NG Tubes and Airway Management

[Veneficus]

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.

I don't think you are using these for anything anyone else isn't. If the tube is winding up in the trachea, it is time the providers paid more attention to what they are doing.

The only reasons that I can think of to use xray for these is to adequetely withdraw the tube if it winds up in the duodenum or if there is perforation/herniation of the abdominal lumen.

Are the people placing these tubes auscultating that the tube is in place or are they just cramming it down somebody and waiting for the xray?

 

[Veneficus]

For the OP

I am not taking sides in the for or against an NG/OG, but if gastric inflation is your concern, could I suggest something less invasive in the interest of patient care?

Get a flow inflating bag. The esophagus requires pressure to unseal it from its natural position.

The self inflating bag maybe providing too much pressure and volume, especially when the people using it are excited and over bagging and squeezing the bag not just to chest rise, but with all the force they can muster.

If you are going to try and institute an NG/OG protocol, you might have some difficulty for a couple of reasons.

As was pointed out, this is an adjunct to intubation, not a replacement, which basically means you are asking for more with the argument that you may not be successful at the first step.

You will have to train and maintain proficency at this skill. Wouldn't that time be better spent on practicing peds intubation if it is going to be attempted?

Along the same lines, if the act of ventilating is being done with poor technique/results, wouldn't it be better to practice that?

How often are you running into this problem that it is a concern enough to spend the money and time on NG/OG?

 

[systemet]

I'm having trouble understanding the reasoning here.

- Is it being suggested that in a patient undergoing BVM ventilation, that we should abandon ventilation for however long it takes to insert an OG / NG tube to decompress the stomach?

- Has consideration been given to how having an NG / OG tube sticking out is going to interfere with BVM mask seal?

- Is there a problem I'm unaware of with either (i) pushing a few cc's of air down the NG while listening over the epigastrum or (ii) aspirating stomach contents through the NG, to confirm placement? Is this insensitive or nonspecific for correct placement? Is this no longer current practice?

I used to throw in an NG when I had an intubated patient with a long transport time, and there was nothing more pressing that needed taking care of. It didn't rate very high in my priority list in an adult. I can see how it could be a critical intervention in a neonate or young ped.

 

[usafmedic45]

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.

Then give me the citations and I'll get the articles.

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

Wow.....can we say "bias"?

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?

In that setting, yes, but then again, I'm also going to be working towards getting us better options so we minimize our chances of winding up in that situation. It's not going to be "I have an unintubated pediatric respiratory failure patient, let me stop bagging him for a couple of minutes while I drop this NG tube". If there is a direct and overt indication for it- which there is not in most cases- then, yes, do the procedure but making it standard practice in cases where you cannot secure the airway definitively is asking for trouble both clinically, professional and- most likely- in the civil legal sense.

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.

But if you take time inserting the NG tube- which requires forgoing the need to ventilate for anywhere from 30 seconds to two minutes (much like an intubation attempt)- to prevent a problem that might not happen at all if you're being careful otherwise, then you are probably going to significantly worsen the chances of the patient having a good outcome.

If you're going to argue for a new skill, argue for one that fixes the primary problem, not just something else you can do to the patient.

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?

Like I said before, not the scenario you originally posed when you started this thread. The more proactive approach would be to get the BLS crew to have an airway adjunct so they can have a protected airway just like most of us have for adults. Work to get LMAs into your protocols both BLS and ALS. That's something I'll support. This idea that taking time to drop an NG on every patient is not something I can because you're afraid of gastric distention. You can have better options, work to get permission to use them. Using an NG tube in an unprotected airway in an unconscious (or especially a semi-conscious) and unstable patient is asking for trouble, especially when it is used for no immediate and pertinent indication (i.e. the patient isn't distended).

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?

How about learning to bag in a way that doesn't cause gastric distention?

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.

I agree with you there, but what I don't agree with (and judging by Veneficus' post, I'm not the only one picking up on this) is that you somehow have come to see dropping an NG tube as a magic bullet in fixing what ails the unprotected pediatric airway. It's not. It's not a replacement for intubation and without means for continuous or mechanically controlled intermittent suction, you're simply doing four things:
1. Increasing the chance of vomiting
2. Making it more difficult to get a good mask seal
3. Increasing the chance of a vagal reaction in a non-arrested patient (minor risk comparatively)
4. Delaying timely access to more appropriate care

If there's an indication, go for it, but don't paint it like this is something that should be done on every patient getting ventilated.

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.

No, you've got this idea that you're correct, can't seem to locate the evidence you claim backs up your stance but yet get defensive and resort to attacks on other career fields (nursing) when we point out better options and the limitations of your idea. It seems to be you who doesn't understand the bigger implications here. You're thinking proactively, which I have to laud you for but your approach is kind of like bailing water out of one side of a canoe as water continues to pour in through the gaping hole in the other.

