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EVIDENCE-BASED-HEALTH  December 1999

EVIDENCE-BASED-HEALTH December 1999

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Subject:

Is this NG feeding tube in the correct place

From:

Mark Newman <[log in to unmask]>

Reply-To:

Mark Newman <[log in to unmask]>

Date:

Fri, 17 Dec 1999 17:20:20 +0000 (GMT)

Content-Type:

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Dear colleagues 

Some nursing colleagues who I have been working with on 
improving our EBP skills came up with the following EBP question.

In patients who are being fed by NG tube how good is pH testing at 
determining whether the tube is in the Stomach or in the lungs ?

Practice at the hospital where they work is currently that the 
position of all tubes when inserted is checked by a pH test and  
also by X-Ray before feeding is commenced. They came up with 
the following observations about this:

1) It seems strange to bother with the ph test if you are going to 
x-ray the patient anyway. 
2) Patients often pull on the tubes or the tubes get pulled and 
therefore moved and often nurses just push the tube back and do a 
ph test only.
3) If everytime patients pull on tube need to get it re x-rayed this 
will results in patients having a lot of x-rays, and will be quite 
expensive 
4) Doing a only a pH test on insertion if sensitive enough would 
reduce patient exposure to radiation and save a considerable 
amount of resources


My recommendation to them (I hope its the correct one ) was that 
they should treat this as a diagnostic test question. The evidence 
they would need to find would therefore be a study whereby a group 
of patients with ng tubes had the position checked by ph testing 
(by your average nurse in real clinical setting (usually visual reading 
of test reagent stick))  and by the gold standard  (x-ray) and then 
the sensivity and specificity, Pos predictive value etc. etc. for ph 
testing could be established   


They have been searching for this kind of study and no luck yet 
(have found a lot of work by Norma Metheny and Colleagues from 
St louis University which we are ploughing through but does not 
seem to answer this particular question )

q.1 if anybody else knows of any other evidence sources for this 
would be grateful to hear about them 

reading so far has thrown up lots of questions about the various 
methods of ph testing. Currently in this hospital they are using 
litmus paper - Some of the evidence we have found on this 
suggests that litmus paper is not good at discriminating between 
gastric fluid and lung fluid because it can change colour for both 
because of ph level at which it is sensitive (sorry can't remember 
what this is at the moment) But evidence is not that good quality 

q2.     Anybody know of any other evidence on this 

I have technical question about such a study. The risk of the tube 
being in the lungs undetected appears to be quite small  (4/605 in 
one study). It would also be unethical if not impossible in practice  
do a study where tubes were deliberately put into the lung as well 
as put into the stomach.

q3.  If in a study all the tests were on ph testing where all the tubes 
were in the stomach would this answer our question - if not what 
else could researchers do?

The risk of the tube being in the lungs undetected appears to be 
quite small, However in the literature it seems to be regarded as 
absolutely imperative that this is established before the feeding 
started due to what are described as the grave consequences of 
starting feeding with the tube incorrectly positioned. 

q4. Does this mean that only a test which is 100%  sensitive (or 
whatever current gold standard level is - presumably x-ray is very 
near this)  is acceptable ?

That will give you something to chew during the festive season. 
Look forward to hearing your replies which I will summarize for list.  
 

seasons greetings 

mark      
***PLEASE NOTE ARCHWAY PHONE NUMBER CHANGED AGAIN*****

Mark Newman
Senior Lecturer: 
School of Health, Biological & Environmental Sciences (HeBES)
Middlesex University & 
Barnet & Chase Farm Hospitals NHS Trust
Furnival Building, Archway Campus 
Highgate Hill
London N19 3UA
Tel: 0181 362 5000 (ex2281) or 0181 366 6600 ex 5775
Fax: 0181 362 6299
E-Mail: [log in to unmask]


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