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LETTER TO EDITOR
Year : 2018  |  Volume : 62  |  Issue : 11  |  Page : 911-913  

Internal jaw thrust for nasogastric tube insertion


Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Web Publication2-Nov-2018

Correspondence Address:
Dr. Satyajeet Misra
Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_400_18

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How to cite this article:
Misra S, Behera BK, Sahoo AK. Internal jaw thrust for nasogastric tube insertion. Indian J Anaesth 2018;62:911-3

How to cite this URL:
Misra S, Behera BK, Sahoo AK. Internal jaw thrust for nasogastric tube insertion. Indian J Anaesth [serial online] 2018 [cited 2018 Dec 15];62:911-3. Available from: http://www.ijaweb.org/text.asp?2018/62/11/911/244840



Sir,

Nasogastric (NG) tube insertion in anaesthetized or unconscious patients is difficult with failure rates of 50%–66% on first pass attempt with the head in neutral position.[1],[2],[3] Common sites of impaction are piriform sinuses and the arytenoid cartilage,[4],[5] as well as the oesophagus which becomes compressed due to the inflated cuff of the endotracheal tube (ETT).[6] Once kinked or coiled, the NG tube is likely to further kink or coil on subsequent manoeuvers.[3] Complications of repeated attempts at insertion include kinking or coiling, bleeding and trauma to nasopharyngeal structures, hemodynamic disturbances, arrhythmias, and rarely lung injuries like pneumothorax and carinal bleed due to the NG tube insertion into the airway.[3]

Several methods for NG tube insertion have been described such as head flexion with lateral pressure, slit ETT guided placement, use of ureteral guidewires and Rusch intubation stylets, fibreoptic guided insertion, reverse Sellick manoeuver, and use of cooled and stiffened NG tubes with varying success rates.[1],[2],[3],[4],[5],[6],[7]

We report a new technique of insertion of NG tubes in intubated patients, the “internal jaw thrust.” With the head in neutral or flexed position, it is done by gently opening the intubated patient's mouth and inserting the thumb of the left hand into the oral cavity to grasp and lift the ETT along with the tongue, whereas the other fingers lift the mandible externally [Figure 1]a; the NG tube is then introduced into the nares with the other hand [Figure 1]b. This manoeuver lifts the arytenoids and makes the cricopharyngeus (upper oesophageal sphincter) patent (arrowhead) [Figure 1]c and allows easy passage of the NG tube (arrow) into the oesophagus [Figure 1]d and Video 1 showing fiberoptic visualization of the passage of NG tube].
Figure 1: (a) Thumb of operator's left hand is used to grasp and lift the endotracheal tube and the tongue, whereas the remaining four fingers grasp and lift the mandible externally. (b) Operator's right hand introduces the nasogastric tube into the nares. (c) Fiberoptic view showing how this manoeuver lifts the arytenoids and makes the cricopharyngeus (upper oesophageal sphincter) patent (arrow head) and (d) easy passage of the tube (arrow) into the oesophagus

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The mechanism of this particular method may be similar to lifting the ETT tube with a laryngoscope, so that the inferior constrictor that marks the anatomical beginning of the oesophagus is displaced anteriorly. However, the advantage as compared with laryngoscopy is that no instrumentation is required. We did not encounter any trauma while practising this method. Digital assistance of NG tube insertion has been described,[8] but the authors have used the index finger to guide the NG tube in the oral cavity, which may be difficult in patients with limited mouth opening. A well-planned study is required to confirm the utility of this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bong CL, Macachor JD, Hwang NC. Insertion of the nasogastric tube made easy. Anesthesiology 2004;101:266.  Back to cited text no. 1
    
2.
Mahajan R, Gupta R. Another method to assist nasogastric tube insertion. Can J Anaesth 2005;52:652-3.  Back to cited text no. 2
    
3.
Appukutty J, Shroff PP. Nasogastric tube insertion using different techniques in anesthetized patients: A prospective, randomized study. Anesth Analg 2009;109:832-5.  Back to cited text no. 3
    
4.
Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: Fiberoptic description of where they go at the laryngeal level and how to make them enter the esophagus. Anesthesiology 1999;91:137-43.  Back to cited text no. 4
    
5.
Parris WC. Reverse sellick maneuver. Anesth Analg 1989;68:423.  Back to cited text no. 5
    
6.
Tsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99.  Back to cited text no. 6
    
7.
Chun DH, Kim NY, Shin YS, Kim SH. A randomized, clinical trial of frozen versus standard nasogastric tube placement. World J Surg 2009;33:1789-92.  Back to cited text no. 7
    
8.
Kandeel A, Elmorhedi M, Abdalla U. Digital assistance of nasogastric tube insertion in intubated patients under general anesthesia: A single-blinded prospective randomized study. Saudi J Anaesth 2017;11:283-6.  Back to cited text no. 8
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