Bedside ultrasonography for the confirmation of nasogastric tube placement: agreement between nurse and physician

Ultrasonografíaa la cabecera para localización de la sonda nasoenteral: concordancia entre enfermero y médico

ABSTRACT

Objective

To evaluate the agreement between nurse and physician in verifying the positioning of the nasogastric tube by ultrasonography and describe the difficulties faced by nurse in performing the technique.

Method

Cross-sectional study conducted in 2021, including critical patients after nasogastric tube insertion who were independently evaluated by a nurse and physician, using bedside ultrasonography. The tube was considered adequately positioned when viewed in infradiaphragmatic location in the topography of the stomach.

Results

In the 30 peer evaluations there was almost perfect agreement (k = 0.93; 95%CI: 0.65 - 0.99). In only one case the nurse was uncertain about the positioning. Some difficulties were reported: abdominal distention (n=2), gas interposition (n=3) and patient movement during the exam (n=2).

Conclusion

A trained nurse obtained very similar results to those found by a physician in identifying the nasogastric tube placement by means of ultrasonography, suggesting a reproducible and safe technique.

Keywords
Intubation, gastrointestinal; Ultrasonography; Nursing; Intensive care units; Enteral nutrition

RESUMEN

Objetivo

Evaluar la concordancia entre enfermero y médico en la verificación del posicionamiento de la sonda nasoenteral por ultrasonido y describir las dificultades enfrentadas por el enfermero en la realización de la técnica.

Método

Estudio transversal, realizado en el 2021, incluyendo pacientes críticos después de la inserción de la sonda nasoenteral, que fueron evaluados de manera independiente por enfermero y médico, utilizando ultrasonido al lado de la cama. La sonda fue considerada correctamente posicionada cuando visualizada en posición infradiafragmatica en la topografía del abdomen.

Resultado

En los 30 pares de evaluaciones hubo concordancia casi perfecta (k = 0,93; IC95%: 0,65 - 0,99). En apenas un caso hubo duda de la enfermera acerca del posicionamiento. Fueron relatadas algunas dificultades: distensión abdominal (n=2), interposición de gases (n-3) y movimiento del paciente durante el examen (n=2).

Conclusión

Un enfermero capacitadoobtuve resultados muy semejantes a los obtenidos por un médico en la identificación del posicionamiento de la sonda nasoenteral por medio de ultrasonido, sugiriendo tratarse de una técnica reproducible y segura.

Palabras clave:
Intubación gastrointestinal; Ultrasonografía; Enfermería; Unidades de cuidados intensivos; Nutrición enteral

RESUMO

Objetivo

Avaliar a concordância entre enfermeiroe médico na determinação da localizaçãoda sonda enteral por ultrassonografia e descrever as dificuldades encontradas pelo enfermeiro na execução da técnica.

Método

Estudo transversal, realizado em 2021, incluindo pacientes críticos após a inserção dasondaenteral, avaliados de modo independente por enfermeiro e médico, utilizando ultrassonografia à beira do leito. A sonda foi considerada adequadamente posicionada quando visualizada em posição infradiafragmática na topografia do estômago.

Resultados

Nos 30 pares de avaliações houve concordância quase perfeita (k = 0,93; IC95%: 0,65 - 0,99). Em apenas um caso houve dúvida do enfermeiro sobre o posicionamento. As

dificuldades relatadas foram:distensão abdominal (n=2), interposição de gás (n=3) e movimentação do paciente durante o exame (n=2).

Conclusão

Um enfermeiro capacitadoobteve resultados semelhantes aos encontrados por um médico na identificação do posicionamento da sondaenteral por meio de ultrassonografia, sugerindo tratar-se de uma técnica reprodutível e segura.

Palavras-chave
Intubação gastrointestinal; Ultrassonografia; Enfermagem; Unidades de terapia intensiva; Nutrição enteral

INTRODUCTION

Despite the frequent use of nasogastric tube (NGT) for administration of diet, water and medication in different care settings and even at home, establishing reliable means to identify the anatomical positioning of the NGT remains a challenge. Examinations performed at the bedside prove to be flawed to ensure that the administration of therapy occurs in a safe way. The pH check can be affected by factors such as diet and the use of gastric acid inhibitors, commonly used in critically ill patients; aspiration for assessment of gastric content not always can be obtained, or may have nonspecific characteristics; and the epigastric auscultation test is considered inadequate to distinguish gastric from pulmonary positioning1. Thus, an imaging examination is mandatory, and the abdominal X-ray is the “gold standard” for checking the NGT positioning after its insertion2.

