Journal of Pediatric Nursing (2011) 26, 373376

CLINICAL PRACTICE COLUMN

Column Editor: Mary D. Gordon, PhD, RN, CNS-BC

Mary D. Gordon, PhD, RN, CNS-BC

Best Evidence: Nasogastric Tube Placement Verification

By the Society of Pediatric Nurses (SPN) Clinical Practice Committee 1 , with content review by the
SPN Research Committee 2
M. Anne Longo MBA, RN-BC, NEA-BC
Cincinnati Children's Hospital Medical Center

THE SOCIETY OF Pediatric Nurses (SPN) is a

professional organization that promotes excellence in
nursing care of children. The Clinical Practice Committee
of SPN advocates for evidence-based practices and has been
charged by the SPN Board of Directors to clarify, improve,
and help standardize practices associated with nasogastric
tube (NGT) placement verification. This article presents the
best-evidence findings and recommendations supported by
SPN with regard to NGT placement verification.
In the pediatric population (newborn to age 18 years),
nasogastric and orogastric tubes are commonly used in
hospitalized children for decompression, enteral gavage
feeding, and medication administration. Proper functionality
of these tubes relies on accurate placement to maximize
benefit and minimize risk. It is of utmost importance for the
NGT to be inserted correctly; otherwise, complications and
even death can occur (Cannaby, Evans, & Freeman, 2002).
Although much discussion has been done in the area of
confirmation of NGT placement in adults, the evidence in
pediatrics is negligible, and to date, no endorsement of any
specific technique has been published. This results in nurses
extrapolating information from the adult literature. This topic is
a common item of discussion on the SPN electronic mailing list
1
Thanks to the following members of the following members of
the SPN Clinical Practice Committee for their contributions to this
article: Peggy MacKay, Tracie Major Cherie McCann, Sonya Phillips,
Claude Rochon & Vicky Bowden.
2
Thanks to the following SPN Research Committee Members for
review of the practice guidelines: Sharon Barton, Patricia Messmer &
Nina Westhaus.
Corresponding author: M. Anne Longo MBA, BSN, RN-BC, NEA-BC.
Society of Pediatric Nurses Clinical Practice Committee, Ctr. for Professional
Excellence/Education, Cincinnati Children's, Cincinnati, OH.
E-mail address: anne.longo@cchmc.org.

0882-5963/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2011.04.030

and forums. A 2008 electronic mailing list/e-mail review of 22

children's hospitals across the country revealed various ways
to measure and confirm NGT placement. Of the hospitals surveyed, none
Multivariate apfollowed the same procedure. NGT
proaches to tube
verification procedures shared by replacement confirmaspondents included auscultation, gastion have great value
tric pH testing, assessing color of
aspirate, measuring length of tubing,
in combination,
and visualizing using radiograph.
although they canSeveral children's hospitals use only
not surpass the cerone method to confirm placement.
tainty radiological
Using procedures that are not
confirmation allows.
standardized within an institution
or by the profession can lead to
error and hinder quality patient outcomes. NGTs can be
misplaced on insertion or after initial placement with or
without clinical symptoms. Many pediatric nurses do not
realize or appreciate the risks associated with such a common
procedure. Adverse events that occur from a misplaced tube
can be aspiration, pneumonia, and pneumothorax. Small-bore
NGTs can also migrate out of position, knot, occlude, or
rupture (Farrington, Lang, Cullen, & Stewart, 2009; Metheny
et al., 2005). To date, no sentinel events in the pediatric
population have been attributed to pulmonary malposition of
NGTs. However, The Joint Commission identifies pulmonary malposition of NGTs as one of the most frequent
procedural complications resulting in postoperative sentinel
events (Bourgault & Halm, 2009).
Because of the high frequency of NGT insertion and
the lack of consensus on the best means to verify placement
in the pediatric patient, SPN Clinical Practice Committee
sought to determine what were the best practices for NGT
placement in children and adolescent patients.

