Question regarding nasogastric tube

Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you

Yes, I would go with the CXR, and advance the tube further, then re-image.

Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.

You mean the nurses were keen to just go ahead and use it? That's odd, usually nurses would err on the side of caution.

Tbh, I would always request a CXR post NG insertion, regardless of aspirate.

Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.

I agree it’s odd for the nurses not to be treading on the cautious side. My argument would be if they haven’t fed for 12 days a few hours won’t hurt as they’ll be on a very strict (likely low volume) refeeding plan. And that delay is far better than a massive pneumonia from feeding them unsafely. I would also remind them that a ph isn’t fool proof.

There are been plenty of never events where people have been fed into the lungs and it would be the doctors who get hung for it. Some trusts I’ve worked in require radiologists to confirm placement prior to feeding.

I agree it’s odd for the nurses not to be treading on the cautious side. My argument would be if they haven’t fed for 12 days a few hours won’t hurt as they’ll be on a very strict (likely low volume) refeeding plan. And that delay is far better than a massive pneumonia from feeding them unsafely. I would also remind them that a ph isn’t fool proof.

Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you

Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.

You mean the nurses were keen to just go ahead and use it? That's odd, usually nurses would err on the side of caution.

Tbh, I would always request a CXR post NG insertion, regardless of aspirate.

Yeah they were keen to get the feed as the patient hadn't eaten for 12 days and okay I asked the doctors and they said they don't always get a CXR post-insertion if the aspirate is okay. But guess its down to the individual.

CXR trumps pH always.

As stated, its your registration on the line, not theirs. Whilst listening to experienced nurses is great advice for new doctors, they are still nurses with no medical training!


Pretty sure there are multiple national guidelines that say a CXR is mandatory and it has been that way for some years e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC549648/

Not doing so would be pretty rogue at this point! I personally would not just dismiss it as 'down to the individual'. As stated above, many trusts insist on not only a CXR, but you phoning a radiologist to report if for you.

Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you

That link is from 2005, and doesn't say a CXR is mandatory.

"It issued a list of recommended tests including measuring the acidity/alkalinity of aspirate (stomach contents) using pH indicator strips in the range 0 to 6 with half point gradations; testing the aspirate should not be done with blue litmus paper.

Radiography is recommended for intensive care patients or neonates but should not be used routinely."


That seems pretty out of date though. I would always do a chest x-ray. I think that's common practice now.