the gastric tube. In Neonatology: A guide for doctors. Department of Paediatrics and Child Health and Stellenbosch University. Tygerberg Hospital South Africa. 2012. p. 159
Joolay Y, Horn A, et al. Guidelines for the insertion of a nasogastric tube: some aspects. In: Neonatal Guidelines and Drug Dosages. Division of Neonatal Medicine Groote Schuur Hospital. 2012. p. 136