NG tube problems

at the bedside

airway, breathing, circulation; full vitals, SpO₂
stop the tube → no feed, flush or drug through a tube you are unsure of
check → what it is for (feeding or drainage); length at the nose vs documented, fixation intact, tube coiled in the mouth

escalate now if

coughing, choking, falling SpO₂ or breathless, with or without a feed running (secretions, vomiting) → aspiration
X-ray shows the tube in the airway → stop using it, remove promptly
drainage tube out with vomiting, distension or obstruction → urgent reassessment and decompression, not a blind reinsertion → out
blood in the aspirate that is more than streaks, persists, or comes with instability or symptoms → GI bleed

chart → documented length, how position was confirmed (pH or X-ray) and when, drugs due by the tube
exam → chest, distended abdomen, aspirate (volume, blood)
before a nasal tube → skull-base fracture or recent nasal or skull-base surgery: no blind nasal tube; recent variceal bleed or banding: a precaution, not an absolute bar; discuss with GI before placing one when possible

new or replaced gastric feeding tube → X-ray showing the whole tube before first use, as local policy requires; where policy accepts it, gastric aspirate pH ≤ 5.5 on CE-marked strips confirms a gastric position and the X-ray follows only if there is no aspirate, pH > 5.5 or any doubt; cross-check current local policy

suspected displacement → length changed, fixation loose, coughing or vomiting since the last check: stop using it, check the external length, reconfirm (pH or X-ray) per local protocol
X-ray → required whenever pH is not accepted locally or cannot reliably confirm the position, and whenever clinically indicated; the film must show the whole tube
never use → whoosh or stethoscope test, bubble test, aspirate appearance alone, or absence of respiratory symptoms

reading the X-ray: all four, or don’t use it

write it → method (pH value, or who read the X-ray), findings, length at the nose, fixation, “safe to use”
scope → these criteria are for standard gastric feeding tubes; drainage and post-pyloric tubes per intended use and local policy

position wrong or in doubt

in the airway → stop using it, remove promptly with suction and oxygen ready; further imaging by the clinical picture, a difficult insertion or suspected injury
in the esophagus or too short → reposition or replace, reconfirm before use
feed or drug may have gone into the airway → assess for aspiration and lung injury, monitor → aspiration; ICU if hypoxic or deteriorating

blocked

check the external tubing for kinks and closed clamps
confirm the position is safe before any flush; then lukewarm water, typically 15–30 mL in a 60 mL enteral syringe, gentle push-pull, per local protocol and any fluid restriction
never force it; no guidewire, sharp objects, fizzy or acidic drinks
still blocked → pharmacy or nutrition team advice, or replace; review the drugs going down the tube (crushed tablets, thick suspensions)

out

drainage tube, with vomiting, distension or obstruction → urgent review and restore decompression: new tube by someone experienced, confirmed before use; treating or surgical team if recent upper GI surgery, a difficult insertion or any doubt
feeding tube, patient stable → decide whether it needs replacing overnight; cover hydration, glucose (insulin with the feed stopped → hypoglycemia) and essential drugs by another route, then the treating team replaces
time-critical drug with no other route → alternative route with pharmacy, or urgent replacement
pulled out again → treat the delirium, check discomfort and fixation, ask whether the tube is still needed; treating team to discuss another route

aspiration

stop the feed, sit up, suction, oxygen to target → oxygen desaturation
pneumonitis vs pneumonia → judged by the overall course, infection features and severity, not by time course or fever alone
uncomplicated chemical pneumonitis → supportive, no routine antibiotics
bacterial pneumonia suspected → worsening, new consolidation, sepsis features: empiric antibiotics

reassess

if aspiration suspected → respiratory rate, SpO₂, work of breathing and chest at 30 min, then each round
every tube → position, fixation and patency before each use; external length against the documented mark
if decompression → abdominal symptoms, distension and drainage output

prevent → head of bed ≥ 30°; flush 30 mL water every 4 h on continuous feeds unless fluid-restricted
hand over → tube status, how position was confirmed and when, feed on or off, drugs rerouted, replacement plan

source	type
ASPEN 2017 · Safe practices for enteral nutrition therapy ↗︎	international guideline
NPSA 2011 · Misplaced NG tubes, X-ray interpretation ↗︎	national safety alert
NHS England 2016 · NG tube misplacement ↗︎	national safety alert
HSIB 2020 · Placement of nasogastric tubes (HSSIB) ↗︎	national safety investigation
NNNG 2023 · Safe insertion and ongoing care of NG feeding tubes in adults ↗︎	national guidance
NHS SPS 2025 · Enteral feeding tube blockages ↗︎	national guidance
Merck Manual 2026 · Aspiration pneumonitis and pneumonia ↗︎	review

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

updated Oct 2026file complaint/ng-tube-problems