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. 2022 Feb 23;12(3):337.
doi: 10.3390/jpm12030337.

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era

Vasiliki Tsolaki  1 , George E Zakynthinos  1 , Paris Zygoulis  1 , Fotini Bardaka  1 , Aikaterini Malita  1 , Vasileios Aslanidis  1 , Epaminondas Zakynthinos  1 , Demosthenes Makris  1
Affiliations

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era

Vasiliki Tsolaki et al. J Pers Med. .

Abstract

Background: Nasogastric tube (NGT) placement is a daily routine in the Intensive Care Unit (ICU), and misplacement of the NGT can cause serious complications. In COVID-19 ARDS patients, proning has emerged the need for frequent NGT re-evaluations. The gold standard technique, chest X-ray, is not always feasible. In the present study we report our experience with the use of ultrasonographic confirmation of NGT position.

Methods: A prospective study in 276 COVID-19 ARDS patients admitted after intubation in the ICU. Ultrasonographic evaluation was performed using longitudinal or sagittal epigastric views. Examinations were performed during the initial NGT placement and every time the patients returned to the supine position after they had been proned or whenever critical care physicians or nurses considered that reconfirmation was necessary.

Results: Ultrasonographic confirmation of correct NGT placement was feasible in 246/276 (89.13%) patients upon ICU admission. In 189/246 (76.8%) the tube could be visualized in the stomach (two parallel lines), in 172/246 (69.9%) the ultrasonographic whoosh test ("flash" due to air instillation through the tube, seen with ultrasonography) was evident, while in 164/246 (66.7%) both tests confirmed correct NGT placement. During ICU stay 590 ultrasonographic NGT evaluations were performed, and in 462 (78.14%) cases correct NGT placement were confirmed. In 392 cases, a chest X-ray was also ordered. The sensitivity of ultrasonographic NGT confirmation in these cases was 98.9%, specificity 57.9%, PPV 96.2%, and NPV 3.8%. The time for the full evaluation was 3.8 ± 3.4 min.

Conclusion: Ultrasonographic confirmation of correct NGT placement is feasible in the initial placement, but also whenever needed thereafter, especially in the COVID-19 era, when changes in posture have become a daily practice in ARDS patients.

Keywords: POCUS; intensive care unit; nasogastric tube; ultrasonography.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Chest X-ray in one of the first COVID-19 ARDS patients admitted in our ICU. The patient was turned from prone to the supine position on the 4th ICU day, late in the night, and nasogastric tube position was checked with palpation of a “flash” of air in the epigastrium, although there could not be observed any aspirated fluid. Enteral nutrition was started. Eight hours later the patient became hypoxemic, and increased tracheobronchial secretions were noted. A chest X-ray was ordered which revealed the NGT mispositioning in the right lower lobe. White arrows indicate the misplaced nasogastric tube in the Right Lower Lobe.
Figure 2
Figure 2
Abdominal ultrasonography. Ultrasonographic confirmation of nasogastric tube presence in the stomach. The liver is seen on the left of the image. Two parallel lines are noted, corresponding to the NGT (white arrows).
Figure 3
Figure 3
Flow chart of the patients with ultrasonographic confirmation of nasogastric tube. Flow chart of the patients in whom ultrasonographic NGT confirmation was performed. NGT, nasogastric tube; u/s, ultrasound.
Figure 4
Figure 4
Abdominal ultrasonography. In picture (A), there is a presentation of the stomach at the center of the image in the longitudinal axis, while the hyperechoic structure beneath is pancreatic tissue. In picture (B), the image is obtained after instillation of a “flash” of air (white arrows) through the nasogastric tube. The pancreatic tissue is obscured (empty arrows), as an amount of air interferes between the ultrasonographic beam and the pancreas.
See this image and copyright information in PMC

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