374

Review of the Literature

Placement of NGTs is verified at initial placement, before
a feeding, before administration of a medication, and every
shift unless otherwise indicated (Farrington et al., 2009). The
prevalence of NGT misplacement in children has been
difficult to trend in the literature due to poor reporting, lack
of standard definitions, and lack of research. Research to date
indicates that erroneous initial placement or subsequent
displacement of tubes in hospitalized children occurs as
much as 43.5% of the time (Ellett & Beckstrand, 1999;
Farrington et al., 2009; Wilkes-Holmes, 2006).
Misplacement is defined as a tube confirmed to be in the
esophagus or intestine when intended to be in the stomach, or
in the esophagus or stomach when intended to be in the
intestine, or in the lungs or bronchial tree. Factors that place
hospitalized children at greater risk for misplaced tubes
include age, vomiting, level of consciousness, dysphasia, and
use of Argyle-brand tubes (Ellett & Beckstrand, 1999;
Farrington et al., 2009; Huffman, Jarczyk, O'Brien, Pieper,
& Bayne, 2004; Westhus, 2004). In a study of 201 children
with NGTs, 15.9% had tube placement errors on Day 1 of
treatment, and 20.9% experienced placement errors during
the course of treatment. Most misplaced tubes (72%) were
not discovered by bedside placement verification methods
(Ellett, Beckstrand, Welch, Dye, & Games, 1992).
Initial blind placement of NGTs requires the caregiver to
estimate the depth of insertion required to reach the desired
site. Traditional methods (NEX methods) employed use of
morphologic landmarks, measuring from the ear to the tip of
nose to xyphoid process or umbilicus (Beckstrand, Ellett, &
McDaniel, 2007; Ellett, 2006; Klasner, Luke, & Scalso,
2002). Misplacement using these methods to predict
distance is between 4.7% and 69% (Ellett, 2006). Graphic
methods for determining esophageal length based on height
have been found to more accurately predict gastric
placement of tubes as much as 95% of the time as confirmed
by radiograph (Beckstrand et al., 2007; Ellett et al., 1992;
Ellett, 2006; Klasner et al., 2002; Tedeschi, Altimier, &
Warner, 2004). Such methods depend on accurate measurement of patient height.
Methods to verify appropriate placement of tubes are
many and are supported to varying degrees in the literature:
radiograph, measurement of tube from point of entry,
auscultation, placing tube in water to assess for bubbling,
aspiration of stomach or intestinal contents for visual
inspection or chemical testing, CO2 testing, and combinations of these.
Radiological confirmation of tube placement is considered the reference standard, whereas recognizing that cost,
radiation exposure for the patient, and its value for only a
point in time must be considered (Arbogast, 2002; Bourgault
& Halm, 2009; Cincinnati Children's Hospital, 2009; Crisp
2006; Ellett & Beckstrand, 1999; Ellett, Croffie, Cohen, &
Perkins, 2005; Premji, 2005; Westhus, 2004; WilkesHolmes, 2006).

Clinical Practice Column

Marking of the tube at point of entry to the patient
and measurement of visible portion are of value if used
in conjunction with the most current placement measurement guidelines already outlined and as a companion to
other methods (Ellett, 2006; Farrington et al., 2009;
Metheny et al., 2005).
Auscultation is the most widely used method of placement
verification by pediatric nurses, but when used alone cannot
differentiate among respiratory, gastric, and intestinal
placement (Ellett & Beckstrand, 1999; Huffman et al.,
2004; Neuman, Meyer, Dutton, & Smith, 1995; WilkesHolmes, 2006). Successful prediction of nasogastric placement of tubes using auscultation alone is not affected by level
of experience of the practitioner and is correct only 34.4% of
the time, odds comparable to chance (Ellett & Beckstrand,
1999; Wilkes-Holmes, 2006).
Placement of the tube tip in water to assess for bubbling is
a traditional method of discovery for a tube mistakenly
placed in the lungs. It is not supported by the literature and is
considered risky to the patient and unreliable (Ellett &
Beckstrand, 1999; Premji, 2005; Wilkes-Holmes, 2006).
Because intestinal fluids can resemble those originating in
the bronchial tree, color cannot be expected to discriminate
on its own (Bourgault & Halm, 2009).
Aspiration of fluid from the tube can differentiate among
bronchial, gastric, and intestinal placement through its
presence (Ellett, 2006; Metheny et al., 2005), as well as its
color and appearance (Arbogast, 2002; Bourgault & Halm,
2009; Ellett, Maahs, & Forsee, 1998; Farrington et al., 2009;
Huffman et al., 2004; Metheny et al., 2005; Neuman et al.,
1995; Westhus, 2004).
Chemical evaluation of aspirates can include testing for
pH, capnography, bilirubin, trypsin, and pepsin (Bourgault
& Halm, 2009; Westhus, 2004). Acidity of tube aspirates has
received more attention in the literature than the other
measurements and although valuable can have limitations for
patients receiving continuous feedings or acid-reducing
medications (Arbogast, 2002; Ellett & Beckstrand, 1999;
Huffman et al., 2004; Peter & Gill, 2009; Phang, Marsh,
Barlows, & Schwartz, 2004). A pH reading of 4 or less is
thought to have predictive value of correct placement in the
stomach second only to x-ray confirmation. Values of 5 or
higher must be carefully examined to distinguish intestinal
placement from bronchial placement (Table 1; Arbogast,
2002; Ellett et al., 2005; Ellett, 2006; Huffman et al., 2004;
Neuman et al., 1995; Peter & Gill, 2009; Phang et al., 2004;
Stock, Gilberston, & Babl, 2008; Westhus, 2004; WilkesHolmes, 2006). An aspirate from a small bowel tube can
have a pH of 6 or greater and is usually bile colored
(American Association of Critical Care Nurses (AACN),
2005). Secretions with a pH of lower than 6 may also reflect
bronchial or esophageal secretions (Ellett, 2006). Further
limitations to pH testing include patients who are receiving
H2 receptor antagonist, a proton pump inhibitor, antacids, or
tube feedings (May, 2007). Another consideration of pH
testing in children with a small bore tube is the potential

