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Fluoroscopic-guided nasogastric feeding tube placement is a safe and effective way of adequately placing a NET for enteric feeding purposes. The use of fluoroscopy proves to be more beneficial in some patients, over blind or endoscopic placement. This activity reviews and explains the role of the inter-professional team in evaluating and managing care for patients who undergo this procedure. Objectives: Describe the indications for the use of fluoroscopic-guided nasogastric tube placement. Review the risk factors involved with this procedure. Identify the most common adverse events associated with this procedure. Summarize the strategies utilized by the interprofessional healthcare team through thorough coordination and communication to ensure proper care. Access free multiple choice questions on this topic.

Nasogastric tube placement begins as the tube is placed through the nares and ends in the stomach. The utilization of fluoroscopy allows for continuous visualization of the tube as it passes through the pharynx and esophagus, reaching its ultimate destination. This ensures proper placement; and allows for the avoidance of traumatic or adverse events. Nasogastric tubes are most often used for decompression of the stomach but additionally can be used for the administration of nutrition or medications, removal of gastric contents in the case of poisoning or overdose, or diagnoses involving upper gastrointestinal bleeds.  Additionally, the use of fluoroscopic-guided placement proves to be more beneficial in the case of difficult anatomy.[1]

Fluoroscopy involves the use of ionizing radiation having the same risk profile as x-ray procedures.  A dreaded complication of fluoroscopy is radiation burns which are very rare given the low doses needed for fluoroscopy. Two types of radiation risk are involved with the use of fluoroscopy: Deterministic and Stochastic. Deterministic risks are dose-related and occur at a certain threshold dose. In other words, at a certain level of does, a deterministic side effect is possible in a cause-and-effect relationship. Stochastic risks are directly proportional to the dosage.  This includes cancer resulting from radiation exposure.  The ALARA principle (as low as reasonably possible) is always adopted for procedures requiring the use of radiation. This safety initiative acknowledges radiation exposure as an accepted, integral part of the procedure while minimizing the radiation exposure needed to accomplish the goal.[11] The advantage of fluoroscopy is that the clinician can advance the tube while visualizing it in real time.  However, there is never a guarantee of proper placement, which may result from human error. In addition, many complications can occur.  Perforation can result at any point along the course of insertion, from the nose to the stomach, which can ultimately result in uncontrolled hemorrhage or infection. Less likely a possibility when using fluoroscopy, the tube can be placed in the respiratory tree, resulting in aspiration pneumonia or pneumothorax. Though if the tube is not properly secured, this can become a more common possibility if dislodged.  Other complications with the tube landing in the respiratory tract include bronchopleural fistula, respiratory failure, and even death. Additional complications resulting after the proper placement are pressure necrosis of the cartilaginous tip of the nose, rhinitis, conjunctivitis, esophageal varices, and the rare complication of vocal cord injury and paralysis. Vocal cord injury or paralysis occurs due to direct pressure or trauma to the tissue or damage to the recurrent laryngeal nerve. Supraglottic edema can result. This phenomenon is known as nasogastric tube syndrome.[12] Other problems include tube blockage, gastrointestinal diarrhea, and refeeding syndrome.[3] Nasogastric tube feeding should not be used for more than 4 to 6 weeks because of complications or poor adherence to treatment.[13]

When considering the procedure, each expert of the healthcare team should understand the indications for the stepwise procedure and the potential outcomes of the fluoroscopic-guided insertion of a nasogastric tube. Additionally, a thorough understanding of the ongoing treatment for each patient is pertinent. Interprofessional communication is paramount to any step of patient care and safety, resulting in improved outcomes.