. 2025 Oct 2;18:6287–6297. doi: 10.2147/JMDH.S553373

Table 3.

Summary of the Best Evidence for Blind Nasoenteric Tube Insertion in Adult Critically Ill Patients

Domain	Evidence Summary	Level of Evidence
Indications	1. Patients with gastric emptying disorders, dysphagia, high risk of aspiration, need for long-term enteral nutrition, or specific conditions such as short bowel syndrome or intestinal dysfunction.^12–19	1a
Contraindications	2. Acute gastroenteritis, bowel obstruction, severe esophageal or gastric dysfunction, intra-abdominal infection or abscess, uncontrolled electrolyte disturbances, significant bleeding, or unstable airway.^12–19	1a
Assessment	3. Assess level of consciousness prior to procedure (eg, using GCS); for conscious and cooperative patients, instruct swallowing during insertion. Altered consciousness increases risk of misplacement into the airway.^12–15	1b
	4. In deeply sedated or comatose patients, closely monitor vital signs, especially oxygen saturation and respiratory status, to ensure stability throughout the procedure.¹²^,¹³^,¹⁹^,²⁰	5a
	5. Monitor artificial airway cuff pressure before insertion to reduce resistance and aspiration risk.^12–14	2a
	6. Confirm ventilator mode and settings to ensure stable airway management; evaluate whether adjustments are needed during the procedure.^12–14	2b
	7. Assess nasal and oral cavity: check for swelling, infection, polyps, or abnormalities; examine oropharyngeal structures for stenosis or tumors.¹⁶^,²¹^,²⁴^,³¹^,³⁶	1b
	8. Auscultate lungs to evaluate for diminished breath sounds, rales, or crackles; assess pulmonary function.¹⁶^,²⁴^,³⁰^,³²^,³⁷	2a
	9. Perform abdominal palpation to check for tenderness or distension, ensuring no signs of acute abdomen.¹⁶^,²⁰^,²³^,³⁰^,³¹^,³⁴^,³⁹	2b
Catheter Preparation	10. Use appropriate tube: polyurethane FR8/FR10 nasoenteric tube, guidewire-assisted (dual-wire), or bullet-tip weighted/unweighted tubes; spiral-shaped with guidewire preferred. Outer diameter 3.3 mm, length 120–145 cm; soft and hydrophilic-coated.¹⁵^,¹⁶^,¹⁸^,²¹	5a
Patient Positioning	11. During insertion into the stomach, semi-recumbent position (head of bed elevated 30–45°) is recommended before and after insertion to aid passage and reduce reflux and aspiration.^12–20^,²⁴	1a
	12. Once the tube reaches the stomach and is advancing toward the pylorus, place patient in right lateral decubitus with pelvis elevated 15–30° to facilitate tube passage via gravity.^16–23^,^28–31	1a
	13. After placement, maintain head-up position (30–45°) to prevent reflux and aspiration, especially during enteral feeding. Supine or semi-recumbent positions may be used with specific techniques (eg, air or water injection) to control advancement and avoid looping.^16–23^,^28–31	1a
Key Insertion Techniques	14. Administer metoclopramide or erythromycin 10–30 min prior to insertion via IM or IV route.¹²^,¹⁴^,²⁵^,²⁷	5a
	15. Lubricate the tube and insert slowly via the nostril. Advance with patient’s breathing rhythm. In conscious patients, swallowing can aid passage through the pharynx.¹⁶^,²⁸^,³¹^,³³	2a
	16. Advance tube to pre-measured first mark to reach the stomach; confirm preliminary placement by auscultating air insufflation or aspirating gastric contents.²⁴^,²⁹^,³⁰^,³⁷	2a
	17. At 60–65 cm near the pylorus, rotate the tube gently during advancement to prevent kinking. Once resistance is felt (75–90 cm), use the “jiggling technique” and partially withdraw guidewire to reduce gastric wall adherence.²²^,²⁸^,³¹^,³⁴^,³⁸	2b
	18. Gradually withdraw ~20 cm of the guidewire; observe for recoil. Smooth recoil suggests no entanglement. If resistance is felt, the tube may be looped or kinked; readjust or reinsert as necessary.³⁵	2a
	19. Insert first guidewire to maintain flexibility and ease passage through oropharynx; once in the stomach, insert the second wire to enhance rigidity and assist pyloric passage. After entering jejunum, withdraw both wires sequentially to prevent displacement.³¹^,³⁸	2a
	20. Assist patient into right lateral position, elevate head of bed to 30–45°, and advance tube slowly. Expect slight resistance at the pylorus. Advance to 110–120 cm as needed.¹⁶^,^28–32	2a
Confirmation of Position	21. Use stethoscope to auscultate after injecting 20–30 mL of air through the tube; listen below the xiphoid or in various abdominal regions for air–fluid sound.³⁰^,³²	1a
	22. Aspirate fluid and test pH. Gastric aspirates are acidic (pH 1–5); alkaline fluid (pH >7) suggests intestinal placement.¹⁷^,¹⁸^,²³^,²⁹^,³⁷	1a
	23. Inject air or warm water and attempt re-aspiration. Resistance or low return suggests post-pyloric placement.^12–14	5b
	24. Abdominal X-ray (gold standard) confirms whether tube is in stomach, duodenum, or jejunum.^12–16^,²⁹	1a
	25. Partial guidewire withdrawal and observing recoil can help confirm successful passage beyond pylorus.³⁴^,³⁵^,³⁸	2a
Remedial Measures	26. Withdraw tube to 50–55 cm (gastric position), readjust angle, and reattempt pyloric passage with rotation.³⁴^,³⁵^,³⁸	2b
	27. If first attempt fails due to tube type or flexibility, switch to a different design (eg, dual-wire tube for added stiffness).¹⁶^,^35–38	2b
	28. If blind insertion fails repeatedly, especially in critically ill patients, use ultrasound or endoscopic guidance.^12–18	5a
	29. Place tube into the stomach, secure externally, and allow peristalsis to advance the tube naturally into the duodenum or jejunum.^12–18	5a
Catheter Maintenance	30. Confirm tube position daily via auscultation, aspirate pH, or external tube length.^12–18^,³⁰	5b
	31. Ensure tube is securely fixed at the nose, ear, or cheek to prevent dislodgment.¹⁶	5a
	32. For high-risk patients, use X-ray to re-confirm placement after insertion or if dislodgement is suspected.¹⁶	1a
	33. After each feeding or medication, flush tube with 20–30 mL of saline to prevent blockage.^12–15	5a
	34. Avoid administering large-particle drugs through the tube; crush and dissolve thoroughly. If blockage occurs, flush with warm water or sodium bicarbonate. Severe blockage may require tube replacement.¹⁹^,²⁰	5b
	35. Clean the fixation site regularly and maintain nasal hygiene to prevent infection.^12–15	5a

Notes: The 2014 version of the JBI evidence hierarchy is adopted to determine the evidence level, where Level 1 represents the highest level and Level 5 represents the lowest level.