When the Tube Won't Go: Strategies for Difficult Nasogastric Intubation

Area of Science:

• Medical Procedures
• Gastroenterology
• Otolaryngology

Background:

• Nasogastric tube (NGT) insertion is crucial for patients with swallowing difficulties.
• Anatomical variations and prior interventions can complicate NGT placement.
• Otolaryngologists often use flexible nasendoscopy (FNE) for difficult NGT insertions in awake patients.

Purpose of the Study:

• To review adjunctive techniques for enhancing difficult NGT insertions under FNE guidance.
• To identify strategies improving success rates, patient comfort, and procedural efficiency.

Main Methods:

• A narrative literature review of PubMed and Google Scholar (2005-2025).
• Search terms included 'nasogastric tube', 'difficult insertion', and 'insertion technique'.
• Included studies focused on adult awake patients; excluded anaesthetised patients. Data extracted on design, technique, and outcomes.

Main Results:

• Eleven publications were identified describing techniques like prechilling the NGT, sniffing position, and the SORT maneuver.
• FNE-assisted methods using surgical knots or gel caps were also examined.
• While techniques improved efficiency and operator control, consistent statistical improvement in success rates was not demonstrated. Patient comfort and independence improved with FNE-guided methods.

Conclusions:

• Difficult NGT insertion remains a clinical challenge.
• Combining physical tube modifications with FNE visualization can improve safety and efficiency in complex cases.
• Further randomized controlled trials are needed to evaluate efficacy and establish standardized protocols for awake patients.