Nasogastric tubes: an historical context
Nicole M. Phillips
Today, insertion of a nasogastric tube into the stomach is a common medical intervention indicated for a wide range of patient situations. These include delivery of enteral nutrition, administration of medications, and gastric decompression following major trauma or intestinal obstruction. In addition, a nasogastric tube may be inserted to perform gastric irrigation or complete diagnostic procedures. Patients with nasogastric tubes currently receive care in a wide variety of settings, such as emergency departments, intensive care units, general and specialized acute care areas, extended care facilities, and home.
Regardless of the setting, caring for patients who require a nasogastric tube is a major nursing responsibility that entails a number of interventions: inserting and removing the tube, assessing correct placement, securing the tube, meeting patient comfort needs, and monitoring patient responses. Because patient outcomes are affected directly by the quality of nursing management, it is imperative that nursing care is based on the best available evidence and not on ritual or convenience. Many publications address nursing interventions associated with nasogastric tubes. In contrast, discussion in the nursing and allied health literature regarding historical accounts of the use of nasogastric tubes is extremely limited. In fact, references are infrequent and superficial. Nurses may benefit from having an appreciation of the evolution of nasogastric tubes, from their initial construction of silver or leather to the current polyurethane fine-bore and large-bore tubes. Although it is not the intention of this discussion to explicate current nursing interventions related to nasogastric tubes, some comparisons will be drawn between past and present practice.
Use of the First Nasogastric Tube for Nutrient Delivery
Nasogastric tubes were used first in humans for the sole purpose of administering nutrition (Boyes & Kruse, 1992; Gharib, Stern, Sherbin, & Rohrmann, 1996; Schwartz, Heyman, & Rao, 1995). However, apparent disparity exists in the literature regarding the earliest use of nasogastric tubes. The first account of inserting a tube into the gastrointestinal tract can be attributed to Aquapendente, who in the 17th century used a silver tube for nasogastric feeding (Boyes & Kruse, 1992; Gharib et al., 1996). Fabricius ab Aquapendente, who was born in Italy in 1537 and died in 1619, was a professor of anatomy and surgery (Hieronymus Fabricius ab Aquapendente, 2005). No further detail is provided in the literature regarding an actual description of the silver tube or its specific use.
Other sources contend that it was much later in 1790 that John Hunter successfully fed a patient via a flexible hollow leather tube inserted into the stomach (Bowers, 1996; Clevenger & Rodriguez, 1995; Schwartz et al., 1995). The tube was made of eel skin that had been stretched over whale bone (Schwartz et al., 1995; Sofferman & Hubbell, 1981). The patient had experienced a stroke and was fed utilizing the tube for 5 weeks. Paine (1934) asserted that knowing definitely who inserted the first tube and for what reason is impossible to discern. However, he attributed the first actual recorded use of a stomach tube to John Hunter because Hunter officially reported the case to the Society for Improvement of Medical and Chirurgical Knowledge.
Developments After 1800
In 1800, Philip Physick, a surgeon from Philadelphia, started to advocate in his lectures the use of a stomach tube as a form of stomach pump (Paine, 1934). This was indicated for patients who had been poisoned for the purpose of washing out their stomachs. Physick published an account of a baby who was comatose from poisoning in an 1813 issue of The Eclectic Repertory and Analytical Review. After having a urethral catheter inserted through the nose and into the stomach, allowing the stomach to be irrigated using a syringe, the infant survived.
Mr. Jukes, an English surgeon, published a description of what he called “a stomach pump” in 1822 (Paine, 1934, p. 754). This rubber tube was 2 feet in length, with perforations and an ivory bead at the distal end; it was attached to an elastic rubber bottle at the proximal end. It was used in instances of poisoning to empty and irrigate the stomach. In 1823 the bottle was replaced by a syringe with two valves, meaning the syringe did not have to be removed, and gastric lavage became established in English medical practice. Paine (1934) asserted that although this was a life-saving intervention it was difficult to understand why gastric lavage was forgotten and not used in the middle of the 19th century.
Although clearly some early progress occurred regarding tube feeding, the preferred route for administering nutrition in the first 30 years of the 20th century was nutrient enemas (Clevenger & Rodriguez, 1995). The use of gastric nutrient delivery was increasing. In 1921, the Levin tube was introduced; this flexible nasogastric tube was made of rubber (Levin, 1921). However, associated complications and problems with toleration led to the eventual development of tubes made of superior plastics–initially polyethylene, then polyvinyl and silicone, and finally polyurethane (Clevenger & Rodriguez, 1995). The improvement of acute care techniques eventually led to improved patient survival and many more people requiring nutritional support, and this resulted in the practical beginnings of modern enteral nutrition (Clevenger & Rodriguez, 1995).