Clinical Practice Column

375

Table 1 Interpretation of Gastric Aspirate for Confirmation of

Nasogastric/Orogastric Tube Placement
Aspirate Location
Gastric
Intestinal
Pulmonary
tracheobronchial

Aspirate Characteristics

pH

Clear, off white, grassy green,

tan, brown tinged if blood present
Bile stained, light to dark
golden yellow
Watery, straw-colored mucus

5
N6
N6

Note: Data from Bowden and Greenberg (2011), used with permission.

inability to obtain aspirate sample. Bedside testing of pH can

be achieved using pH-specific paper or litmus paper, and
although the merits of each are reported, pH-specific paper is
preferred (Freer & Lyon, 2006; Nyqvist, Sorrell, & Ewald,
2005; Tamhe, Tuthill, & Evans, 2006). Aspirates can also be
tested for trypsin, pepsin, and bilirubin levels, and although
this information is thought to have positive predictive value
for tube placement when used in combination with other
methods, practical limitations of availability at the bedside
and cost have prevented their widespread use (Bourgault &
Halm, 2009; Ellett et al., 2005; Westhus, 2004). Capnography or CO2 testing of gasses captured from a placed tube
can be additive in its ability to identify misplacement in the
bronchial tree but cannot otherwise distinguish tube location
in esophagus, stomach, or intestine (Bourgault & Halm,
2009; Ellett et al., 2005).
Multivariate approaches to tube placement confirmation
such as pH and color, auscultation and pH, or pH and tube
length have great value in combination, although they cannot
surpass the certainty radiological confirmation allows
(Bourgault & Halm, 2009; Farrington et al., 2009; Huffman
et al., 2004; Neuman et al., 1995).

Summary of Findings
Verification of NGT placement is required in the
following instances:

After initial tube insertion

Before each intermittent feeding
Before medication administration
Once a shift (or every 8 hours) with continuous
feedings.

For initial verification of NGT, the following is

recommended (Bowden & Greenberg, 2011, p. 265;
Cincinnati Children's Hospital, 2009):
For orogastric tubes and NGTs, use a syringe to
aspirate stomach contents and visually assess the
characteristics of aspirate, and test acidity by pH
product (Table 1). Confirm that the external length of
the tube is at baseline measurement.

Failure to obtain aspirate from an orogastric/NGT

does not indicate that the enteral tube is placed
improperly. There may be marginal stomach contents
to aspirate, or the catheter may not be in contact with
the gastric fluid. A pH level of 5 or lower suggests
gastric placement.
A pH level higher than 5 may indicate intestinal or
respiratory placement or may be present if the child
is receiving acid suppression medications or continuous feedings. X-ray of the abdomen to verify
placement is the most accurate verification method
and may be indicated before instituting use of the
enteral tube.
If unable to confirm placement after testing gastric
aspirate, request order for abdominal x-ray (AACN,
2005; Farrington et al., 2009). It is important to note that
x-ray placement only confirms placement at the exact time
of the radiographic procedure (Wilkes-Holmes, 2006).
Radiological verification is recommended for those
patients who are considered high risk (Cincinnati
Children's Hospital, 2009): patients in pediatric
and cardiac intensive care unit, patients with altered
level of consciousness, and those patients with
swallowing problem.

For Ongoing Verification Methods of NGT

When possible, multiple methods of NGT placement
are recommended for ongoing verification and/or if xray confirmation is not available.
Auscultation is not a reliable indicator of NGT
placement. This verification method should only be
used as a secondary means (AACN, 2005; Ellett,
2006; Farrington et al., 2009).
Gastric pH testing 5 or lower can be correlated with
correct placement in the stomach (Ellett et al., 2005)
and is usually grassy green or clear in appearance
(AACN, 2005). Visual appearance of gastric secretions is less accurate than pH testing but may be used
as a secondary confirmation method. Based on the
intended location, aspirate color (clear, light yellow,
or light green) will vary (Westhus, 2004).
Marking the tube after initial verification and
measuring the external length in centimeters
(AACN, 2005) may provide secondary confirmation data. This technique has limited value and
only provides an estimate as to whether the tube
has been dislodged but does not indicate the
position of the distal tip. The use of cloth tape or
permanent marker may be used to mark exit point
from the nare.
Testing gastric aspirate for enzyme levels and the use of
a CO2 monitoring devices for verifying NGT placement
has been inconclusive in children (Ellett, 2006).

376

Summary
Further research on cost-effective techniques to verify
enteral tube placement is warranted using a variety of
pediatric populations with differing conditions that may
impact gastric pH. It is imperative that clinical facilities
review current policies and procedures to ensure that
evidence-based findings are guiding nursing practice.
Many nurses continue to rely on auscultation to verify
NGT placement. Education and competency validation can
assist with current practices for NGT placement being
consistently incorporated by all personnel in the health care
setting. Continuing to search for evidence related to
nursing care will guide the direct care RN in providing
best practice.

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Clinical Practice Column

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