Frequent situations, such as patient mobilization, coughing, procedures for aspiration of secretions, vomiting and transportation, can result in displacement of the tube3. In critically ill patients, adds the risk of bronchoaspiration related to sedation, alteration in the level of consciousness or reduction in the cough reflex1. In this patient profile, therefore, the systematic verification of the tube positioning becomes even more important.

In this context, ultrasonography (US) to verify NGT positioning has been presented as a promising alternative, due to the possibility of performing it at the bedside, with real-time interpretation, without the need for patient displacement or radiation exposure4.

In a study that evaluated 41 NGT insertions with guide wire in patients using NGT and invasive mechanical ventilation, abdominal ultrasonography detected 38 patients with adequate positioning and three with inadequate positioning. The demonstrated sensitivity was 97% (95%CI 84.9-99.8%) and the specificity was 100% (95%CI 19.7-100%)5.

Ultrasonography has been shown to be reliable in supporting the diagnostic decision and as a guide to procedures. In last years, this technology has been incorporated into procedures performed by nurses, such as venous and arterial puncture, evaluation of device positioning (such as urinary catheters), skin evaluation and urinary volume evaluation6^,7.

Recently, the Federal Nursing Council (Conselho Federal de Enfermagem - COFEN) stated the regulation of the use of US by trained nurses both in the pre-hospital setting and at the bedside; this was classified as a support technique to perform more complex nursing procedures and as a strategy to improve the safety of professionals and patients8.

In the field of nutritional therapy, ultrasonography gained space9⁾ and the accuracy of bedside ultrasonography in detecting NGT positioning has been investigated. Researchers obtained excellent results, with sensitivity varying between 93% and 100% and specificity between 97% and 100%5^,9^-12.

However, adequate training of professionals who use ultrasonography is essential, since its application is operator dependent. Errors in its interpretation can underestimate clinical conditions, or overestimate them, leading to unnecessary procedures13. Besides training, it is important to evaluate agreement in practice of US.

Like other procedures that require skill development, ultrasonography is subject to measurement bias, as it can be affected by the performance of the observer. For this reason, the evaluation of agreement between observers, aiming to identify if different professionals produce identical results when performing an US in the same patient, under the same conditions, becomes important in the assessment of US reliability14.

A cross-sectional study evaluated the agreement between three intensive care physicians, who received the same training in pulmonary bedside US, in the identification of pulmonary B-lines in 67 adult patients. Moderate to substantial agreement was identified (Kappa from 0.41 to 0.79; 95% CI) in 80% of the pulmonary areas evaluated, suggesting good reproducibility of the technique15.

When analyzing the agreement between nurses and physicians in the use of ultrasonography to assess quadriceps thickness in 45 critically ill patients, a study identified excellent agreement (ICC: 0.97-0.99; 95% CI). The authors state that trained nurses can develop this assessment with quality, similar to that of an experienced physician, contributing to the care of critically ill patients16. This opinion was affirmed by another study, in which the learning curve of nurses was similar to that of physicians and physical therapists17.

Considering the findings in the literature, we postulate that a trained intensive care nurse can properly identify the NGT positioning by US, which adds autonomy to their care practice, assists in decision-making and promotes patient safety in the care of critically ill patients using NGT. Thus, this study aimed to evaluate the agreement between nurse and physician in determining the nasogastric tube placement by US and to describe the main difficulties faced by nurses in performing the technique.

METHOD

A cross-sectional study was conducted from January to April 2021, in the general ICU of a large hospital in southern Brazil. Adult patients (age >18 years), who had an indication for NGT insertion were included; patients with operative wounds, drains, using peritoneostomy or other conditions that prevented US abdominal exam, as well as patients with indication for endoscopy-guided of the NGT were excluded.

Patients were selected by convenience, when there was simultaneous availability of both evaluators (a nurse and a physician), and the screening for inclusion of patients was carried out after the dismissal of NGT by the satellite pharmacy of the ICU.

The nurse, considered an evaluator in test, has specialization in intensive care and short-term training in ultrasonography applied to nursing procedures. The physician (reference evaluator) has a specialty in intensive care, 10 years of experience in the ICU, is experienced in the use of Point-of-Care ultrasonography (POCUS) and has experience in its use to verify NGT positioning.

Before the beginning of data collection, the nurse received training to assess the NGT positioning by US. Two moments of training were carried out, each lasting about one hour; this occurred at the bedside and included theoretical and practical aspects related to the use of ultrasonography, handling the equipment, recognizing anatomical structures and the parameters for verifying the NGT positioning. Next, the nurse performed five assessments supervised by the physician and was considered “able” for the beginning of data collection. This training strategy was designed based on the experience of professionals in other training courses, and also on experiences described in the literature, although there is no formally recommended strategy18^-20.

