UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 11·Bedside / standard·Standard tier
11.

NG/OG Tube

Insertion.

Decompression · enteral access · gastric lavage.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_Procedures/11_*
NG/OG Tube · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
02 · Why this matters
Tracheobronchial misplacement · adult NG placements
1–3%
and the consequence of an undetected miss — feed or medication instilled into the airway — is chemical pneumonitis, aspiration pneumonia, death.
  • NG/OG tubes are among the most frequently misplaced bedside devices in adult inpatient care.
  • Verification before first use is non-negotiable — chest X-ray is the gold standard before instillation of feeds, water, or medications (NPSA 2011 / AACN 2016).
  • Air-bolus auscultation is no longer acceptable as a stand-alone verification — has produced fatal misfeeds.
  • NG in suspected basilar skull fracture has caused intracranial placement and fatal CSF disruption — OG is mandatory here.
AACN. Initial and ongoing verification of feeding tube placement in adults. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
NPSA/2011/PSA002. Reducing the harm caused by misplaced nasogastric feeding tubes in adults.
NG/OG Tube · Why this matters
02 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
03 · Course objectives

What you'll leave with — six competencies.

01 · Cognitive

Anatomy & route choice.

Describe upper aerodigestive anatomy; justify why insertion is straight back along the nasal floor — never angled toward the brow.

02 · Cognitive

Indications & contraindications.

Differentiate accepted NCC indications; recognize basilar skull fracture as absolute contraindication to NG — select OG instead.

03 · Psychomotor

NEX measurement & insertion.

Measure NEX, position high-Fowler with chin tuck, lubricate, advance straight back, coordinate with swallow to pre-marked depth.

04 · Psychomotor

Tube selection.

Match tube and Fr size to indication — 14–18 Fr Salem Sump for decompression; 8–12 Fr small-bore weighted for feeding.

05 · Cognitive

Radiographic confirmation.

Confirm gastric placement on KUB or chest X-ray before any feed or medication, per AACN 2016 — auscultation alone is insufficient.

06 · Affective

Misplacement response.

Recognize cough / desaturation as tracheobronchial signals; withdraw immediately; hold feeds; escalate; disclose per UCI standards.

NG/OG Tube · Course objectives
03 / 21
UUCI · APP Class II
Section I of IV
I.
Section one

Anatomy & route choice.

Nasopharynx → oropharynx → hypopharynx → esophagus. The sequence is unforgiving when ignored — and the cribriform plate lies immediately above. Pick the route before you pick the tube.
Objectives C-1 · C-2 · C-3 — slides 5–8
NG/OG Tube · Section I
04 / 21
UUCI · APP Class II
Key fact · gold standard
AACN 2016 Practice Alert · NPSA 2011
CXR
is the only reliable tube-position confirmation before the first feed, the first medication, or the first flush. Auscultation is unreliable and has produced fatal misfeeds.
Below
the
diaphragm.
Left
of the
spine.
Gastric bubble
around
the tip.
Read
with the
interpreting team.
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
05 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
04 · Indications

When to place — four buckets.

  • Gastric decompression — ileus, small-bowel obstruction, post-operative gastroparesis
  • Gastric lavage — selected acute toxic ingestion or upper-GI bleed cases
  • Enteric medication delivery in NPO patients unable to swallow safely
  • Short-term enteral feeding when oral intake is contraindicated — intubated, GCS ≤ 8, status epilepticus on continuous infusion
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
Marino PL. The ICU Book, 4th ed. Ch 48. Wolters Kluwer; 2014.
Neurocritical-care examples
  • Post-operative SAH patient with ileus → decompression
  • Intubated TBI patient · GCS 6 → enteral feeding initiation
  • NPO status epilepticus patient on continuous AEDs → medication delivery
  • Anything outside these buckets → escalate before placing
MGH Internal Medicine Housestaff Manual 2024-25 ed. Nasogastric section. MGH Dept of Medicine.
NG/OG Tube · Indications
06 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
05 · Contraindications

Basilar skull fracture is an absolute no for NG.

