I had an opportunity to have a nasogastric tube inserted during my placement just to get an idea of how it felt.
What is it?
Often when people are unable to meet nutritional requirements in the short term through a regular diet, NG tube feeding is considered. Other options that are more invasive e.g. PEG are considered for the longer term.
A nasogastric gastric tube (NGT) is a long thin, bendable tube which is inserted from the nose (“naso”) to the stomach (“gastric”) and a tube feed (liquid-based nourishment) is passed through this tube to provide some or all of a person’s nutrition requirement.
Common conditions that require tube feeding include neurological and neuromuscular disorders (e.g. Parkinson’s, stroke, MS, ALS), difficulties with swallowing, anatomical and post-surgical malformations of the mouth and oesophagus (e.g. cancer), digestive disorders (e.g. IBD), children who fail to thrive and so on.
Dietitians work out feeding regimes based on individual requirements taking into consideration the patient’s lifestyle, preferences, practicalities, refeeding syndrome risk, feeding tolerance, etc. and provides discharge support for home enteral feeding.
Additionally, dietitians liaise with the patient, family and multidisciplinary team (MDT) regarding tube feeding decisions weighing out the pros and cons.
The medical team provides any medical updates, reviews medications, assesses patient capacity, makes the decision regarding tube placement after taking into consideration of patient wishes and every team member’s opinion.
Nurses take care of mouth care as patients may not be taking food and drinks orally, involved in the caring of the tube and the one who provides constant support for the patient and family.
Speech and Language Therapists (SLT) who assesses the person’s ability to swallow as enteral feeding will be the next step if the patient cannot tolerate a soft diet or thickened fluids to meet their nutrition needs.
Physiotherapists to ensure feeding regime to fit in with rehab goals.
Occupational Therapists to work on relevant skills around feeding, assessing the home environment and support decisions around discharge destination.
Psychologists to provide counselling, support around difficult decisions, assess mood and capacity as it can be a distressing process.
Social workers who are involved with discharge planning, ensuring the patient has enough support in the community.
Pharmacists who give out advice taking medications safely either orally or through the tube, any drug interactions with the feed.
The dietitian has to work closely with the nutrition nurse who trains individuals how to manage their tube, deals with the practicalities of living with the tube (e.g. cleaning, replacing the tube etc.) providing very useful and practical tips for people and their families which is very important if they need to be enterally fed at home. Patients returning home has to get the right amount of equipment such as syringes, feeds, pumps, etc. delivered ASAP and this is done by the discharge coordinator.
How did it go?
Everyone’s experience will be different. If I told you it was a breeze, that’s the biggest lie of my life. However, it was not painful, just extremely uncomfortable especially when you had it done in the office with other dietitians in there. I don't think it was pleasant for them to watch either.
I knew there was no turning back and I said my prayers silently as the nurse took the tube out of its packaging. My irrational thoughts DID NOT help – is the tube going into my brain? It’s going to puncture my lungs! What if it came out of my ears? I may seriously need to top-up my human anatomy classes again.
The procedure normally takes 1-2 minutes but it took me 5 minutes as I paused for a while because I ran out of tea from my cup.
The nurse prepared all the equipment and placed some lubricant jelly at the end of the tube so that it would slide down my throat easier.
The tube was inserted into my nose and then it felt odd when the tube passed through my nasal cavity and that felt alright. The worst part came when it went down my throat as that’s when it triggered my gag reflex.
I felt like regurgitating the tube back out but drinking plenty of fluids (around 2 cups) really aided the process. I was told to drink something acidic to ensure the acidity of my stomach so I found some questionable apple juice in the fridge and some raspberry tea.
It was a quick process from there on into the stomach. Once it reached the stomach, the tube was taped onto my face and the guide wire inside the tube was removed. The cm marking on the tube was taken showing that was 56cm from my nostril to my stomach. Having this taken before each feed is important (plus pH readings) to ensure that the tube is still in place each time.
The nurse then aspirated the tube meaning that she used a syringe to suction out a bit of my stomach contents. The acidity of this liquid is tested with pH test strips to confirm that the tube is in the stomach rather than the lungs (REALLY DANGEROUS). With the concoction of fluids, it gave me a pH of 3.3 which confirmed the placement of the tube.
Sometimes an X-ray is needed to confirm placement if the pH is >5.5 but the pH can be affected by a number of reasons e.g. medications like PPIs, antacids, what you had before the NG tube placement, etc.
The tube remained inside for 10 minutes and it was not the best feeling in the world. My throat was not happy as I felt something foreign inside me. My voice was funny, dry and crackly and I did not want to speak with anyone as any facial and body movement made my pain worse. Swallowing was painful but some people do take pain relief for this. It would be really interesting if I could have tried a feed down the tube, to see how it feels in the stomach.
Honestly, I think this would deter me from eating, drinking and taking any medications orally. Fortunately, the nurse did say it will take people a few days (3-4 days) to get used to this sensation. A lot of people does say it gets better!
Removing the tube
The tape was removed and the nurse slowly pulled out my tube which took around 15 seconds. It felt odd as I felt like my stomach contents were being pulled out but it did not feel painful nor uncomfortable.
The psychological effect of having the tube in my throat did remain throughout that day.
I think it was a bit distressing, just having the thought of having a tube placed. Being able to experience this was useful as I could explain to patients the procedure, how it feels like, why it is necessary and provide them with reassurance.
I would always encourage an oral diet e.g. going for something soft and easier to swallow before resorting to enteral feeding.
As dietitians, it is important to think about the practicalities for people living with the tube which is something I would probably not understand – how it would affect social life, sleep, exercise, travel, not being able to taste food if nil by mouth (NBM), etc.
At the same time, I have heard positive comments from people saying that they feel much better physically and mentally. With support, they are able to be independent e.g. being able to aspirate themselves and even replace the tube themselves. It may take a while to get used to and a lot of educating is needed not only for the patient themselves but also for families and friends. I have also heard from a little boy who had the tube taped with a cute dinosaur plaster saying that he felt very special like he has gained some sort of superpower as his classmates all admired how he was fed differently from others.
This was not a pleasant experience but I would totally recommended for other healthcare professionals (HCPs) to try it. I have a better appreciation for those who are tube-fed and a deeper understanding of why people would refuse or pull out the tube but it is our role to support patients throughout this process.