In the 1930s, nurses training in Australia and the United Kingdom utilized a text entitled Modern Professional Nursing (Scott, c1930). It included discussion of using a tube inserted via the nose into the stomach, apparently for the sole occasional purpose of administering bolus artificial feeding. This is consistent with other historical discussions indicating the practice of nasogastric feeding was on the increase but tube insertion was still not the preferred route for delivering nutrients in the early 1900s (Clevenger & Rodriguez, 1995). Scott (c1930) described a nasogastric tube as a 2-foot-long rubber catheter that was joined to a glass funnel or syringe barrel. Consistent with current practice, insertion of the tube was the responsibility of the nurse; however, the actual method of insertion was discussed very briefly in the text:
The air should be pressed out
of the tube, and the end of the
catheter smeared with a thin
layer of sterile vaseline
before the feed is given. The
nurse takes the catheter in
her right hand, passes it slowly
and gently up one nostril,
“feeling” the roof of the nostril
as she [sic] proceeds.
When the end of the catheter
reaches the posterior nares,
it may droop slightly; in this
case, the nurse should not be
alarmed; she [sic] should
allow the point to travel back
until the soft posterior wall of
the pharynx is reached. After
which it is not difficult to pay
out the rubber tubing and to
allow the catheter to go down
into the stomach via the
oesophagus (Scott, c1930,
Discussion referred to the possibility of the tube being inadvertently placed in the larynx; however, this was identified as very uncommon because spasm of the epiglottis is too strong for the catheter to pass into the trachea. In addition, it was considered that the asphyxiating reaction of the patient when the tube was in the trachea made malposition very clear. The principal method to ascertain correct positioning of the tube in the stomach after insertion was to ensure the marking on the tube was aligned with the opening of the nostril; individual variation was reportedly negligible (Scott, c1930).
In a second text used by nursing students in the 1930s, Pugh (1934) added that if the tube quickly came to a standstill when being inserted, it must be in the trachea because the trachea is much shorter than the esophagus. Consistent with Scott (c1930), the author asserted that the tube must be in the stomach if the mark on it is at the opening of the nostril. The nurse was instructed in both texts to press on the epigastrium and listen for bubbles of air escaping from the stomach; the use of a stethoscope for this procedure was not mentioned.
The only other discussion related to administering the feed slowly and steadily and then removing the tube slowly (Scott, c1930). Each time a feeding was to be administered, the tube was reinserted.
In addition to nutrition delivery in the 1930s, nasogatric tubes also were used to relieve pressure in the stomach caused by gas and gastrointestinal secretions (decompression). A nasogastric tube reportedly was first used for decompression in 1884 by Kussmaul (Gharib et al., 1996; Schwartz et al., 1995). The earliest reference to postoperative nasogastric decompression was reportedly by Levin (Montgomery, Bar-Natan, Thomas, & Cheadle, 1996; Schwartz et al., 1995); however, it was not an accepted practice until 1933 when research was carried out by Wangensteen and Paine (Huerta, Arteaga, Sawicki, Liu, & Livingston, 2002; Montgomery et al., 1996; Soybel, 1996).
According to Wangensteen and Paine (1933), McIver and his associates demonstrated satisfactorily in 1926 that postoperative abdominal distension was due mainly to swallowed air and speculated that nasogastric tubes could prevent this distension (Bauer, Gelernt, Salky, & Kreel, 1985; Wolff et al., 1989). Wangensteen and Paine (1933), who were surgeons from the United States, subsequently conducted studies and published their findings regarding small bowel obstruction and the use of nasogastric tubes for decompression. Previously, an enterostomy (surgically formed artificial opening into the intestine through the abdominal wall) would be performed to treat acute mechanical obstruction (Wangensteen & Paine, 1933). Researchers compared this traditional method of treating small bowel obstruction with the insertion of a tube into the stomach or duodenum via the nose to decompress the contents. They concluded that “the nasal catheter constitutes a satisfactory manner of dealing with many instances of acute mechanical intestinal obstruction” (p.1538).
In a surgical nursing text used in the training of nurses in the mid-to-late 1930s, Darling (1935) discussed paralytic ileus as a rare complication after abdominal surgery. Paralytic ileus referred to a decrease or absence of peristalsis. No prophylactic interventions were discussed; however, once a patient exhibited a distended abdomen, constant vomiting, dyspnea, and signs of severe collapse, a stomach tube was inserted via the nose to relieve the large volumes of gas and dark green or brown fluid. Specifics regarding how that relief occurred were not elucidated. No reference was made to aspirating the contents, free drainage, or lavage. Whether insertion of the tube was a medical or nursing responsibility and how successful insertion was as an intervention also were not mentioned. Once the stomach was emptied, the tube was removed immediately.
A medical text of the time entitled The Principles and Practice of Medicine, utilized by medical practitioners and students of medicine, discussed paralytic ileus briefly (Osier, 1938). Although Wangensteen and Paine’s work had been published previously, the text did not refer to the use of a nasogastric tube specifically to decompress the stomach contents. It referred to “washing out” (p. 673) the stomach if the patient refused surgery, was vomiting, and had abdominal distension; however, surgery (presumably an enterostomy) was cited as the only intervention to prevent death.
