NG Tubes and Airway Management

[18G]

I am looking for research that has been done on the use and benefit of NG tubes in the pediatric population during positive pressure ventilation. I have searched online and have not been able to find a whole lot.

I have been advocating NG tubes at my service for a few months and would like to have research to back up my claims that NG tubes are important adjuncts to airway management in both children and adults.

If anyone has any links or other resources on the issue I would appreciate it very much!

 

[8jimi8]

The problem with OG and NG tubes is that even in the hospital, we are not allowed to use them without radiographic confirmation of correct placement.

You don't want to be suctioning out any lung lobes do ya?

 

[usafmedic45]

If you have a properly placed ETT, there's really no need in the emergent setting to spend time placing an ETT. There is some evidence that it reduces the rate of pneumonia/pneumonitis associated with intubation/ventilation in ICU patients but the main reason. The only conceivable reason for it in the field/ER with a ventilation patient where it really would be an adjunct would be to reduce gastric insufflation and honestly if you're going to spend the time placing the OG/NG tube (which is not that easy to do nor quick, not to mention that you can't ventilated the patient while doing so unless they are tubed) the better option is simply to take that time to place an ETT or an LMA.

Suffice to say, I see where you're coming from and applaud you for thinking proactively, but don't agree that we should be spending time dropping gastric tubes in the field when we have much more immediate fixes to the issues at hand and the technical issues inherent with your suggestion make it feasible in a minority of cases.

 

[MrBrown]

For neonate resuscitation we place an LMA wherever possible (we have always generally done this but it is now stated firmly as preference rather than trying to intubate) and have the option of using a small, soft suction catheter to decompress the stomach if required.

 

[Aidey]

If you have a properly placed ETT, there's really no need in the emergent setting to spend time placing an ETT.

I think you need another cup of coffee

I have only heard of a couple of places having pre-hospital NG tubes and all of them were either flight agencies or had long transports.

 

[usafmedic45]

*facepalm* Actually I can blame it on a lack of caffeine. I'm about 10 days "sober". Thank you for catching that.

 

[18G]

Here is my stance on NG tubes:

I view them as a very valuable adjunct to airway management in both the adult and pediatric populations of patients... more so pediatrics and here is why.

It's no secret that we don't get the intubation experience that we should with adults let alone children. And it has been showed that BVM ventilations in children during short transport times is as effective as ventilations with an ETT. So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube? I understand your not gonna be able to ventilate the patient during insertion, but I feel confident in saying that an NG tube can be placed quicker and safer than multiple attempts at intubating and is a much lower acuity skill than intubation.

I think we all agree that the pressures required for air to enter the stomach in an unconscious/arrested child are very low and further decrease the deeper the level of unconsciousness. Air takes the path of least resistance which is going to be right down into the stomach.

Gastric insufflation is dangerous along two fronts:

• Airway Compromise / Aspiration
• Ineffective Ventilation / Decreased Tidal Volume

Problem #1
As air accumulates in the stomach, the diaphragm is compressed and the abd organs are pushed up into the thoracic cavity impeding lung expansion and delivery of an adequate tidal volume - there is a decreased lung compliance and overall difficulty with ventilation and oxygenation of the child.

Problem #2
Regurgitation and aspiration risk. It's inevitable that a child receiving BVM ventilations is going to vomit making airway management much more difficult and putting the child at great risk for aspiration. I think we all also agree on the great dangers of aspiration which result in severe infection which will compound the already present problem the patient is experiencing.

To me these are priority issues that need to be addressed in the field and not overlooked. Almost every resource I have read advocates use of NG tubes so I am kinda surprised the posters so far haven't really been in favor of their use. And these resources ranged from those for EMS and In-hospital.

They are cheap, quick, and easy to insert. Carry a very low risk from insertion and yield great benefits.

Why do providers not favor NG/OG tubes given the benefits of their use? Our goal is to maximize ventilation and oxygenation and protect the airway, right? Isn't that what an NG/OG tube helps us do?

You don't want to be suctioning out any lung lobes do ya?

We intubate in the field which is later confirmed by x-ray so I'm not seeing the difference.

 

[MrBrown]

Brown has not found gastric distention/aspiration a significant problem with manual ventilation.

Most patients who are being manually ventilated here either have LMA in place or have been intubated although LMA exceeds intubation by far and if working well, there is now a firm preference it not be changed over to an endotrachel tube in the field.

 

[18G]

We don't use LMA's and I am in favor of having NG tubes available for certain cases where intubation cannot be achieved.

Brown has not found gastric distention/aspiration a significant problem with manual ventilation.

Really? None of your arrested or ventilated patients vomit? That's unique.

