Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study

Mayara Carvalho Godinho Rigobello; Jorge Elias Junior; Carlos Alberto Grespan Bonacim; Renata Cristina de Campos Pereira Silveira; Fernanda Caroline Bonardi; Roosevelt Santos Nunes; Rosana Aparecida Pereira; Fernanda Raphael Escobar Gimenes

doi:10.1136/bmjopen-2019-036033

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Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study

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Letter to the Editor for , “Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study,” by Rigobello et al.
Dentonique Anthonae Lewis
Published on: 22 November 2020
Reponse to Torsy T, Eriksson M, Verhaeghe S, and Beeckman D’s comment on Rigobello MCG, Elias Junior J, Bonacim CAG, et al. upcoming prospective study
Fernanda RE Gimenes
Published on: 16 October 2020
Comment on Rigobello MCG, Elias Junior J, Bonacim CAG, et al. Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study.
Tim Torsy, Mats Eriksson, Sofie Verhaeghe and Dimitri Beeckman
Published on: 7 October 2020

Published on: 22 November 2020
Letter to the Editor for , “Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study,” by Rigobello et al.
- Dentonique Anthonae Lewis, Nursing student at the School of Nursing and Allied Health Professions University of the Bahamas
Dear Editors,
This letter is in relation to your article, “Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study,” by Rigobello et al. on September 30th, 2020. First, I would like to express my gratitude to the authors for publishing this study because it utilizes two common methods used at the bedside for nasogastric tube insertion in order to determine the accuracy and direct cost of each method. This article immediately piqued my interest because it is important to the patient in that it is concerned with reducing the adverse reactions and risks of incorrect nasogastric tube placement. This is important because it can prevent aspiration. As a nursing student, it is crucial to know the most accurate method to confirm the correct placement of a gastric tube as this is very important to prevent aspiration.
The article mentions the method of insertion protocol in which it is measured from: “the top of the nose to the earlobe and from the earlobe to the xiphoid appendix (NEX method)” (Rigobello et al., 2020). In the Bahamas, like many other places, we utilize this method and I have practiced this procedure in the laboratory. This a common method for many countries, although it can be argued that it is not the safest. It was also stated that a pH value lower than 6 confirms correct gastric positioning and excludes possible displacement of the tube i...
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Dear Editors,
This letter is in relation to your article, “Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study,” by Rigobello et al. on September 30th, 2020. First, I would like to express my gratitude to the authors for publishing this study because it utilizes two common methods used at the bedside for nasogastric tube insertion in order to determine the accuracy and direct cost of each method. This article immediately piqued my interest because it is important to the patient in that it is concerned with reducing the adverse reactions and risks of incorrect nasogastric tube placement. This is important because it can prevent aspiration. As a nursing student, it is crucial to know the most accurate method to confirm the correct placement of a gastric tube as this is very important to prevent aspiration.
The article mentions the method of insertion protocol in which it is measured from: “the top of the nose to the earlobe and from the earlobe to the xiphoid appendix (NEX method)” (Rigobello et al., 2020). In the Bahamas, like many other places, we utilize this method and I have practiced this procedure in the laboratory. This a common method for many countries, although it can be argued that it is not the safest. It was also stated that a pH value lower than 6 confirms correct gastric positioning and excludes possible displacement of the tube into the lungs.” It is also important to note that although radiography is the golden standard to determine between gastric and pulmonary placement, it has been found to have a few disadvantages. These include exposing the patient to radiation, can be expensive, and can delay enteral feeding.
Moreover, this article addresses the topic in such a way that leads readers to further research the topic and practice the correct method to confirm nasogastric tube placement. This article is unique in that there has been no prior study done to evaluate the cost associated with confirming correct nasogastric tube placement.
Dentonique Lewis
Student, School of Nursing and Allied Health Professions
The University of the Bahamas
Nassau, Bahamas
Conflict of Interest: None declared
References
Fan, E.M.P., Tan, S.B., & Ang, S.Y. (2017). Nasogastric tube placement confirmation: where we are and where we should be heading. Proceedings of Singapore Healthcare, 26(3), 189-195. https://doi.org/10.1177/2010105817705141
Metheny, N. (2016). Initial and ongoing verification of feeding tube placement in adults. Critical Care Nurse, 36(2), 8-13. https://doi.org/10.4037/ccn2016141
Rigobello, M.C.G, Elias Junior J, Bonacim, C.A.J., Silveira, R.R., Bonardi, F.C., Nunes, R.S.,
Pereira, R.A., & Gimenes, F.R. (2020). Accuracy of the combined method
(auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study. BMJ Open. Doi: 10.1136/bmjopen-2019-036033.
Show Less

