What should you do if someone coughs during an NG tube insertion?

Nasogastric (NG) tubes can be easily displaced. If you are concerned the tube is not in the stomach and/or the pH strip indicates a reading of more than 5.5, do not put anything down the tube. In this situation, please read the troubleshooting section of this information or seek advice from your healthcare professional.

Before discharge from hospital

Before you are discharged with an NG tube, you should have discussed the topics outlined in this leaflet with your healthcare professional.

Confirming the correct position of your NG tube

It is important to check your NG tube is in the correct position to reduce the risk of feed or water from entering your lungs. This is because it may cause a chest infection or serious harm. You always need to check the position of your NG tube before you do any of the below:

• feeding via the tube
• giving medications down the tube
• water flush.

Additionally, the position of the NG tube should be checked any time you feel the position of the tube may have moved, for example after a coughing spasm, vomiting, retching, difficulty in breathing or reflux. If the tube has moved it may appear longer, have fallen out of the nose or be coiled in the throat.

How to check the tube’s position

Before you begin, think about whether there is a reason to suspect the tube has moved out of the stomach.

• Check the measurement from your nose to the tip of the tube is the same as the correct position during previous checks.
• Check aspirate pH using pH paper.
  • Wash your hands before and after checking your feeding tube.
  • Remove the end cap of the tube and attach a 60ml syringe to the end of the tube.
  • Pull back carefully on the plunger until a small amount of fluid – also known as aspirate – appears in the syringe (approximately 1 to 2ml).
  • Remove the syringe and replace the end cap – some people find it more convenient to kink the end of the tube before doing this.
  • Place a little of the fluid onto the pH indicator paper.
  • Check the colour change of the paper against the chart on the container. The pH value of the aspirate must be 0 to 5.5 to proceed.
• Are there any unexplained breathing problems?
• Has there been any retching, which might have caused the tube to move?
• Has there been any vomiting, which might have caused the tube to move?
• Has the tape which secures the tube come loose?
• Is there any visible coiling of the tube at the back of the throat?

If you cannot pull back aspirate from your NG tube

Try one or more of the following:

• Change your position, perhaps lying down on your left side.
• For adults only – inject 10 to 20ml of air into the tube using a 60ml syringe.
• For children – inject 1 to 5ml of air into the tube using a 60ml syringe.
• Wait 15 to 30 minutes before trying again.
• If you cannot confirm the tube is in the correct position, do not give any water or feed. Contact either your community nurse, staff on your named ward or the enteral feed company nurse.

Flushing your NG tube

If you are not using your NG tube for feeding, make sure you flush the tube at least once a day with fresh tap water to reduce the risk of the tube blocking. Please contact your dietitian to advise you on the amount of water required.

Method for flushing your NG tube

Please only do this after you have confirmed the tube is in the correct position.

• Wash your hands well.
• Place all the equipment you require on a clean surface:
  • 60ml syringe
  • measured water in a jug or cup
  • disposable gloves (if using).
• Make sure the position of the feeding tube has not moved by:
  • checking the skin-level centimetre marking
  • aspirating fluid from the tube and checking pH is 5.5 or below
  • checking for anything unusual about your tube.

There are then two options to flush the tube.

Option one

• Remove the cap from the end of your NG tube.
• Remove the plunger from the syringe and attach it to your feeding tube.
• Use your syringe as a funnel to slowly pour the correct amount of water into your feeding tube, keeping the syringe higher than the stoma site.
• Remove the syringe and recap your tube.

Option two

• Draw up the required amount of water into your syringe.
• Remove the cap from the end of your NG tube. Attach the syringe to your NG tube and slowly press down the plunger in the syringe to flush the water into the tube.
• Remove the syringe and recap your NG tube.

When flushing your tube, you may wish to try to avoid emptying the tube completely by kinking the end of the tube before removing the syringe or as the last drops of water are entering the tube. This can reduce the risk of air entering your stomach which can make you feel uncomfortable and bloated.

Try to remain upright for at least 30 minutes after a feed or flush to help prevent reflux and regurgitation.

The syringes can be washed according to instructions or, when time to do so, can be disposed in your normal household waste.

Feeding via an NG tube

When feeding, please sit or lay in an upright or semi-upright position – at a 30 to 45-degree angle. Always flush the tube with water before and after giving any feed or medication. This reduces the risk of the tube blocking. Your dietitian will tell you how much water and feed to use as part of your feeding plan.