Absolute (to NG route)
  • Basilar skull fracture or suspected cribriform-plate injury — reported NG cases have caused intracranial placement, fatal
  • Severe maxillofacial trauma with disrupted nasal architecture
Wolter G et al. Cureus. 2025;17(7):e89085 · PMID 40896069
NPSA/2011/PSA002. Reducing the harm caused by misplaced nasogastric feeding tubes in adults.
Relative — coordinate first
  • Esophageal varices — coordinate with GI before insertion
  • Recent upper-GI surgery — coordinate with surgical team
  • Known stricture or esophageal pathology
  • Coagulopathy or active anticoagulation — weigh epistaxis risk
  • Chronic nasal obstruction — switch nostril or convert to OG
Any basilar-skull concern shifts you to OG. The teaching is absolute.
NG/OG Tube · Contraindications
07 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
06 · Route & tube selection

Match the route — and the tube — to the job.

Small-bore weighted enteral feeding tube — full-length product view with weighted tip and stylet seated
Tenbergen · Wikimedia CommonsCC BY-SA 4.0
Route — NG vs OG
  • OG preferred — intubated, comatose, or unable to protect airway
  • OG required — basilar skull fracture or midface trauma; never NG here
  • NG preferred — awake, cooperative patient; better tolerated for prolonged use
Tube — Fr size by indication
  • Salem Sump 16–18 Fr — double-lumen decompression; blue pigtail vents to atmosphere · never clamp the blue pigtail
  • Levin tube — single-lumen; short-term suction only; not preferred long-term (mucosal trauma)
  • Small-bore weighted feeding tube 8–12 Fr with stylet — weighted tip aids transpyloric passage
  • Too small for decompression → clogs · too large for feeding → alar-rim pressure injury
Boullata JI et al. ASPEN safe practices for enteral nutrition therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15–103 · PMID 27815525
NG/OG Tube · Route & tube selection
08 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
07 · Equipment

What you need on the table.

Kit checklist
  • Salem Sump (decompression) or Levin tube
  • Small-bore weighted tube (feeding)
  • Water-soluble lubricant · never oil-based
  • 60-mL catheter-tip syringe
  • Emesis basin · tape · pH strips
  • Cup of water + straw if awake & not aspiration-risk
  • Capnography / colorimetric CO2 if available
  • Penlight for posterior pharynx inspection
  • Suction setup at bedside · Yankauer + canister
  • CXR access for post-placement confirmation
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
UCI clinical photo
NG/OG equipment tray — to be supplied by APP Education
UCI Health · APP Educationplaceholder
NG/OG Tube · Equipment
09 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
08 · Pre-procedure · time-out

Before you insert — the last gate.

  • 01
    Verify the patient. Two identifiers, allergies, indication. Re-screen for new basilar-skull-fracture findings or recent epistaxis.
  • 02
    Informed consent. Procedure, expected discomfort (gagging, nasopharyngeal irritation, watering eyes), risks (epistaxis, malposition, aspiration, rare esophageal injury). Surrogate decision-maker if patient lacks capacity.
  • 03
    Name the stop signal. For awake patients — raised hand, tap on rail. Rehearse it. Document that the patient understands they may abort.
  • 04
    Universal Protocol time-out. Per TJC UP.01.03.01 — correct patient, correct procedure (NG vs OG), correct side (which nare), equipment ready, suction at bedside.
  • 05
    Document indication and route in EHR. The chart entry starts the maintenance and verification clock.
Misplacement response framework
  • Hold all feeds and medications immediately
  • Remove the tube if position cannot be verified radiographically
  • Escalate to attending
  • Disclose per UCI event-reporting standards
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
NG/OG Tube · Pre-procedure · time-out
10 / 21
UUCI · APP Class II
Section II of IV
II.
Section two

The insertion
sequence.