Conflict of Interest:
None declared.
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Published on: 16 October 2020
Reponse to Torsy T, Eriksson M, Verhaeghe S, and Beeckman D’s comment on Rigobello MCG, Elias Junior J, Bonacim CAG, et al. upcoming prospective study
- Fernanda RE Gimenes, RN, Ph.D, Associate Professor University of São Paulo at Ribierão Preto College of Nursing
Dear editors

We thank Torsy and colleagues to publish their comments on our upcoming prospective study aimed to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm the correct placement of the nasogastric tube (NGT), on 7 October 2020. Based on a decision analytical modelling approach proposed by Ni et al.(2017), Torsy and colleagues argue that the pH test with 5 is the safest cut-off for the verification of nasogastric feeding tube placement. However, Ni and colleagues concluded that is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximize safety and to minimize the use of chest X-rays. In addition, in a recent review of 14 international guidelines to distinguish between gastric and pulmonary placement of NGT, Metheny and colleagues (2019) found considerable disagreement about the ‘best’ pH cut-point to distinguish between gastric and respiratory aspirates and that geographical location has a strong influence on recommendations for use of the pH method. In Brazil there is no national safety guideline recommending a pH cut-point. Thus, we will reconsider the set pH cut-off value to 5 to differentiate between gastric and oesophageal NGT placement in our study.
In their comments, Torsy and colleagues affirm that the NEX (Nose-Earlobe-Xiphoid appendix) method to calculate the NGT insertion length is not the mos...
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Dear editors

We thank Torsy and colleagues to publish their comments on our upcoming prospective study aimed to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm the correct placement of the nasogastric tube (NGT), on 7 October 2020. Based on a decision analytical modelling approach proposed by Ni et al.(2017), Torsy and colleagues argue that the pH test with 5 is the safest cut-off for the verification of nasogastric feeding tube placement. However, Ni and colleagues concluded that is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximize safety and to minimize the use of chest X-rays. In addition, in a recent review of 14 international guidelines to distinguish between gastric and pulmonary placement of NGT, Metheny and colleagues (2019) found considerable disagreement about the ‘best’ pH cut-point to distinguish between gastric and respiratory aspirates and that geographical location has a strong influence on recommendations for use of the pH method. In Brazil there is no national safety guideline recommending a pH cut-point. Thus, we will reconsider the set pH cut-off value to 5 to differentiate between gastric and oesophageal NGT placement in our study.
In their comments, Torsy and colleagues affirm that the NEX (Nose-Earlobe-Xiphoid appendix) method to calculate the NGT insertion length is not the most safe method. Although we agree with them, in our study, the insertion of the NGT will be performed by the hospital's nurses in order to reflect the context of its use. Therefore, the NEX measure will be adopted because it is an institutional protocol. We believe that our results will contribute to future discussion in Brazil about safest NGT insertion length and to the review of guidelines to distinguish between gastric and pulmonary placement of NGT at national level.

References
Metheny, N. A., Krieger, M. M., Healey, F., & Meert, K. L. (2019). A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart Lung, 48(3), 226-235. doi:10.1016/j.hrtlng.2019.01.003
Ni, M. Z., Huddy, J. R., Priest, O. H., Olsen, S., Phillips, L. D., Bossuyt, P. M. M., & Hanna, G. B. (2017). Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach. BMJ Open, 7(11), e018128. doi:10.1136/bmjopen-2017-018128
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Conflict of Interest:
None declared.
- Back to top
Published on: 7 October 2020
Comment on Rigobello MCG, Elias Junior J, Bonacim CAG, et al. Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study.
- Tim Torsy, RN, MSc, PhD candidate Odisee University College, Brussels, Belgium; Ghent University, Ghent, Belgium
- Other Contributors:
  Mats Eriksson, RN, MSc, PhD
  
  Sofie Verhaeghe, RN, MSc, PhD
  
  Dimitri Beeckman, RN, MSc, PhD
Dear editors

We thank Rigobello and colleagues to publish their protocol of an upcoming prospective study to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm a correct placement of the gastric tube (Rigobello et al., 2020). The authors emphasize the importance of verifying a correct tube placement to reduce adverse events and patient safety risks. We confirm the need for such study. However, the pH cut-off value to differentiate between gastric and oesophageal NG tube placement and the NEX method to calculate the NG tube insertion length are to be discussed.