EDIT: Pennsylvania allows Paramedic's to use NG tubes its just my service does not currently carry them. NG tubes received specific mention in the revised resuscitation protocols that go into effect 7/11.

 

[Veneficus]

The problem with OG and NG tubes is that even in the hospital, we are not allowed to use them without radiographic confirmation of correct placement.

You don't want to be suctioning out any lung lobes do ya?

No offense, that sounds like somebody's agenda to bill for radiology or make up for substandard employees using radiology more than an actual legitimate concern of the device.

I have placed easily a hundred of them, never once were they confirmed unless there was another reason for the CXR/AXR.

 

[MrBrown]

Really? None of your arrested or ventilated patients vomit? That's unique.

Of course some patients vomit. We may be upside down and use that funny stuff called adrenaline but physiology is the same ;P

Brown however does not consider it to be a significant problem to the point of where prophylactic gastric tube placement should be undertaken.

If it is that much of a problem - where is the real problem; with the patient or with the person who is ventilating them?

 

[18G]

Brown however does not consider it to be a significant problem to the point of where prophylactic gastric tube placement should be undertaken.

If it is that much of a problem - where is the real problem; with the patient or with the person who is ventilating them?

I see your point and appreciate your feedback. I guess I am coming from the point of view that a gastric tube does aid in support of the airway and is beneficial to reduce the risk of vomiting and aspiration. Would we be using them in every case? No. But in the cases where we may not be able to secure an ETT than why not place an NG tube while "bagging" a infant or small child for 20mins or more?

And I don't view a provider opting to use a BVM, OPA, and an NG tube as bad airway management. If I can achieve the same results doing the above then why attempt to intubate 2 or 3 times, cause bradycardia and possibly hypoxia?

And I don't view the use of an NG tube as being prophylactic. It is an active modality that maintains tidal volumes and lung compliance and prevents complications from vomiting. How is this not a good thing? That is what I am asking? What am I missing?

 

[8jimi8]

No offense, that sounds like somebody's agenda to bill for radiology or make up for substandard employees using radiology more than an actual legitimate concern of the device.

I have placed easily a hundred of them, never once were they confirmed unless there was another reason for the CXR/AXR.

With what we use these for I think a protocol for radiographic confirmation is a necessary evil. I have seen many times... Ng and og tubes end up in the trachea.

18g,Have you seen how much people gag when you use these devices?

 

[usafmedic45]

And it has been showed that BVM ventilations in children during short transport times is as effective as ventilations with an ETT.

It's been showed? LOL Sorry after my recent flub, I couldn't resist.

So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube?

Why not resort to simply placing a non-visualized airway? Are the medics' ego in your area too sensitive and too overwhelming of patient safety that we must have an all or nothing approach?

The main reason I would argue against placing an NG tube in a patient that is being bagged is that it significantly interferes with mask seal, carries a decent risk of inducing vomiting and it is seldom a quick procedure especially when talking about a decompensating patient who needs to be ventilated. Also, most people's BVM technique makes your average paramedic's intubation skills look like those of an anesthesiologist. It's the one airway skill that most EMS providers spend the least amount of time on and have the least amount of pride for.

We don't use LMA's and I am in favor of having NG tubes available for certain cases where intubation cannot be achieved.

Then what is your backup airway? So you have a failed airway and you're advocating not ventilating the patient for a minute or two while you place an NG tube?

I feel confident in saying that an NG tube can be placed quicker and safer than multiple attempts at intubating and is a much lower acuity skill than intubation.

Prove it. Even if you can prove that even the dumbest person on your squad (because one should write protocols for the guy with the worst skills, not the best) can do what you're saying, it still is not the most practical option for the failed airway because it still leaves the patient prone to complications associated with NG placement (including vomiting) and without any airway protection whatsoever.

It's inevitable that a child receiving BVM ventilations is going to vomit making airway management much more difficult and putting the child at great risk for aspiration.

And the surest way to make a patient with gastric insufflation vomit is to shove something through the cardiac sphincter. It's also not "inevitable" if you actually practice giving ventilations, are careful, cautious and are not simply using the risk of aspiration to justify adding another skill to your bag of tricks.

They are cheap, quick, and easy to insert. Carry a very low risk from insertion and yield great benefits.

How many have you placed?

 

[18G]

It's been showed? LOL Sorry after my recent flub, I couldn't resist.

I know it should have been spelled "shown"


Why not resort to simply placing a non-visualized airway? Are the medics' ego in your area too sensitive and too overwhelming of patient safety that we must have an all or nothing approach?

The only supraglotic device we have is a King Airway which isn't going to work in an infant or small child.

