280 Section VII ■ Tube Replacement

8. Nasal insertion (avoid this route in very low-birthweight

infants in whom nasal tubes may be associated with

periodic breathing and apnea) (1,8).

a. Stabilize head. Elevate tip of nose to widen nostril.

b. Insert tip of tube, directing it toward occiput rather

than toward vertex (Fig. 40.2).

c. Advance tube gently to oropharynx.

d. Monitor for bradycardia.

9. If possible, use pacifier to encourage sucking and swallowing.

10. Tilt head forward slightly.

11. Advance tube to predetermined depth.

a. Do not push against any resistance.

b. Stop procedure if there is onset of any respiratory

distress, cough, struggling, apnea, bradycardia, or

cyanosis.

12. Determine location of tip using a combination of several

measures. Radiograph of the abdomen to verify placement is the gold standard but is expensive and subjects

neonates to additional radiation. Injecting air to verify

placement is not a reliable method, as the sound of air in

the respiratory tract can be transmitted to the GI tract

(5,8,18,19). Measuring the pH of the aspirate as the sole

method to verify tip position is not reliable, as stomach

acid in infants can be weakly acidic, and the degree of

acidity of the aspirate can be affected by the timing of

feeding, the exact location in the stomach of the tube

tip (distal versus proximal), and timing of medication

delivery (18–22).

a. Aspirate any contents; describe and measure.

(1) Gastric contents may be clear, milky, tan, pale

green, pale yellow, or blood stained.

(2) Determine acidity by measuring pH. If the pH

of the aspirate is <5, one can be reasonably certain the tube is in the stomach. If the pH is ≥5,

placement should be confirmed using an additional method, such as radiography or character

of secretions (4,18,20,23).

(3) Assess for any respiratory compromise or instability.

b. If there is difficulty obtaining aspirate, use a largersized syringe, reposition the infant, and instill a small

Table 40.1

Guidelines for Minimum

Orogastric Tube Insertion Length

to Provide Adequate Intragastric

Positioning in Very LowBirthweight Infants

Weight (g) Insertion Length (cm)

<750 13

750–999 15

1,000–1,249 16

1,250–1,500 17

Data from Gallaher KJ, Cashwell S, Hall V, et al. Orogastric tube insertion length

in very low birth weight infants. J Perinatol. 1993;13:128.

Fig. 40.2. Anatomic view of the neonatal nasopharynx. The natural direction in tube insertion is toward

the nasal turbinates, where it might stop and give an impression of obstruction. By pushing the nostril up,

one can direct a tube toward the occiput with less trauma.