Position, measure, lubricate, angle, swallow, secure. Each step has a verification gate. Skip a gate, inherit the consequence.
Objectives P-1 · P-2 · P-3 · P-4 · P-5 — slides 12–17
NG/OG Tube · Section II
11 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
09 · Positioning · NEX measurement

High Fowler, chin tuck, NEX before you insert.

Positioning
  • Head of bed 45–90° (high Fowler) — closes airway, opens esophagus
  • Chin tucked to chest during advancement — directs tube posteriorly toward esophagus
  • Suction setup and emesis basin within reach before advancing
  • If intubated/sedated — head midline, verify cuff inflation before OG attempt
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
Step 01 — NEX measurement
  • Tip of nose → earlobe → xiphoid process
  • Mark the tube at the measured length with tape or marker
  • Adult NEX typically 50–60 cm — expect this depth at the nostril once seated
  • Re-measure if anatomy makes standard NEX implausible
  • CRITICAL ACTION · documented before insertion
OpenStax Anatomy & Physiology 2e · Fig 23.13 · CC BY 4.0
NG/OG Tube · Positioning & NEX
12 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
10 · Step 02 · lubricate tip

Water-soluble — never oil-based.

Small-bore weighted enteral feeding tube with stylet partially withdrawn — distal-tip detail
Tenbergen · Wikimedia CommonsCC BY-SA 4.0
  • Apply water-soluble lubricant to the distal 4–6 inches of the tube
  • Never mineral oil or petroleum-based lubricant — aspiration causes lipid pneumonitis
  • Inspect tube for defects before insertion
  • For feeding tubes with stylet — flush to confirm patency before insertion
  • Stylet handling per institutional protocol — never re-insert a stylet once the tube is past the carina
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
Boullata JI et al. ASPEN safe practices. JPEN. 2017;41(1):15–103 · PMID 27815525
NG/OG Tube · Step 02 · lubricate
13 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube · Critical checkpoint
Critical checkpoint · cribriform-plate avoidance

Step 03 — angle straight back
along the nasal floor.

Do
  • Direct the tube straight back along the nasal floor — parallel to the palate
  • Resistance at 5–7 cm usually means turbinate contact — withdraw, redirect, try the contralateral nare
  • Stop immediately on sudden give or any CSF-like drainage — withdraw and image
Do not
  • Do not angle upward toward the brow — turbinates bleed
  • Do not use the nasal route in suspected basilar skull fracture — intracranial NG placement is reported and fatal
Skull-base trauma
NG is absolutely contraindicated.
Use OG.
Wolter G et al. Cureus. 2025;17(7):e89085 · PMID 40896069
NPSA/2011/PSA002 · OpenStax A&P 2e · Fig 22.4 · CC BY 4.0
NG/OG Tube · Step 03 · angle straight back
14 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
11 · Steps 04 & 05

Coordinate the swallow — past the tongue, midline.

04

Coordinate with
swallowing.

  • At the oropharynx — pause and instruct
  • If safe — small sips of water through a straw; advance during each swallow
  • Each swallow closes the airway via epiglottic deflection and opens the UES
  • If unsafe to swallow (NPO, dysphagia, intubated) — advance steadily with chin tucked
  • Persistent cough / dyspnea / voice change / desaturation → STOP, WITHDRAW, REASSESS · never advance through respiratory distress
Elmahdi A et al. Nutr Clin Pract. 2023;38(6):1247–1252 · PMID 37227191
05

Past the tongue,
midline.

  • Inspect oropharynx with penlight — tube passes midline, not coiled
  • Tube curling in the mouth → withdraw to oropharynx and re-advance with swallow
  • Continue advancing to the pre-marked NEX length
  • For OG — advance past midline of tongue; jaw-lift or laryngoscope assist if intubated/sedated
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
NG/OG Tube · Steps 04 & 05
15 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
12 · Step 06 · secure & document

Tape the tube — and write down the depth.

