Internal jaw thrust for nasogastric tube insertion.

Sir,

Nasogastric (NG) tube insertion in anaesthetized or unconscious patients is difficult with failure rates of 50%–66% on first pass attempt with the head in neutral position.[1],[2],[3] Common sites of impaction are piriform sinuses and the arytenoid cartilage,[4],[5] as well as the oesophagus which becomes compressed due to the inflated cuff of the endotracheal tube (ETT).[6] Once kinked or coiled, the NG tube is likely to further kink or coil on subsequent manoeuvers.[3] Complications of repeated attempts at insertion include kinking or coiling, bleeding and trauma to nasopharyngeal structures, hemodynamic disturbances, arrhythmias, and rarely lung injuries like pneumothorax and carinal bleed due to the NG tube insertion into the airway.[3]

Several methods for NG tube insertion have been described such as head flexion with lateral pressure, slit ETT guided placement, use of ureteral guidewires and Rusch intubation stylets, fibreoptic guided insertion, reverse Sellick manoeuver, and use of cooled and stiffened NG tubes with varying success rates.[1],[2],[3],[4],[5],[6],[7]

We report a new technique of insertion of NG tubes in intubated patients, the “internal jaw thrust.” With the head in neutral or flexed position, it is done by gently opening the intubated patient's mouth and inserting the thumb of the left hand into the oral cavity to grasp and lift the ETT along with the tongue, whereas the other fingers lift the mandible externally [Figure 1a]; the NG tube is then introduced into the nares with the other hand [Figure 1b]. This manoeuver lifts the arytenoids and makes the cricopharyngeus (upper oesophageal sphincter) patent (arrowhead)Figure 1c and allows easy passage of the NG tube (arrow) into the oesophagusFigure 1d and Video 1 showing fiberoptic visualization of the passage of NG tube].

Figure 1

(a) Thumb of operator's left hand is used to grasp and lift the endotracheal tube and the tongue, whereas the remaining four fingers grasp and lift the mandible externally. (b) Operator's right hand introduces the nasogastric tube into the nares. (c) Fiberoptic view showing how this manoeuver lifts the arytenoids and makes the cricopharyngeus (upper oesophageal sphincter) patent (arrow head) and (d) easy passage of the tube (arrow) into the oesophagus

The mechanism of this particular method may be similar to lifting the ETT tube with a laryngoscope, so that the inferior constrictor that marks the anatomical beginning of the oesophagus is displaced anteriorly. However, the advantage as compared with laryngoscopy is that no instrumentation is required. We did not encounter any trauma while practising this method. Digital assistance of NG tube insertion has been described,[8] but the authors have used the index finger to guide the NG tube in the oral cavity, which may be difficult in patients with limited mouth opening. A well-planned study is required to confirm the utility of this technique.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.