 

[8jimi8]

I don't think you are using these for anything anyone else isn't. If the tube is winding up in the trachea, it is time the providers paid more attention to what they are doing.

The only reasons that I can think of to use xray for these is to adequetely withdraw the tube if it winds up in the duodenum or if there is perforation/herniation of the abdominal lumen. just wait, you will encounter one of these patients who has a 60cc h2o bolus plus some meds in their lungs one day.

Are the people placing these tubes auscultating that the tube is in place or are they just cramming it down somebody and waiting for the xray?

We use them for gastric decompression/ intermittent suctioning and enteral feeds/ meds.


All OG/NG/ND/NJ tubes are to be inserted using the 2 step method.

1. An order is obtained and the tube is inserted using the standard of care. then a CXR is obtained. If the CXR shows that the tube is not in the lungs, proceed to step 2.

2. Advance the tube [For DHT obtain a KUB.] the tube is ok to use (but must have a doctors order).


Repeated failed insertions will result in placement under fluoroscopy.



It is no longer accepted hospital protocol to use auscultation or pH measurement as methods for verification of correct tube placement.

Acceptable verification of correct placement is (per hospital policy)

1. Radiographic confirmation
2. measurement of external tube
(no longer acceptable are auscultation or pH measurement of aspirate.)


My opinion on enteral tubes? I don't care if the patient has them or not.
Do I auscultate for placement, yes, every time. Do i just shove a tube in someone and walk away...

Vene, I realize that you are on fire to improve healthcare, is there any medical profession that does not need improvement?


My opinion on these monologues of pediatric cardiac arrests...

"The incidence of pediatric OHCA was 8.04 per 100 000 person-years (72.71 in infants, 3.73 in children, and 6.37 in adolescents) versus 126.52 per 100 000 person-years for adults." http://circ.ahajournals.org/cgi/content/short/119/11/1484
Pediatric Cardiology

Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children

The Resuscitation Outcomes Consortium Epistry–Cardiac Arrest Dianne L. Atkins, MD; Siobhan Everson-Stewart, MS; Gena K. Sears, BSN; Mohamud Daya, MD, MS; Martin H. Osmond, MD, CM, FRCPC; Craig R. Warden, MD, MPH; Robert A. Berg, MD; the Resuscitation Outcomes Consortium Investigators


I feel like your heart is in the right place 18G. But first of all, please don't just make up arguments, ascribe them to me, and then proceed...


Here's the scenario, infant cardiac arrest. (because the stats up there says roughly 70% of POHCA)

Failed ETT. (Do the new AHA HCPCPR guidelines state that the ped algorithm starts with Circulation, also?)

next intervention, OG/NG tube... NOT

REALISTIC next intervention: LMA - (or other approved rescue airway device). [hmm do they make infant LMAs /c NG/OG tube ports??]

How are you going to get the NG/OG tube down the esophagus when there is an LMA "occluding" the lumen?



OK. Now we can move to your box on the algorithm.

INFANT OOH CARDIAC ARREST

FAILED ETT
NO APPROVED RESCUE AIRWAY
NGTUBE INSERTION (DURING CPR -- yea right.)
BVM and NPA, OPA

(what provider is double fisted bagging an infant, or an adult sized ped for that matter?)


Sorry Bro, just doesn't sound realistic to me.

But oh yah, for the record, i don't care one way or the other about enteral tubes. gottem or don't. You are the only one who stated i had an opinion on that matter.

 

[usafmedic45]

How are you going to get the NG/OG tube down the esophagus when there is an LMA "occluding" the lumen?

You throw a bougie or tube exchanger down the lumen of the LMA, pull the LMA, introduce an ETT and then go from there if you really have a need to decompress the stomach.

 

[Veneficus]

Vene, I realize that you are on fire to improve healthcare, is there any medical profession that does not need improvement?

I don't see this as improvement, I see it as a US hospital basically trying to use technololgy to make up for a relatiely uncommon adverse event. (at least uncommon if providers aren't botching it up.)

What's next at your hospital? Radiology confirmation of peripheral IV placement because there are extravasiations?

This seems to me like nothing more than waste and abuse, are they billing for this too?

 

[8jimi8]

I don't see this as improvement, improvement is not the original statement that I typed here. At first, I said something defensive, then I realized that you weren't really directing the statements personally at me.I see it as a US hospital basically trying to use technololgy to make up for a relatiely uncommon adverse event. (at least uncommon if providers aren't botching it up.)

What's next at your hospital? Radiology confirmation of peripheral IV placement because there are extravasiations?