Caring for your tube and skin

• Wash your hands before and after caring for your tube.
• Replace the tape daily.
• When changing the tape, clean your skin with your normal method and dry very well.
• Try to change the position of the tape to reduce the risk of soreness.
• Avoid using creams and powders as they can make the tube slip.
• You may bathe or swim with an NG tube, but avoid the tape coming off through prolonged soaking. If necessary, dry the face well afterwards and change the tape.

If your skin becomes sore or irritated, contact your community nurse or GP for advice.

Troubleshooting tips

If you have learned how to pass the NG tube yourself you might want to refer back to your proficiency documents.

What if my tube becomes blocked?  

The most common causes for feeding tubes to become blocked are feed or medications.

The following tips can help clear a feeding tube which has become blocked with feed or medications:

Milking the tube
Use your thumb and forefinger to squeeze and roll along the length of the tube until the blockage is cleared.

Push and pull technique
Using a 60ml syringe draw up some cooled-boiled warm water. Connect to the tube. Push and pull on the syringe (like using a bicycle pump) to try to dislodge the blockage.  This may take 20 to 30 minutes before the tube becomes unblocked. Never force the syringe as this may damage the tube.

Soda water
If the blockage persists, try flushing the tube with soda water and leave it for 20 to 30 minutes to help dissolve the blockage. Then using the push pull technique, flush the tube with cooled-boiled warm water. Never flush with sugary drinks such as cola or lemonade as these may cause the tube to breakdown or the blockage to harden, and make it worse.

If you think the tube is blocked by medication, check your technique and process for administering medications or ask your nurse to check with you. If it’s a persistent problem and you are following the correct procedures for administering medicines, your GP might be able to review your medication if an alternative is available.

What if I still can’t get any aspirate to check the position of my tube before feeding?

It remains vital that you obtain aspirate from the nasogastric tube and you test it using pH paper and you obtain a pH of 5.5 or below before you commence feeding via the tube. If you still cannot get any aspirate from the tube you might be able to:

• change your position again, for example lie on your side and try aspirating
• wait 15 to 30 minutes and try again
• move the tube 2cm, and try aspirating again (if you are trained to do this)
• try drinking something, if you are able to drink safely and you are not nil by mouth

If you are still unable to obtain aspirate, contact your nurse or the contact given when you first came home with your tube, to discuss a way forward.

What if I can get aspirate from the tube but the pH is six or above?

It is possible for the pH of your stomach to be higher than 5.5. This can be caused by some medications, or the presence of feed or food. It can feel very frustrating when you want to feed but the aspirate pH is six or above.

However, it remains vital that you obtain aspirate from the nasogastric tube, you test it using pH paper and you obtain a pH of 5.5 or below before you commence feeding via the tube. If you have just placed the tube and you want to use it for water, feeding or medication for the first time follow the procedure for replacing a nasogastric tube.

In some circumstances, with a tube that has been confirmed as being in the correct position on previous occasions you may be able to follow a different process. Your dietitian or nurse may give you additional training and additional information about what to do when the pH of an existing, correctly placed tube is high.

What do I do if my nasogastric tube comes out?

If your nasogastric tube comes partially or fully out when you are not feeding through it, remove it, the securing tape, and discard as you would normally.

If you are feeding when your tube comes out it is possible that the tube has dislodged and gradually worked its way out and therefore you may have inadvertently got feed in your wind pipe or lungs. If you feel unwell or are concerned, you must obtain medical advice.

Your feeding tube will probably need replacing. If you have been taught how to do this, you may go ahead if you have passed the NG proficiency assessment. If you do not replace your own nasogastric tube you should contact the person, ward, or children’s community nurse, as agreed when you were discharged from hospital.

If the tube has come out during the night and you are not concerned you have inadvertently got feed into your windpipe, it is possible for some people to leave the tube replacement until the morning. Agree a plan with your doctor, nurse or dietitian so you are prepared if this happens. The plan will vary from person to person depending on your age, condition and/or treatment plan.

What should I do if the tape securing the tube starts to peel off?

• Make sure you are taught how to replace the tapes securing your nasogastric tube so you can do this whenever you need to.
• Keep your skin, where the tube is secured, clean and dry.
• Ask your nurse for a different type of tape or to show you a different way of securing the tube.
• You may benefit from a different dressing called a hydrocolloid, stuck to your cheek, under the tube before you tape the tube down. A nurse can show you how to do this.
• If you are still having trouble securing your tube, ask your nurse or dietitian for further advice.

What if I still need help?

If you still need help with your nasogastric feeding, contact the Abbott or Nutricia. Alternatively, contact your designated contact, community nurses or the Home Enteral Nutrition Service for advice.

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