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Guideline Summary
Guideline Title
Best evidence statement (BESt). Confirmation of nasogastric/orogastric tube (NGT/OGT) placement.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Confirmation of nasogastric/orogastric tube (NGT/OGT) placement. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Aug 22. 9 p. [25 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Confirmation of nasogastric tube placement in pediatric patients. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Apr 27. 11 p. [20 references]

Scope

Disease/Condition(s)

Conditions in pediatric and adolescent patients that require a nasogastric/orogastric tube (NGT/OGT)

Guideline Category
Assessment of Therapeutic Effectiveness
Evaluation
Clinical Specialty
Critical Care
Pediatrics
Radiology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To evaluate, among pediatric patients who require nasogastric/orogastric tube (NGT/OGT) placement, if auscultation, acidity (pH), enzyme, visual inspection of aspirate, and carbon dioxide (CO2) testing compared to radiological verification provides an accurate confirmation of tube placement.
  • To evaluate, among pediatric patients who require NGT/OGT placement, if tube length predictions using age-related height-based (ARHB) methods compared to nose-ear-xiphoid (NEX) morphological measurements are more accurate in predicting tube length.
Target Population

Pediatric patients who require nasogastric/orogastric tube (NGT/OGT) placement for feeding or gastric decompression

Interventions and Practices Considered
  1. Verification methods
    • Radiological verification
    • Aspirate pH
    • Gastric auscultation (not recommended as the sole verification method)
    • Visual inspection of aspirate in conjunction with aspirate pH
    • Aspirate testing of enzyme levels for bilirubin, pepsin, and trypsin
    • Carbon dioxide (CO2) monitoring
  2. Nasogastric tube length prediction:
    • Age-related height-based methods
    • Morphological measurements, including nose-ear-xiphoid (NEX) and nose-ear-mid-xiphoid-umbilicus (NEMU)
Major Outcomes Considered
  • Incidence of misplaced nasogastric/orogastric tube (NGT/OGT) tubes
  • Reliability of NGT/OGT placement verification methods
  • Effect of feeding and medications on gastric aspirate testing
  • Predictive success of methods to calculate NGT/OGT tube length
  • Reduction in exposure of pediatric patients to x-rays
  • Time to delivery of clinical care via NGT/OGT
  • Patient/family satisfaction

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

OVID Databases

  • Medline, CINAHL, PubMed and the Cochrane Database for Systematic Reviews (CDSR)

OVID Filters

  • Publication Date: 1996 to present
  • Limits: Humans and English language
  • Study Type: Highest quality evidence

Search Terms and MeSH Terms

  • Children, nasogastric tube, NG tube, aspirate, auscultation, radiology, morphological, age-related height based, accuracy, prediction, length.

Additional articles identified from reference lists and clinicians.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: general review, expert opinion, case report, consensus report, or guideline

a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Reviewed against quality criteria by two independent reviewers.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5) are defined at the end of the "Major Recommendations" field.

  1. It is recommended that radiologic verification be used to determine nasogastric/orogastric tube (NGT/OGT) placement in pediatric patients who are at high risk of aspiration or when non-radiologic methods are not feasible, or results are unclear.

    Note: Pediatric patients at risk for incorrect tube placement include those who have neurologic impairment and other conditions which may increase the difficulty of safe, effective tube placement and include patients who are obtunded, sedated, unconscious, critically ill and those with reduced gag reflex or static encephalopathy (Metheny et al., "Techniques," 1994 [3a]; Phang et al., 2004 [3b]; Ellett & Beckstrand, 1999 [4b]).

    Note: Radiologic verification is considered the gold standard but may contribute to higher costs, decreased convenience, and increased radiation exposure (Metheny et al., "Techniques," 1994 [3a]; Metheny & Stewart, 2002 [3a]; Nyqvist, Sorell, & Ewald, 2005 [4a]; Peter & Gill, 2009 [4a]; Ellett & Beckstrand, 1999 [4b]; Westhus, 2004 [4b]).