Applying a 5.5 pH cut-off to confirm the correct placement of the nasogastric (NG) tube in the stomach is debatable. Based on a decision analytical modelling approach, Ni et al. (2017) concluded a pH of ≤ 5 as an adequate cut- off value to indicate correct positioning of the NG tube tip in the stomach and therefore a non-pulmonary placement. Ni et al. (2017) concluded that the pH test with a 5.5 pH cut-off point has low sensitivity (81.0%) in detecting oesophageal placements (Ni et al., 2017). Therefore, a 5.0 pH cut-off has been adopted by several guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN], 2017; American Association of Critical-Care Nurses [AACN], 2016) to confirm a non-pulmonary NG tube placement (Boullata et al., 2017; Metheny, 2016).

Rigobello et al. (2020) describe that th...
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Dear editors

We thank Rigobello and colleagues to publish their protocol of an upcoming prospective study to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm a correct placement of the gastric tube (Rigobello et al., 2020). The authors emphasize the importance of verifying a correct tube placement to reduce adverse events and patient safety risks. We confirm the need for such study. However, the pH cut-off value to differentiate between gastric and oesophageal NG tube placement and the NEX method to calculate the NG tube insertion length are to be discussed.

Applying a 5.5 pH cut-off to confirm the correct placement of the nasogastric (NG) tube in the stomach is debatable. Based on a decision analytical modelling approach, Ni et al. (2017) concluded a pH of ≤ 5 as an adequate cut- off value to indicate correct positioning of the NG tube tip in the stomach and therefore a non-pulmonary placement. Ni et al. (2017) concluded that the pH test with a 5.5 pH cut-off point has low sensitivity (81.0%) in detecting oesophageal placements (Ni et al., 2017). Therefore, a 5.0 pH cut-off has been adopted by several guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN], 2017; American Association of Critical-Care Nurses [AACN], 2016) to confirm a non-pulmonary NG tube placement (Boullata et al., 2017; Metheny, 2016).

Rigobello et al. (2020) describe that the NG tube insertion length will be decided using the NEX method, measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid. Although being a commonly used method, evidence indicates that this is not the most safe method (Taylor, 2020). In a randomised trial by Torsy et al. (2018), using the NEX method, 20.2% of all NG tube tips were located in the oesophageal danger zone (Torsy et al., 2018), increasing the risk of regurgitation and pulmonary aspiration. In another study by Torsy et al. (2020), they concluded that the corrected nose-earlobe-xiphoid distance formula was a safer option to determine the NG tube insertion length (Torsy et al., 2020). All nasogastric feeding tubes in this study, whose length was determined by this alternative method, were correctly positioned in the stomach.

Considering these concerns, we suggest to reconsider the set pH cut-off value to differentiate between gastric and oesophageal NG tube placement and to consider an alternative for the NEX method to calculate the NG tube insertion length.

Sincerely,
Tim Torsy, Mats Eriksson, Sofie Verhaeghe and Dimitri Beeckman
tim.torsy@odisee.be

References
1. Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15–103. https://doi.org/10.1177/0148607116673053
2. Metheny, N. (2016). Initial and ongoing verification of feeding tube placement in adults. Critical Care Nurse, 36(2), e8–e13. https://doi.org/10.4037/ccn2016141
3. Ni, M. Z., Huddy, J. R., Priest, O. H., Olsen, S., Phillips, L. D., Bossuyt, P. M. M., & Hanna, G. B. (2017). Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: A decision analytical modelling approach. BMJ Open, 7(11), e018128. https://doi.org/10.1136/bmjopen-2017-018128
4. Rigobello, M. C. G., Elias Junior, J., Bonacim, C. A. G., Silveira, R. C. de C. P., Bonardi, F. C., Nunes, R. S., Pereira, R. A., & Gimenes, F. R. E. (2020). Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study. BMJ Open, 10(9), e036033. https://doi.org/10.1136/bmjopen-2019-036033
5. Taylor, S. J. (2020). Methods of Estimating Nasogastric Tube Length: All, Including “NEX,” Are Unsafe. Nutrition in Clinical Practice, 35(5), 864–870. https://doi.org/10.1002/ncp.10497
6. Torsy, T., Saman, R., Boeykens, K., Duysburgh, I., Eriksson, M., Verhaeghe, S., & Beeckman, D. (2020). Accuracy of the corrected nose-earlobe-xiphoid distance formula for determining nasogastric feeding tube insertion length in intensive care unit patients: A prospective observational study. International Journal of Nursing Studies, 110. https://doi.org/10.1016/j.ijnurstu.2020.103614
7. Torsy, T., Saman, R., Boeykens, K., Duysburgh, I., Van Damme, N., & Beeckman, D. (2018). Comparison of Two Methods for Estimating the Tip Position of a Nasogastric Feeding Tube: A Randomized Controlled Trial. Nutrition in Clinical Practice, 33(6), 843–850. https://doi.org/10.1002/ncp.10112
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Conflict of Interest:
None declared.
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