Review
Methods to determine the internal length of nasogastric feeding tubes: An integrative review

https://doi.org/10.1016/j.ijnurstu.2016.06.004Get rights and content

Abstract

Objectives

Improper placement of nasogastric tube used for feeding may lead to serious complications, including death of the patient. There are several different methods used to determine the appropriate length of nasogastric tube for optimal placement in adults. This integrative review of the literature was designed to identify the most accurate method to determine the internal length of nasogastric feeding tube in adults.

Design

An integrative review of the research literature (1979–2015) using the population–intervention–comparison-outcomes strategy.

Data sources

The literature search included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Joanna Briggs, PubMed (MEDLINE), SCOPUS, and Web of Science electronic databases.

Review methods

Two researchers evaluated the literature to determine if an article met inclusion and exclusion criteria. The quality of the evidence was assessed using the Johns Hopkins Strength of the Evidence critical appraisal tool.

Results

Twenty studies, published between 1979 and 2014, met inclusion criteria. Of these, nine articles were expert opinion, seven were original research, three were review articles, and one was a guideline. Despite seven original research papers being found, only five reports were about the methods to determine the internal length of nasogastric feeding tube in adults. The literature suggests that four different methods for measuring the tube length are likely to result in proper placement of the tip of the tube in the stomach and all side ports inside it: [nose-to-ear-to-xiphisternum – 50] cm/2 + 50 cm]; [gender-weight and nose-umbilicus-flat]; [xiphisternum-to-ear-to-nose + 10 cm]; [earlobe to xiphisternum to umbilicus – tip of the nose to earlobe]. Four studies found nose-to-ear-to-xiphisternum was most likely to result in a tube that is positioned incorrectly, either ending in the esophagus, in the stomach but too close to the esophagus, or too far into the stomach or duodenum.

Conclusions

The nose-to-ear-to-xiphisternum and Hanson method should no longer be taught in nursing programs or used in practice by the nurse. The [gender-weight and nose-umbilicus-flat] method has been shown to be safer.

Section snippets

Background

Gastric feeding is the most preferred route of tube feeding (Gottrand and Sullivan, 2010). Feeding patients via NGT involves introducing a thin tube through the nostril, down the esophagus, and into the stomach. The process is usually quick and although somewhat unpleasant, is usually well tolerated (Medlin, 2012). NGT can be used for aspiration of gastric residues or for feeding. In the adult population, tubes for feeding are of small diameter (8–12 Fr) and are manufactured with polyurethane,

Methods

We conducted an integrative review using the population, intervention of interest, comparison and outcomes (PICO) strategy (Santos et al., 2007). The PICO question for this review was: “In adults requiring enteral nutrition via NGT (P), which external landmark measurements used to determine ideal placement of the nasogastric feeding tube (I) (C) are most accurate (O)?”

Search methods

A search of the literature was conducted in February and March 2015. The search included articles having all levels of evidence. The Johns Hopkins Strength of the Evidence method (Newhouse et al., 2005) was used to analyze the evidence (Table 1). The studies were selected, analyzed, and the results synthesized.

The databases searched were: CINAHL, Cochrane Library, Joanna Briggs Institute (JBI), PubMed (National Library of Medicine), SCOPUS, and Web of Science. Key words used for searching

Results

Our search strategy (Fig. 1) produced a total of 5011 articles as follows: CINAHL = 622, Cochrane Library = 25, JBI = 36, PubMed = 559, SCOPUS = 531, and Web of Science = 3238 (Fig. 1). We excluded 4864 based on our inclusion and exclusion criteria. Studies were included if they described measurement of external landmarks to determine position of a NGT. Studies were excluded if they did not include measurement of external landmarks; were carried out in neonates and children; used other methods, such as

Limitations

This review summarizes information on methods to determine the insertion internal length of NGT in adults. Several methodologies were described and there may have been recommendation bias. Several studies contained small samples sizes and groups that may not be directly comparable. For instance, the Hanson (1979) study was composed of cadavers. We considered that all studies were equally reliable. However, the methods were heterogeneous, which may have led to a biased conclusion.

Conclusion

The literature describes four competing methods for measuring the insertion internal length of NGT in adults: NEX, Hanson, GWNUF, and XEN + 10 cm. Four studies demonstrated that NEX is not a safe method, may actually cause harm, and should no longer be taught or used in practice. Hanson's method was shown by Ellett et al. (2005) to be less safe than GWNUF because the tube tip more often lies in the esophagus. In addition, for patients with larger external dimensions, Hanson's method yields shorter

Implications for future research

  • Randomized controlled trials by using larger sample sizes are needed to determine the accuracy of NGT method for feeding in adults.

  • Dissemination of knowledge produced by evidence-based practice is vital to avoid mistakes in the development of policies and protocols that guide patient care.

Acknowledgments

The authors are grateful for the financial support of the Science Without Borders Program, CNPq, Brazil and the Illinois State University (ISU), IL, USA for the use of Milner Library, to perform the collection of study data. Authors are also grateful to Prof. Sandro Guedes de Oliveira, from the “Gleb Wataghin” Physics Institute, University of Campinas, for the discussion on the comparison of Hanson's method and NEX. We also thank the three anonymous reviewers for their valuable comments and

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