Application of lidocaine before inserting an NGT has been shown to significantly decrease pain during the procedure.⁵^–⁷ Lidocaine can be delivered as viscous, nebulized, or atomized preparations. Application of viscous lidocaine to the nasal passage combined with lidocaine spray applied to the posterior pharynx has been shown to be superior to other forms of anesthetics when placing an NGT or transnasal bronchoscope.^6,⁸ However, no definitive study or review article has determined the best concentration, form, or dose of lidocaine to use.⁷

lidocaine options

• Viscous lidocaine—5 to 10 mL of 2% lidocaine applied to an adult nasal passage 0 to 5 minutes before NGT placement combined with lidocaine spray applied to the posterior pharynx.^6,^8,⁹ Introduce 3 mL of 2% viscous lidocaine into the nostril and then have the patient snort the medication.

• Nebulized lidocaine—2.5 to 5 mL of 4% lidocaine nebulized before insertion via face mask.¹⁰

• Atomized lidocaine—1.5 mL of 4% lidocaine or two puffs of 10% lidocaine atomized to the nasal passage.^6,¹¹

3 Lubrication of the Tube

Once the naris has been pretreated with the vasoconstrictor and anesthetic agents, a water-soluble lubricant is applied to the distal aspect of the tube.

4 Insertion of the Tube

The tube is inserted into the naris along the floor of the nose inferior to the lower turbinates. The tube should be inserted at close to a 90-degree angle with the face and directed parallel to the floor of the nose (posteriorly), not cephalad (Fig. 46.2). Gentle pressure should be used to advance the tube past the nasopharynx and into the oropharynx. Once the tube is in the posterior pharynx, the patient is asked to swallow or take a sip of water to aid in smooth passage of the tube into the esophagus. The tube is then quickly advanced to the premeasured length to minimize discomfort. Care should be taken to not use excessive force when placing an NGT to avoid mucosal injury.

Fig. 46.2 The nasogastric tube is passed parallel to the floor of the nose posteriorly and usually passes inferior to the inferior turbinate. The tube should not be directed cephalad.

(From Samuels LE. Nasogastric and feeding tube placement. In: Roberts JR, Hedges JR, editors. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders; 2004. pp. 794-816.)

Alternative Approaches with Difficult Tube Insertions

In comatose, paralyzed, or sedated patients, an NGT may be placed under direct visualization with the use of a laryngoscope and McGill forceps. The tube is inserted via the nose into the nasopharynx. The mouth is opened, and a laryngoscope is used to directly visualize the hypopharynx. With Magill forceps, the NGT is grasped and inched into the esophagus under direct visualization.

Alternatively, digital placement of an NGT can be accomplished in a paralyzed, sedated, and intubated patient. The emergency physician places the second and third fingers in the posterior pharynx of the patient and depresses the tongue. The tube is passed through the nose into the posterior pharynx with the fingers in the pharynx to direct the tube into proper location (Fig. 46.3).²

Fig. 46.3 Digital placement of a nasogastric (NG) tube in a paralyzed, sedated, intubated patient.

(From Samuels LE. Nasogastric and feeding tube placement. In: Roberts JR, Hedges JR, editors. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders; 2004. pp. 794-816.)