Securement — NG
  • Tape to the nose without pressure on the alar rim — pressure injury is preventable
  • Document length at the nostril (e.g., 55 cm at the nare) — this is the daily-rounding reference
  • Record nare used, attempts, patient tolerance, external length in the procedure note
  • Do not connect to suction or feeding until radiographic confirmation is in hand
Securement — OG
  • Secure to the cheek, never to the nose
  • Document length at the incisor
  • Indicated for basilar-skull / cribriform / severe maxillofacial trauma — never use NG route here
UCI clinical photo
Midline tube past tongue — to be supplied by APP Education
UCI Health · APP Educationplaceholder
Wolter G et al. Cureus. 2025;17(7):e89085 · PMID 40896069
NPSA/2011/PSA002. Reducing the harm caused by misplaced NG feeding tubes in adults.
NG/OG Tube · Step 06 · secure
16 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube · Critical checkpoint
Critical safety checkpoint · before first feed or medication

Confirm position on X-ray
before any feed.

Gold standard — KUB or chest X-ray

Tip sits below the diaphragm, to the left of the spine, with the gastric bubble around the tip. Read with the interpreting team.

Auscultation is unreliable

Air-bolus auscultation has produced fatal misfeeds and is not a stand-alone confirmation method.

No X-ray, no feed
Hold feeds and medications until radiographic
placement confirmation is verified.
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348
NPSA/2011/PSA002 · Boeykens K et al. Crit Care. 2023;27(1):317 · PMID 37596615
NG/OG Tube · Verification
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UUCI · APP Class II
Procedure 11 · NG/OG Tube
13 · Adjunct verification

pH · capnography · EM placement — adjuncts only.

AdjunctWhat it tells youWhat it does not tell you
Gastric pH pH ≤ 5.5 supports gastric placement; pH > 6 raises concern for respiratory or small-bowel position. PPI / H2 acid suppression blunts the discriminator. Not definitive. Repeat at first confirmation and before each subsequent feed (ASPEN 2017).
Capnography / colorimetric CO2 Absence of CO2 helps rule out tracheal placement during insertion. Presence of CO2 is a strong tracheal / bronchial signal — withdraw immediately.
Auscultation DO NOT USE as a primary or sole verification method. Cannot reliably distinguish gastric / esophageal / pulmonary placement — NPSA 2011 / AACN 2016 explicitly advise against.
EM placement (Cortrak) Bedside trace can support placement during advancement. Does not replace radiographic confirmation for feeding tubes per NPSA / AACN.
Bottom line — chest X-ray remains the gold standard before first feed, medication, or flush. Bedside adjuncts inform but do not authorize use.
AACN. Crit Care Nurse. 2016;36(2):e8–e13 · PMID 27037348 · Boullata JI et al. JPEN. 2017;41(1):15–103 · PMID 27815525
NG/OG Tube · Adjunct verification
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UUCI · APP Class II
Procedure 11 · NG/OG Tube
14 · Complications & daily maintenance

What can go wrong — and what to chart daily.

01 · Catastrophic

Tracheobronchial malposition.

Feed or medication into airway → chemical pneumonitis, aspiration pneumonia, death. CXR before any feed.

02 · Catastrophic

Intracranial placement.

NG in basilar skull fracture — reported and fatal. Use OG whenever skull-base injury is suspected.

03 · Immediate

Epistaxis.

Turbinate contact from upward angulation. Withdraw, redirect, contralateral nare. Pack if severe.

04 · Immediate

Esophageal perforation.

Rare. Forced advancement against resistance. Stop on unexpected resistance — escalate.

05 · Delayed

Sinusitis.

Prolonged NG dwell. Consider OG conversion if > 7–10 days and clinical signs develop.

06 · Delayed

Alar-rim pressure ulcer.

Tape tension on the nasal alar rim. Daily skin check; rotate tape position; use foam securement.

07 · Maintenance

Daily — measure external length each shift.