The main reason I would argue against placing an NG tube in a patient that is being bagged is that it significantly interferes with mask seal, carries a decent risk of inducing vomiting and it is seldom a quick procedure especially when talking about a decompensating patient who needs to be ventilated. Also, most people's BVM technique makes your average paramedic's intubation skills look like those of an anesthesiologist. It's the one airway skill that most EMS providers spend the least amount of time on and have the least amount of pride for.

I hear what your saying and my rebuttal to you is, why does virtually every text from PALS, PEPP, Paramedic text, Physician authored articles, and other clinical resources, specifically state to utilize NG tubes for reasons I already stated? And not to mention my States EMS protocols which are highly based on best practices as demonstrated through research now includes mention of NG tubes. How do you explain the differences in your opinion compared to other authoritative sources?


Then what is your backup airway? So you have a failed airway and you're advocating not ventilating the patient for a minute or two while you place an NG tube?

Our back up device in the pediatric population of patients is BVM ventilations and oral adjunct. Intubation is the primary. For adults we have King Airways which cannot be placed in infants and toddlers.


Prove it. Even if you can prove that even the dumbest person on your squad (because one should write protocols for the guy with the worst skills, not the best) can do what you're saying, it still is not the most practical option for the failed airway because it still leaves the patient prone to complications associated with NG placement (including vomiting) and without any airway protection whatsoever.

Define failed? Is the ability to assess an airway and decide to BVM versus take 5 attempts at intubating really a failure or a success as long as ventilation and oxygenation is sufficient? Airway management is not intubation.

And the surest way to make a patient with gastric insufflation vomit is to shove something through the cardiac sphincter. It's also not "inevitable" if you actually practice giving ventilations, are careful, cautious and are not simply using the risk of aspiration to justify adding another skill to your bag of tricks.

I totally agree that vomiting and gastric distention can be greatly minimized through focus on minimal tidal volumes, avoiding excessive pressure, utilizing cricoid pressure, and an airway adjunct. But there are gonna be certain patients where that is not enough and the stomach is gonna get bigger and bigger which is gonna impede our ability to ventilate. And in an unconscious / arrest patient, the gag reflex and stimulation of vomiting is gonna be pretty much non-existent in most cases.

Also, my service provides ALS to areas that are only BLS so we could have a patient who has been ventilated with a BVM for a good 15-20mins before ALS care. That is a long time for air to accumulate in a infant or childs stomach. Even if I do get the pedi pt. intubated, the gastric distention should not be over looked.

Yeah, its great I got the tube but now sucks that lung compliance is so poor from the poor child's diaphragm being compressed and abd organs being pushed up into the chest rendering ventilation extremely difficult and inefficient. Because of poor lung compliance we would have to use greater pressure which is gonna just add to the problem to gastric distention, agreed?

Even with intubation, an NG tube is standard care.

18g,Have you seen how much people gag when you use these devices?

The patient's we would be inserting an NG tube in wouldn't even know it was being inserted. There would be no gag reflex.


Again, I appreciate the feedback guys but want to stress the use would be for arrest or unconscious patients only.

 

[usafmedic45]

The only supraglotic device we have is a King Airway which isn't going to work in an infant or small child.

Then instead of trying to get your medical director to let you drop NG tubes on difficult airways, how about working to get him and the state to give you more options to actually handle the problem? Pointing out the field day a good malpractice attorney and an expert witness (such as myself) would have with this scenario should help out.

I hear what your saying and my rebuttal to you is, why does virtually every text from PALS, PEPP, Paramedic text, Physician authored articles, and other clinical resources, specifically state to utilize NG tubes for reasons I already stated? And not to mention my States EMS protocols which are highly based on best practices as demonstrated through research now includes mention of NG tubes. How do you explain the differences in your opinion compared to other authoritative sources?

Two things:
1. Show me actual research specifically on NG tubes in this setting. These "authoritative sources" are basically making an educated best guess.
2. All those sources are talking about as an adjunct to another airway device, not as a replacement for it. There's little to no evidence that what you're suggesting when used outside of the presence of either an ETT or a non-visualized airway is a good idea.

Define failed?

As in the common paramedic definition of it: "I couldn't secure an airway on that guy. The tube just wouldn't go in so I had to bag him".

s the ability to assess an airway and decide to BVM versus take 5 attempts at intubating really a failure or a success as long as ventilation and oxygenation is sufficient?

No, and I'm glad you see that. However, I would argue that wasting time dropping an NG as a matter of course is a pretty questionable action given the attendant risks of hypoxia and vomiting.

Airway management is not intubation.