  2. It is recommended that non-radiological verification methods be used to confirm placement of NGT/OGT in pediatric patients who are not considered at high risk for aspiration as outlined above, using the following method:

    Aspirate acidity (pH) testing: Use aspirate pH ≤5 to confirm gastric placement (Ellett et al., 2005 [3a]; Metheny et al., "Indicators," 1999 [4a]; Metheny & Stewart, 2002 [3a]; Metheny et al., "pH," 1999 [4a]; Metheny et al., 1993 [3a]) (see Table 1 in the original guideline document).

    Note: Gastric aspirate pH mean is statistically lower (higher acidity) compared to intestinal aspirate mean pH (Metheny et al., "pH," 1999 [4a]).

    Note: Mean pH of respiratory aspirate from the tracheobroncheal tree or plural space is statistically higher than gastric aspirate pH (Metheny et al., "pH," 1999 [4a]).

    Note: pH testing can be accurately done with pH paper or pH meter (Ellet et al., 2005 [3a]; Metheny et al., "pH," 1994 [3a]; Westhus, 2004 [4b]).

    Note: Mean values for gastric aspirate are not significantly different when patients are fed or fasting (Metheny & Stewart, 2002 [3a]; Metheny et al., "pH and concentration," 1999 [4a]).

    Note: Mean values for aspirate are not significantly different when patients are on or off acid suppression medications (Ellett et al., 2005 [3a]; Metheny et al., "pH," 1994 [3a]).

    Note: Auscultation has been shown to have poor reliability and is not recommended as a sole verification method. (Ellett & Beckstrand, 1999 [4b]; Metheny & Stewart, 2002 [3a]; Metheny et al., 1990 [4a]; Neumann et al., 1995 [3b]).

    Note: Visual inspection of aspirate has not been shown to be a reliable sole method of verification; however, it may have some use when done in conjunction with pH testing (Garpure et al., 2000 [4a]; Metheny & Stewart, 2002 [3a]; Metheny et al., "Indicators," 1999 [4a]; Metheny et al., "Techniques," 1994 [3a]; Metheny et al., "Visual," 1994 [4a]; Phang et al., 2004 [3b]; Westhus, 2004 [4b]).

    Note: Aspirate testing of enzyme levels for bilirubin, pepsin, and trypsin also provide an alternate method of verification, but it is limited to laboratory assessment (Ellett et al., 2005 [3a]; Garpure et al., 2000 [4a]; Metheny & Stewart, 2002 [3a]; Metheny et al., "pH and concentration," 1999 [4a]; Westhus, 2004 [4b]).

    Note: While carbon dioxide (CO2) monitoring provides an alternate method of verification, it requires a capnograph monitor to determine incorrect tube placement (Ellett et al., 2005 [3a]).

  3. It is recommended that NGT/OGT length be predicted as follows:

    For children >2 weeks, age-related height-based (ARHB) methods are more accurate than other morphological measures such as nose-ear-xiphoid (NEX) or nose-ear-mid-xiphoid-umbilicus (NEMU) in predicting tube length and can be calculated using prediction equation tables (see Table below: Age-related height-based equations for nasogastric tube [NGT] length predictions) (Beckstrand, Ellett, & McDaniel, 2007 [4a]; Ellett et al., 1992 [4b]; Klasner, Luke, & Scalzo, 2002 [2b]; Putnam & Orenstein, 1991 [4a]; Strobel et al., 1979 [4b]).

    For neonates less than 2 weeks of age, patients with short stature, or if unable to obtain an accurate height, use morphological measurements such as NEX or NEMU (Beckstrand, Ellett, & McDaniel, 2007 [4a]).

    Note: Measurement using the NEMU method for tube length prediction versus the NEX method is slightly more reliable for tube length prediction (Beckstrand, Ellett, & McDaniel, 2007 [4a]; Gallaher et al., 1993 [3a]; Weibley et al., 1987 [4a]).