This seems to me like nothing more than waste and abuse, are they billing for this too?

Perhaps you didn't realize american healthcare is still a captitalist mechanism?

Sorry Vene, you are not going to find an argument with me about the price or who is charged what. I know that i strive to live up to the virtue of stewardship for my patients every day, by canceling extraneous costs, e.g. charting something as a 29 minute bolus ($200) versus an IVPB ($500). I honestly can proudly say that I NEVER look into the financial status (funded/unfunded) of my patients. The only time that I will ask a patient about anything regarding a financial situation is when I am forced to ask if the patient is worried about incurring hospital costs, during my admission history (it is a MUST FILL response in the computer form).

I bet they charge for it. Will you?

Of course I can be quoted as saying... "when the sh*t hits the fan, i'll be the guy trading cardioversion for chickens... that's why I wanna be a paramedic..."

Is this still on topic?

 

[8jimi8]

You throw a bougie or tube exchanger down the lumen of the LMA, pull the LMA, introduce an ETT and then go from there if you really have a need to decompress the stomach.

So in the END... you wind up INTUBATING THE PATIENT.


THEN


MAYBE AN NG/OG...



USAF... Do they make infant size ILMAs? Or are you talking about blindy enchanging /c a bougie? Does a bougie fit in an infant trachea?!! diameter of a standard bougie is 1cm... right?

At the cctmc we intubated ferrets...(which was supposed to simulate neonatal airway) i don't think you could get a bougie in a ferret /s massive trauma.

 

[Veneficus]

Perhaps you didn't realize american healthcare is still a captitalist mechanism?

Sorry Vene, you are not going to find an argument with me about the price or who is charged what. I know that i strive to live up to the virtue of stewardship for my patients every day, by canceling extraneous costs, e.g. charting something as a 29 minute bolus ($200) versus an IVPB ($500). I honestly can proudly say that I NEVER look into the financial status (funded/unfunded) of my patients. The only time that I will ask a patient about anything regarding a financial situation is when I am forced to ask if the patient is worried about incurring hospital costs, during my admission history (it is a MUST FILL response in the computer form).

I bet they charge for it. Will you?

Of course I can be quoted as saying... "when the sh*t hits the fan, i'll be the guy trading cardioversion for chickens... that's why I wanna be a paramedic..."

Is this still on topic?

Jimi,

My comments are not directed at you personally.

The probelm is not whether capitalism is right or wrong, it is about gouging who is paying regardless of medical need. (which in turn drives up everyone's costs.)

I have no doubt that patients are not told that most of the civilized world doesn't xray these tubes routinely. Which means the patient is getting an uneeded screening test.

That may be beyond your job description, but it doesn't make me less angry hearing it and I am really not trying to start an argument with you. More like just venting my frustration.

Especially since I am willing to bet money that the hospital doesn't really do it for the patient, they do it for the hospital. No different than performing a test for a lawyer. Which I know is often needed but I still don't like it.

 

[8jimi8]

Jimi,

My comments are not directed at you personally.

The probelm is not whether capitalism is right or wrong, it is about gouging who is paying regardless of medical need. (which in turn drives up everyone's costs.)

I have no doubt that patients are not told that most of the civilized world doesn't xray these tubes routinely. Which means the patient is getting an uneeded screening test.

That may be beyond your job description, but it doesn't make me less angry hearing it and I am really not trying to start an argument with you. More like just venting my frustration.

Especially since I am willing to bet money that the hospital doesn't really do it for the patient, they do it for the hospital. No different than performing a test for a lawyer. Which I know is often needed but I still don't like it.

We are on the same page my friend.

 

[18G]

British Journal of Anaesthesia (1999)
Pediatric Trauma
E.H. Dykes

Dept of Pediatric Surgery, University Hospital Lewisham, London.

"... gastric distention also increases the likelihood of vomiting and aspiration, a major concern for those responsible for airway management. For these reasons, the presence of even minimal adbominal distention, respiratory compromise or diminished consciousness is an indication for the passage of an oro- or nasogastric tube. Although this intervention may be potentially distressing for a conscious child, the consequences of untreated gastric distention may be fatal".

 

[Aidey]

British Journal of Anaesthesia (1999)
Pediatric Trauma
E.H. Dykes

Dept of Pediatric Surgery, University Hospital Lewisham, London.

"... gastric distention also increases the likelihood of vomiting and aspiration, a major concern for those responsible for airway management. For these reasons, the presence of even minimal adbominal distention, respiratory compromise or diminished consciousness is an indication for the passage of an oro- or nasogastric tube. Although this intervention may be potentially distressing for a conscious child, the consequences of untreated gastric distention may be fatal".