Isn't that what I just said? Remember, you're talking to a guy who specializes in the cardiopulmonary systems, who gets paid a couple hundred dollars an hour on weekends to speak at conferences on difficult airway management and also acts as an expert witness for malpractice attorneys (normally, malpractice defense) when RTs and EMS personnel manage to screw up this sort of thing bad enough to wind up in court over it.

And in an unconscious / arrest patient, the gag reflex and stimulation of vomiting is gonna be pretty much non-existent in most cases.

But in a hyper-inflated and partially food laden stomach, if you shove an NG into it you're going to often explosively decompress it. It's not a gag reflex issue, it's a "path of least resistance being something other than that skinny little tube you put down there" issue.

Even with intubation, an NG tube is standard care.

Yes, after the airway is secured. You don't endanger the patient simply to drop an NG. Secure the airway first and then worry about the long term risk of aspiration pneumonitis.

Yeah, its great I got the tube but now sucks that lung compliance is so poor from the poor child's diaphragm being compressed and abd organs being pushed up into the chest rendering ventilation extremely difficult and in efficient. Because of poor lung compliance we would have to use greater pressure which is gonna just add to the problem to gastric distention, agreed?

Agreed. That's when you drop the NG but that's not the scenario you were suggesting in your initial posts.

 

[mikie]

3rd Reason?

Gastric insufflation is dangerous along two fronts:

• Airway Compromise / Aspiration
• Ineffective Ventilation / Decreased Tidal Volume

How about from vagal stimulation from the gastric distention, especially in the (younger) pedi patients?

 

[8jimi8]

Not to mention the difficulty of maintaining stomach decompression /s automated mechanical suction.

 

[18G]

Two things:
1. Show me actual research specifically on NG tubes in this setting. These "authoritative sources" are basically making an educated best guess.

To build on that... as an expert witness aren't you just making a "best guess" as well if there really isn't any evidence out there to support your position? I know there is evidence that shows benefits of gastric tube placement in kids in cardiac arrest with BVM and ETT ventilation because I have found it but don't have access to the sites to access the full-articles on the research.

But in a hyper-inflated and partially food laden stomach, if you shove an NG into it you're going to often explosively decompress it. It's not a gag reflex issue, it's a "path of least resistance being something other than that skinny little tube you put down there" issue.

You make a really great point. My take on that is this though.... if you address the issue of distention late in the patients care your more than likely going to have a worse problem then if you avoid the "explosive" forces and decompress early when the distention and decreasing lung compliance is first noticed. Granted, by the time we get to the pt. the FD / BLS crew may already have lots of air in the stomach and we need to consider that but what do you do about the problem? Not address it? Continue with difficult ventilation when u have a tool to fix it?

You don't endanger the patient simply to drop an NG. Secure the airway first and then worry about the long term risk of aspiration pneumonitis.

Expand on this. I'm not seeing how you can outright say that inserting an NG tube to relieve gastric distention which has been proven to substantially increase the effectiveness of ventilation and helps protect against aspiration is dangerous.

What I see as dangerous is an ever increasing size of the stomach that goes unaddressed and results in vomitus occulding the airway and impeding good ventilation. To me that is more dangerous.

At least with an NG tube you MAY encounter vomitng as a result of its insertion, but at least it's more than likely a one time deal and you can be immediately prepared for it and expect it and aggressively suction and roll the patient.

The alternative is to not insert the gastric tube, not have any idea when the patient is gonna erupt all over the place, not be as quick on the suction and log roll, and then what? Start bagging again only to have a repeat of what just happened?

The NG tube can prevent the reoccurrence.

Like I said, it's a Paramedic skill here in PA and the Medical Director has no objections with it. In fact I talked to the CRNP who advises and handles most of the ALS stuff with my service and he agree that we should be carrying them as well. I just have been having a problem getting my department to actually spend the money and order em which after a meeting last night sounds like they have ordered em already.

I don't want to sound all wrong... no they are not a miracle tool and certainly are not to be used in every pt who is being ventilated. But if its clear distention is taking place and compliance is worsening than we need to have the tool on the ALS units to be able to handle the issue and provide more complete care.

 

[18G]

Not to mention the difficulty of maintaining stomach decompression /s automated mechanical suction.

As an RN your totally against these little tubes aren't ya?

Im just curious, if your in the field and have say a 1y/o who is in arrest, being ventilated with an OPA and BVM, and has noted gastric distention and it's hard to ventilate, and you have an NG tube on your unit, your not gonna use it?

Your gonna keep exerting higher ventilatory pressures to bag this poor child causing their problem to worsen? Your going to actually contribute to your patient puking and getting pneumonia and having an even harder time at recovery if your lucky enough to achieve ROSC?

I don't understand.