Trick of the Trade: Use an endotracheal tube as an introducer guide

Materials:

8.0 endotracheal tube (ET)

Nasogastric (NG) tube (16 or 18 French size)

Lubricating jelly

Glove

We have all been in the situation: an intubated patient needs an orogastric (OG) tube and no one has been able to place it successfully. Unfortunately, we typically find out about this situation after several failed attempts, when the patient is bleeding and/or the anatomy is distorted. It may coil in the mouth or esophagus. Here I present a novel technique to rapidly place an OG tube within seconds.

Procedure:

Hold the ET tube with your dominant hand, like you would throw a dart. If you are right-handed, stand on the patient’s right side, and use your non-dominant hand to grasp the mandible and pull anteriorly (maintain cervical-spine stabilization as necessary). Reverse this if you are left-handed. Gently advance the lubricated ET tube into the oropharynx in a downward fashion. It should slide in effortlessly without resistance. Place a glove over the ET tube hub end to prevent expulsion of gastric contents Advance a lubricated NG tube through the ET tube. Connect to NG tube to suction. Once critical resuscitation and advanced imaging have been performed, the introducer ET can be removed. First, remove the hub adaptor on the ET tube. Then carefully slide it out of the oropharynx, over the OG tube, while holding the OG tube in place. The ET tube can then be cut off with shears. Secure the OG tube.

NOTE: For pediatric patients, use the same size ET tube as for endotracheal intubation and follow the Broselow-Luten recommendations for the NG tube

Pitfalls

This procedure should only be performed on intubated only whose airway is protected in case of inadvertent gag reflex-induced vomiting. When inserting the ET tube introducer, be sure to gently insert it because of the risk of esophageal rupture. Do NOT force it into place. Secure the esophageal ET tube to the tracheal ET tube to prevent migration

Final Thoughts

Placement of an OG tube may be challenging for some intubated patients. This trick provides a potential solution to help gently guide the OG tube into place by using an ET tube as an introducer. OG tubes are especially important for patients that receive prehospital resuscitation without ET tube placement, it is common for bag valve mask ventilation to cause gastric distention. Gastric distention poses several problems such as the high risk of aspiration, decreased in venous return, and increased intra-abdominal pressure which all hinder adequate resuscitation.

In patients with massive upper GI hemorrhage requiring airway intervention, one might consider inserting an OG tube peri-intubation. This may be contrary to the traditional sequence of airway management events, but this approach may help to reduce aspiration risks from hematemesis in addition to improving visualization of the vocal cords during endotracheal intubation.

1. Arch Otolaryngol Head Neck Surg. 2008;134(5):547-550. PubMed] Lo J, Wu V, Reh D, Nadig S, Wax M. Diagnosis and management of a misplaced nasogastric tube into the pulmonary pleura.. 2008;134(5):547-550. 2. Crit Care Med. 1983;11(3):210-211. PubMed] Nakao M, Killam D, Wilson R. Pneumothorax secondary to inadvertent nasotracheal placement of a nasoenteric tube past a cuffed endotracheal tube.. 1983;11(3):210-211. 3. J Am Coll Surg. 2004;199(1):39-47; discussion 47-50. PubMed] Marderstein E, Simmons R, Ochoa J. Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill.. 2004;199(1):39-47; discussion 47-50. 4. Nutr Clin Pract. 2006;21(1):40-55. PubMed] Baskin W. Acute complications associated with bedside placement of feeding tubes.. 2006;21(1):40-55. 5. Emergency Nurses Association. Clinical Practice Guideline: Gastric Tube Placement Verification. August, 2015. 6. N Am J Med Sci. 2013;5(1):68-70. PubMed] Ghatak T, Samanta S, Baronia A. A new technique to insert nasogastric tube in an unconscious intubated patient.. 2013;5(1):68-70. 7. NG Tube FAQ. ACEP, Clinical and Practice Management. https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/NG-Tube-FAQ/

The above video received consent by the patient for educational use.

Disclaimer: Tricks of the Trade represent the opinions of expert clinicians; the recommendations presented are not necessarily studied to rigorous standards of safety or efficacy. Please utilize these techniques at your own clinical discretion.