How to insert a gastric tube

When a person's normal swallowing ability is affected, a gastric tube is needed for nasogastric feeding. When the gastric tube is first inserted, the patient will feel very uncomfortable, but after a period of adaptation, this uncomfortable feeling will gradually disappear. More importantly, if the correct method is not used during the process of inserting the gastric tube, it is indeed easy for the patient to suffer bleeding incidents. So what is the correct way to insert a gastric tube?

Simply put, gastric tube insertion is divided into three steps: measuring the insertion length of the gastric tube - inserting the tube - fixing and checking. The step that clinical medical staff encounter most problems with is probably the intubation step.

Insertion of a gastric tube is an invasive procedure that irritates the nasal cavity and nasopharyngeal mucosa. During the intubation process, uncomfortable symptoms such as nausea, vomiting and pain are inevitable. Some patients find it difficult to accept and become nervous and uncooperative, which can easily lead to intubation failure. How to improve the success rate of catheterization? Today we will learn a summary of several methods of gastric tube insertion.

First, let’s take a look at the experience summary (notes) of clinicians:

1. Determine whether the comatose patient has swallowing reflex and whether the tongue falls back so as to select the corresponding method; for comatose patients with a lot of sputum, it is necessary to suction the sputum before intubation.

2. Nasal septum deviation is very common. It is necessary to check the patency of the nasal cavity before intubation and choose the side that is convenient for inserting the tube. Do not force the tube in if there is obvious obstruction, otherwise it will easily cause damage to the mucosa. It will be smoother to insert the tube quickly at the end of inhalation.

3. The front end of the gastric tube enters the nasal cavity along the anterior wall of the nasal cavity and then turns to the posterior wall to make the tube placement smoother. When placing the tube, pinch the head of the esophagus and try to close the piriform recesses on both sides to avoid the situation where the tube cannot be placed in the oropharynx.

4. When inserting the gastric tube, the heart rate will increase and the blood pressure will rise. Therefore, for patients with obviously high blood pressure, antihypertensive drugs and heart rate control drugs can be temporarily given in advance.

5. For patients with long-term indwelling gastric tubes, the part of the gastric tube that needs to be inserted should be sufficiently lubricated (practice has shown that using ordinary hydrophilic lubrication with water bubbles to lubricate the gastric tube is more likely to cause bleeding than directly lubricating it with paraffin oil). When replacing the gastric tube, try to alternate the two nasal cavities. Long-term pressure on one side will cause the local mucosa to be easily damaged.

How many methods are there to insert a gastric tube?

1.70° right side lying position:

(1) Applicable subjects: patients with impaired consciousness, especially those with retroglossia

(2) Specific operation: When the patient lies flat, first measure the required length of the gastric tube, then assist the patient to lie on the right side with the face at a 70° angle to the bed surface, and insert the gastric tube on the right side of the patient.

(3) Advantages: The supine intubation method of first tilting the head back and then supporting the head is not suitable for patients with tongue prolapse, while this method is suitable for comatose patients with tongue prolapse; it is easy to extract gastric juice when confirming whether the gastric tube is coiled in the stomach (because the level of gastric juice is higher in the right lateral decubitus position)

2. First tilt your head up and then lift your head:

(1) Not suitable for: patients with tongue prolapse, acute cerebral hemorrhage and neck injury

(2) Specific operation: The patient is placed in a semi-recumbent or supine position, and the required length of the gastric tube is measured and marked with adhesive tape. The part where the gastric tube needs to be inserted is fully lubricated. For conscious patients, they are asked to tilt their heads back and wait for the end of the gastric tube to enter the oropharynx (about 15 cm has been inserted). Then they are asked to lower their heads so that their chin is as close to the manubrium as possible. For comatose patients, the neck is supported by the pillow to raise their heads. After the end of the gastric tube enters the epiglottis, their heads are lifted up so that their chin is as close to the manubrium as possible. Then the gastric tube is inserted.

(3) Advantages and disadvantages: The advantage is that the chin is close to the sternal manubrium, which can increase the curvature of the throat passage and make the tube descending more smoothly. The disadvantage is that it is not suitable for patients with tongue prolapse, and it may increase the risk of primary disease in patients with acute cerebral hemorrhage and neck stiffness. It may cause the tracheal tube to fall out in patients with tracheotomy.

3. Pull the chin forward and upward:

(1) Specific operation: After inserting the tube for 10-15 cm, the assistant uses the index and middle fingers to hook the patient's mandibular angle and pull it upward and forward, so that the lower alveolar groove exceeds the upper alveolar groove by 1-1.5 cm. The operator continues to insert the tube when he feels the resistance at the front end of the tube disappears.

(2) Advantages and disadvantages: The advantage is that the success rate of intubation is higher, which is especially suitable for comatose patients and patients with tracheotomy. The disadvantage is that it is laborious.

4. Gastric tube withdrawal method:

(1) Applicable subjects: patients in coma or with loss of swallowing reflex

(2) Specific operation: For patients with cough reflex, when the gastric tube is inserted 20-24 cm and causes coughing, withdraw the gastric tube 1-3 cm, and quickly continue to insert the tube at the last moment of inhalation after the cough stops. For patients with no cough reflex, when the tube is inserted 20-24 cm and slight resistance is felt, withdraw the gastric tube 1-3 cm, and then use the thumb of one hand to gently push the larynx and insert the tube at the last moment of inhalation.

5. Lateral tongue pull method:

(1) Applicable subjects: patients who are in coma or have tracheotomy

(2) Specific operation: routinely insert the gastric tube into the oropharynx. When resistance is felt, the assistant pulls out the patient's tongue with tongue pullers. For patients with tracheotomy, when the gastric tube is lowered to 2-4 cm below the throat (tracheotomy site) and resistance increases, the assistant gently pulls out the tracheal tube 0.5-1 cm and returns the tube to its original position after the end of the gastric tube passes the tracheotomy site.

(3) Advantages: Greatly increases the success rate of one-time intubation in patients with retroglossia.

6. One-mouth measurement method:

(1) Specific operation: The patient lies in the supine position with the head of the bed raised 15-30 degrees. When the gastric tube is inserted 14-16 cm in the normal position, the patient holds the gastric tube with the left hand and uses a syringe with the right hand to inject 5-8 cm of water into the patient's mouth. The gastric tube is then inserted while the swallowing reflex occurs.

(2) Advantages and disadvantages: The advantage is that it reduces mucosal damage. The disadvantage is that giving too little water will not cause swallowing reflex. If too much water is injected into the mouth or too quickly, it will cause choking and coughing. It is not suitable for patients with disappeared swallowing reflex.