No offense, but no one is going to argue they aren't good during surgery. It is pre-hospital that is the concern.

 

[18G]

The context of the article has nothing to do with surgical care specifically. The article deals with all phases of pediatric trauma from initial assessment, resuscitation, etc.

The quoted section I provided is from the article heading "Initial Resuscitation and Primary Survey".

 

[18G]

I'm tempted to start a discussion on bleeding and direct pressure and see how many people are oppositional and see if we get 7 pages of replies on how direct pressure is a waste, all bleeding stops on its own, it's really only useful in certain cases, show me the research that it works so well, etc, etc, etc.

Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here?????

This is the only forum where people speak of the complete opposite of what is standard and accepted every where else. I could read in 31 different texts and medical journals that something works and is indicated, but then state it here and be informed that the 31 texts and journals authored and reviewed by physicians are all wrong.

 

[usafmedic45]

So in the END... you wind up INTUBATING THE PATIENT.

Right. It's just a different way of achieving the same end.

THEN


MAYBE AN NG/OG...

If specially clinically indicated, yes. Otherwise, leave it for the hospital.

USAF... Do they make infant size ILMAs? Or are you talking about blindy enchanging /c a bougie? Does a bougie fit in an infant trachea?!! diameter of a standard bougie is 1cm... right?

No, a bougie is not 1 cm. It's the same diameter as an ETT stylet. The ones we use are about 3mm if that (and outside of premies, there's no good reason to be using a 2.0 or 2.5 ETT because it's so small you can't pass a suction catheter through it). The widest one I've seen is only about 4-5mm. A vascular guidewire could also be used if you were really concerned about the width of the bougie.

I don't know if they make infant ILMAs but you don't need an ILMA to intubate someone in the manner I described. A normal LMA works just fine.

British Journal of Anaesthesia (1999)
Pediatric Trauma
E.H. Dykes

Dept of Pediatric Surgery, University Hospital Lewisham, London.

"... gastric distention also increases the likelihood of vomiting and aspiration, a major concern for those responsible for airway management. For these reasons, the presence of even minimal adbominal distention, respiratory compromise or diminished consciousness is an indication for the passage of an oro- or nasogastric tube. Although this intervention may be potentially distressing for a conscious child, the consequences of untreated gastric distention may be fatal".

OK. Where does that say you should interrupt ventilations to do so? That's not really good evidence. It's like you typed in "pediatric, gastric distention, airway" into Pubmed and grabbed the first article you found. I am beginning to think that you've got your mind made up and are unwilling to critically assess your desire to add this skill.

 

[8jimi8]

Glad you clarified. Not sure where I got 1cm from b/c obviously I remembered it incorrectly.

 

[usafmedic45]

I'm tempted to start a discussion on bleeding and direct pressure and see how many people are oppositional and see if we get 7 pages of replies on how direct pressure is a waste, all bleeding stops on its own, it's really only useful in certain cases, show me the research that it works so well, etc, etc, etc.

It's not the tool that is the problem in this case, it is how you're trying to apply it.

Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here?????

I think it has something to do with the attitude (at least the perceived attitude most of us take away) from your posts that you have it all figured out, that you're right and any attempt to question you, suggest alternatives or to inquire further are met with resistance and hostility. Even as the reigning forum ***hole, I'm more amenable to change and being questioned than you seem to be.

This is the only forum where people speak of the complete opposite of what is standard and accepted every where else.

You're taking a standard and leaving out a couple of vital elements and then trying to hide because a particular indication when we call you on the discrepancy. It's like saying that you believe we should change the oil in the ambulance but not bother to put the new oil filter in after removing the old one.

could read in 31 different texts and medical journals that something works and is indicated,

Probably, but you'll notice that none of them say to interrupt ventilation or airway management efforts to pass an NG tube.

but then state it here and be informed that the 31 texts and journals authored and reviewed by physicians are all wrong.

Three things:
1. Physicians are fallible. All of us are.
2. Just because something is in writing does not make it correct. Examples include such wildly different tomes as Mein Kampf and the medical "standards", many of which are not based on any scientific evidence.
3. I didn't say they were wrong, I said they were making educated best guesses. (the last clause of point #2).

 

[Sasha]

Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here?????

Amazing that's how I feel when i'm reading your posts.

 

[usafmedic45]

Amazing that's how I feel when i'm reading your posts.

I wondered if he migrated over from "the City" where the folks aren't as focused on education and more on maintaining the status quo and stroking each other's egos. He mentions other forums and that's the only one I know of that wouldn't treat him the way we have been. Well, that and the Firehouse one, but that's not even a medical forum. You mention anything about "evidence" and they think you're talking about arson investigation.