Re-image with CXR if dislodgement is suspected. pH at each feed as adjunct.

08 · Maintenance

Daily — is the tube still indicated?

Flush 30 mL water before/after meds and q4–6h on continuous feeds. Remove as soon as not needed.

NG/OG Tube · Complications & maintenance
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UUCI · APP Class II
Procedure 11 · NG/OG Tube
15 · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of NG/OG privilegeFirst 3 independently performed cases · per-case review within 14 days · aggregate at 3 · closure within 6 months
OPPEContinuous baselineEvery 6 mo · 10% sample (min 2, max 10) · 100% review on any misplacement flag
Trigger reviewMisplacement · feed before CXR · absent skull-base screen in trauma patientAd-hoc focused review · minimum 3 subsequent cases
Reinstatement< 5 independent cases over rolling 24 moStream B skills checklist + 1 proctored live case rated Independent
Tracked OPPE indicators
  • Misplacement rate zero-tolerance
  • X-ray confirmation before any feed/med 100%
  • Basilar-skull screen documented (head/face trauma) 100%
  • Documentation completeness — route, Fr, NEX, length, CXR ref, pH, complication 100%
  • Complication rate — per-case review on any occurrence
Standard tier · LOW risk
Catastrophic failure mode (tracheobronchial / intracranial) drives the zero-tolerance indicators.
NG/OG Tube · FPPE / OPPE pathway
20 / 21
UUCI · APP Class II
Procedure 11 · NG/OG Tube
16 · References & next steps

Sources of truth · and what's next.

  1. 01AACN. Initial and ongoing verification of feeding tube placement in adults. Practice Alert. Crit Care Nurse. 2016;36(2):e8–e13. PMID 27037348.
  2. 02NPSA. Reducing the harm caused by misplaced nasogastric feeding tubes in adults. NPSA/2011/PSA002. National Patient Safety Agency; March 2011.
  3. 03Wolter G, Naqvi ZU, Jalali A, et al. Intracranial injury following nasogastric tube placement after skull base surgery: a case report and systematic review. Cureus. 2025;17(7):e89085. PMID 40896069.
  4. 04Elmahdi A, Eisa M, Omer E. Aspiration pneumonia in enteral feeding: a review on risks and prevention. Nutr Clin Pract. 2023;38(6):1247–1252. PMID 37227191.
  5. 05Boeykens K, Holvoet T, Duysburgh I. Nasogastric tube insertion length measurement and tip verification in adults: a narrative review. Crit Care. 2023;27(1):317. PMID 37596615.
  6. 06Boullata JI, Carrera AL, Harvey L, et al. ASPEN safe practices for enteral nutrition therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15–103. PMID 27815525.
  7. 06aCompher C, Bingham AL, McCall M, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12–41. PMID 34784064.
  8. 06bPerry A, Kaiser J, Kruger K, et al. ENA clinical practice guideline synopsis: gastric tube placement verification. J Emerg Nurs. 2024;50(2):301–304. PMID 38453344.
  9. 07Marino PL. Marino's The ICU Book, 4th ed. Ch 48 (enteral access). Wolters Kluwer; 2014.
  10. 08MGH Internal Medicine Housestaff Manual, 2024-25 ed. Nasogastric section. MGH Dept of Medicine.
  11. 09The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
  12. 09aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  13. 09bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  14. 09cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  15. 09dThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  16. 10The Joint Commission. HR.01.06.01 — competence verified before care. TJC Hospital Accreditation Standards; 2024.
  17. 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
  18. 12OpenStax College. Anatomy & Physiology 2e. Figures 22.4 (nasal anatomy) & 23.13 (GI). CC BY 4.0.
Stream A
12-item post-test
≥ 10/12
Stream B
18-item skills checklist
all 4 critical † · Independent
Stream C
3 proctored live cases
per Training Plan
Routing
IDPC → Chair → APP Director
→ Credentials → MEC → Board
NG/OG Tube · References & close
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