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Canadian Journal of Anesthesia 52:1106-1107 (2005)
© Canadian Anesthesiologists' Society, 2005

Correspondence

Insertion of a nasogastric tube with the patient in the prone position

Masanori Yamauchi, MD PhD, Shingo Furuse, MD, Makoto Asano, MD PhD, Masanori Watanabe, MD, Soushi Iwasaki, MD and Akiyoshi Namiki, MD PhD

Sapporo Medical University School of Medicine, Hokkaido, Japan, E-mail: my3{at}rb4.so-net.ne.jp

To the Editor:

Although many techniques to facilitate the passage of a nasogastric tube (NGT) have been reported, the insertion of an NGT in anesthetized patients can at times be unexpectedly difficult.1–3 We evaluated a novel approach of using the prone position to facilitate NGT insertion compared with classic insertion in the supine position. The Hospital Ethics Committee approved this protocol, and informed consent was obtained from 45 patients scheduled for elective lumbar supine surgery. After orotracheal intubation under general anesthesia, a 14-French silicon NGT (Create Medic Company, Ltd., Yokohama, Japan) was generously lubricated and inserted in the supine position. The anesthesiologist was permitted to lift the patient’s tongue jaw, the cricoid cartilage and the thyroid cartilage. The right nostril was filled with the lidocaine jelly, and the NGT was gently inserted into the naris and blindly advanced into the stomach. If the NGT coiled or failed to advance into the stomach on the first attempt, the NGT was withdrawn slightly and secondary insertion was attempted. Placement of the NGT in the stomach was confirmed by the presence of a swooshing sound heard through a stethoscope placed over the stomach while injecting 10 mL of air into the NGT. After a successful insertion or failure twice in the supine position, the NGT was withdrawn slightly, and the patient was turned to the prone Hall-frame position on a lumbar supine surgery table. The patient’s neck was rotated 45° to the right on the table and the NGT was inserted. The number of successful inserted cases within two attempts at either position was compared. In one patient, neck lateral x-ray imaging was taken in both positions.

The number of successful cases in the prone position (42/45, 93%) was significantly higher than in the supine group (15/45, 33%), (P < 0.01). Cervical x-ray imaging (FigureGo) shows that there was sufficient space to pass an NGT at the hypopharynx and esophageal constrictions in the prone position. In this patient, the NGT was coiled at the pharynx, and did not advance to the esophagus in the supine position. However, in the prone position, the NGT was easily advanced into the stomach.



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  		FIGURE Cervical x-ray imaging of a case in which a nasogastric tube (NGT) could not be advanced into the stomach with the patient in the supine position (A), but could be advanced with the patient in the prone position (B). There was obviously a wide space (arrow) to pass an NGT at the hypopharynx and esophageal constrictions in the prone position, but no space in the supine position.

 
Ozer et al.1 reported that the arytenoid cartilages and piriform sinuses resist passage of an NGT at the laryngeal level. Isono et al.4 reported in patients with obstructive sleep apnea that the supine position not only decreased static pressure-area curves and maximum cross-sectional area, but also increased the closing pressure at both the retropalatal and retroglossal airways. We report that the prone position facilitates the insertion of an NGT compared with the supine position, and suggest that the prone position would give wider space to the hypopharynx and upper esophagus than the supine position under general anesthesia with muscle relaxant. We recognize the indications for this prone position method are limited. However, an NGT easily advances into the stomach almost uniformly on the first attempt in the prone position, and this simple and fast technique may be useful in certain clinical situations.

References

1 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.[Medline]

2 Shetty S, Henthorn RW, Ganta R. A method to reduce nasopharyngeal trauma from nasogastric tube placement (Letter). Anesth Analg 1994; 78: 410–1.[Medline]

3 Mundy DA. Another technique for insertion of nasogastric tubes (Letter). Anesthesiology 1979; 50: 374.

4 Isono S, Tanaka A, Nishino T. Lateral position decreases collapsibility of the passive pharynx in patients with obstructive sleep apnea. Anesthesiology 2002; 97: 780–5.[Medline]




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