    Note: Short stature is defined as a standing height more than 2 standard deviations (SDs) below the mean (or below the 2.5 percentile) for sex (Cohen et al., 2008 [5]).

    Note: Mark tube length at the nare for NGT, or corner of the mouth for OGT with indelible permanent marker and document amount of tube remaining (external visible length) (EVL) outside the patient in the patient record (Weibley et al., 1987 [4a]).

Table: Age-related Height-based (ARHB) Prediction Equations for the Internal Distance to the Body of the Stomach for Use in Clinical Practice, by Route of Insertion and Age in Children

Route Age Group (months) Predicted Internal Distance to the Body of the Stomach
Oral Age ≤28 9.1 cm + 0.183 (height cm) + 6 cm + 1.5 cm = 16.6 + 0.183 (height cm)
28 < age ≤ 100 9.1 cm + 0.183 (height cm) + 8 cm + 3 cm = 20.1 + 0.183 (height cm)
100 < age ≤ 121 4.5 cm + 0.218 (height cm) + 7.5 cm + 5 cm = 17 + 0.218 (height cm)
Age >121 4. 5cm + 0.218 (height cm) + 9 cm + 5 cm = 18.5 + 0.218 (height cm)
Nasal Age <28 10.1 cm + 0.197 (height cm) + 6 cm + 1.5 cm = 17.6 + 0.197 (height cm)
28 < age < 100 10.1 cm + 0.197 (height cm) + 8 cm + 3 cm = 21.1 + 0.197 (height cm)
100 < age < 121 4.5 cm + (2.7) + 0.218 (height cm) + 6.5 cm + 5 cm = 18.7 + 0.218 (height cm)
Age >121 4.5 cm + (2.7) + 0.218 (height cm) + 9 cm + 5 cm = 21.2 + 0.218 (height cm)

Note: the distance measured is to the bottom of the distal pore on the tube Beckstrand, (2007) [4a] Used with permission.

See Figure 1 in the original guideline document for Algorithm: Confirmation of NGT/OGT Placement.

Definitions:

Table of Evidence Levels

Quality Level Definition
1a or 1b Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: general review, expert opinion, case report, consensus report, or guideline

a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence
  2. Safety/harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

A clinical algorithm for the confirmation of nasogastric or orogastric tube (NGT/ORT) placement is provided in the original guideline document.

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate placement of a nasogastric/orogastric tube (NGT/OGT) in pediatric patients using radiological or non-radiological methods
  • Non-radiological NGT/OGT placement methods contribute to decreased radiation exposure for pediatric patients.
  • Methods which can be performed at the bedside allow greater convenience for the patients, families and staff, and may contribute to decreased costs.
Potential Harms
  • Side effects include improperly placed tube due to measurement or placement error.
  • Risks of improperly placed tubes include aspiration, feeding into the wrong place, and irritation.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Confirmation of nasogastric/orogastric tube (NGT/OGT) placement. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Aug 22. 9 p. [25 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Apr 27 (revised 2011 Aug 22)
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Revision Group/Team Leader: Sherri Sievers, MSN, RN, CNP, Department of Anesthesia

Support Personnel: Barbara K. Giambra, MS, RN, CPNP, Center for Professional Excellence, Research and Evidence-Based Practice

Ad Hoc Team Members, Development Group: Kim Klotz, BSN, RN, Vascular Access Team (Chair); Lois Siegle, BSN, RN, Home Care Services; Anne Longo, MBA, BSN, RN-BC, Center for Professional Excellence, Education; Karen Burkett, MS, CNP, RN, Center for Professional Excellence, Research and Evidence-Based Practice

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Confirmation of nasogastric tube placement in pediatric patients. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Apr 27. 11 p. [20 references]

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on October 2, 2009. This NGC summary was updated by ECRI Institute on March 28, 2012.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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