This historical discussion clearly illustrates that complexity of nursing care involved in caring for a patient with a nasogastric tube has increased considerably, and that the nursing considerations and interventions are many. Main indications today for the insertion of a nasogastric tube are to decompress the stomach, administer enteral nutrition, administer medications, perform gastric lavage, and perform diagnostic testing. Historically, tubes were inserted each time they were to be used for a particular purpose. Currently, depending on the intention for the nasogastric tube, it may be inserted on one occasion and removed upon completion of the particular intervention or procedure, or it may be left in place.
A number of reasons support leaving nasogastric tubes in place as opposed to removing and reinserting them frequently. Developments in tube material with polyurethane ensure greater tolerance, patient comfort, and tube longevity. Other factors include reducing patient discomfort and anxiety associated with tube insertion and removal, and preventing the possible complications related to insertion, as well as nursing time and overall cost of repeated insertions.
The historic method to assess correct positioning of the tube in the stomach was to check the alignment of the mark on the tube with the patient’s nostril (Pugh, 1934; Scott, c1930). Notably, Scott (c1930) asserted that variation in individuals is negligible. This is inconsistent with current practice in which the appropriate length of tube to be inserted is identified for each patient. Prior to insertion, the tube is used to estimate the distance between the nose and earlobe, and earlobe and xiphisternum (Baker, Smith, Stead, & Soulsby, 1999; “Nasogastric Tubes,” 2002). The tube is then marked to inform the nurse when the appropriate length of tube has been inserted. This guide to assess correct positioning of the tube should never be used in isolation. Even though a nasogastric tube may appear to be taped securely, with the visible mark on the tube at the nostril, it can still migrate out of the stomach; this is particularly likely with the more pliable fine-bore tubes (Sanko, 2004).
Current methods utilized by nurses to confirm tube placement include auscultation and testing the pH of aspirate. The detection of C[O.sub.2] at the distal end of nasogastric tubes to ascertain respiratory placement has been investigated and found to be 100% accurate (Araujo-Preza, Melhado, Gutierrez, Maniatis, & Castellano, 2002; Thomas & Falcone, 1998). However, this technique only was evaluated on mechanically ventilated patients and is not used routinely by nurses. The pH method is considered to be generally effective in distinguishing between respiratory and gastric aspirates, and gastric and intestinal aspirates as gastric pH is lower than the pH of respiratory or intestinal aspirates (Metheny, Smith, & Stewart, 2000). Problems associated with these and other techniques have led to ongoing discussion in the literature regarding method validity. Consensus holds that more than one technique should be used and an x-ray should be obtained if any doubt exists about placement (Ellett, 2004; Grant & Martin, 2000; Metheny & Titler, 2001; Sanko, 2004; Williams & Leslie, 2005). Radiography thus is viewed commonly as the “gold standard” for accurately validating tube placement (Ellett, 2004; Metheny & Titler, 2001).
Two main categories of nasogastric tubes are distinguished by their diameter: fine or small-bore tubes, and large-bore tubes. Descriptions of the size of small-diameter and large-diameter tubes differ in the literature. Some consider small-diameter tubes to be less than 12 Fr, and large-bore tubes 12 Fr and above (Metheny, Stewart, Nuetzel, Oliver, & Clouse, 2005; Metheny & Titler, 2001), while others contend only tubes that are 14 Fr or bigger are large-bore tubes (Vanek, 2002; Williams & Leslie, 2004). Large-bore tubes can be used for decompression, medication administration, and enteral feeding (Vanek, 2002), gastric lavage, and diagnostic testing (Lord, 2001). Small-bore nasogastric tubes generally are used for enteral nutrition. They were developed in 1976 by Dobbie and Hofmeister (Rassias, Ball, & Corwin, 1998). Small-bore nasogastric tubes often are used for delivering enteral nutrition because they reduce patient discomfort and provide a decreased risk of aspiration; the smaller diameter does not affect the competency of the lower esophageal sphincter to the same extent as large bore-tubes (Sriram, Jayanthi, Lakshmi, & George, 1997). However, small-bore tubes are known to migrate out of position, knot, occlude, and rupture (Williams & Leslie, 2004). The vast majority of nasogastric tubes now are made of polyurethane, a nonreactive material that is soft and remains flexible when compared to previous polyvinyl tubes which stiffen over time as polyvinyl chloride reacts with acid (Grant & Martin, 2000).
Nurses frequently manage patients with nasogastric tubes in a variety of settings. However, most of them lack any knowledge of the evolution of nasogastric tubes because little in the literature addresses this area. The discussion presented in this article addressed this gap in the literature. Having an awareness of the historical context of nasogastric tubes is not only interesting from the point of view of nursing practice history, but it also reinforces that technologies are always changing, and as such, associated practice.
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Nicole M. Phillips, DipAppSci(Nsg), BN, GDipAdvNsg(Educ), MNS, is a Lecturer and PhD Student, La Trobe University, School of Nursing and Midwifery, Bundoora, Victoria, Australia.
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