The US for the evaluation of agreement were performed independently, consecutively, with both evaluators being blind to the evaluation of the other. Data about the nurse's impression of the anatomical position of the NGT and notes regarding the difficulties in performing the US were recorded in a form developed for research.

The ultrasonography equipment used was the Sono Site Edge II®, with a transducer for curvilinear abdominal US 5-2 Mhz. In all insertions, a radiopaque probe with weight at the distal tip, Dobbhoff type, 12 French, with guide wire was used. Its insertion was performed via the nasal route, by ICU nurses with no bond with the research and without the presence of the evaluators, following the measure standardized by the institution (from the nostril wing to the ear lobe, from there to the tip of the xiphoid process, and from there to the umbilical scar, or adding 10 cm from the xiphoid process21), the guide wire was removed after insertion, being absent at US assessment.

In all evaluations, the patients were under the same environmental conditions and in the same position, preferably in dorsal decubitus position with the headboard kept at 30º; the test comprised the abdominal assessment, starting with the epigastric region, extending to the left upper quadrant, scanning the region with the transducer in a sagittal and transverse position; the tube was considered as visualized and properly positioned when it was identified in the stomach topography, therefore, in an infradiaphragmatic position.

In compliance with the institutional protocol and the literature recommendation3^,22, after insertion, all patients underwent an abdominal X-ray, performed in bed, with portable equipment. Upon evaluation of X-ray images by the ICU medical team, which did not participate in the study, the NGT was released (or not) for use. The parameter for release (adequate NGT placement) was the presence of the distal tip of the probe in an infradiaphragmatic position23.

The number of evaluations performed in the study was defined from research on POCUS learning and studies of interobserver agreement that suggest that the acquisition of skills of US to guide procedures seems to have a short learning curve, with a mean of 25 to 50 evaluations24^,25.

The Shapiro-Wilk was performed to test the normality in the distribution of variables. Continuous variables were presented as mean ± SD, while categorical variables as absolute and relative frequency. Interobserver agreement was evaluated using the adjusted Kappa coefficient (k) (PABAK - Prevalenceand Bias Adjusted Kappa) and its 95% confidence interval. The StatisticalPackage for the Social Sciences - SPSS® and Rstudio® software were used.

According to Kappa coefficient values, agreement was classified as: none (k = 0.00); poor (k = 0.00 - 0.20); weak (k = 0.21 - 0.40); moderate (k = 0.41 - 0.60); substantial (k = 0.61 - 0.80); almost perfect or complete (k = 0.81 - 1)14.

The study was approved regarding its ethical and methodological aspects by the Research Ethics Committee (REC) of the institution where the study was conducted (CAE: 39161820,8,0000,5530).

RESULTS

Thirty adult patients admitted to the ICU, whose mean age was 52±14.6 years, were evaluated in a paired manner, 60% were male; most (70%) used invasive mechanical ventilation, and half (50%) were sedated. The principal reason for ICU admission was COVID-19; as for previous pathologies, more than half of the patients (53.3%) were diabetic and hypertensive. The tube was indicated mainly due to the use of invasive or non-invasive mechanical ventilation (90%) (Table 1).

Table 1 -
Characteristics of patients included in the study. Porto Alegre, Rio Grande do Sul, Brazil, 2021

Characteristics of patients	N (%)
Age (in years)	52±14.6*
Male	18 (60)
Main reason for hospitalization
COVID-19	19 (63.3)
Sepsis	6 (20)
Respiratory insufficiency	2 (6.7)
Stroke	1 (3.3)
Cardiorespiratory arrest	1 (3.3)
Surgical	1 (3.3)
Previous pathologies
Diabetes Mellitus	16 (53.3)
Systemic arterial hypertension	16 (53.3)
Obesity	8 (26.7)
Heart disease	5 (16.7)
Smoker/Ex-smoker	8 (26.7)
Chronic renal insufficiency	5 (16.7)
Chronic obstructive pulmonary disease	3 (10%)
Human immunodeficiency virus	3 (10%)
PAD	2 (6.7)
Alcoholic	1 (3.3)
Previously Healthy	5 (16.7)
Indication of NGT
Altered level of consciousness	1 (3.3)
Dysphagia	2 (6.7)
Using mechanical ventilation	27 (90)
Level of consciousness
Lucid and oriented	4 (13.3)
Drowsy and/or confused	11 (36.6)
Sedated	15 (50)
Type of ventilatory support
Invasive mechanical ventilation	21 (70)
Non-invasive mechanical ventilation	2 (6.7)
Nasal cannula oxygen supply	5 (16.7)
Ambient air	2 (6.7)

• Source: research data, 2021.
• Data expressed by absolute numbers and proportion in parentheses, or as ^* mean ±standard deviation, when flagged.

Considering the total of pairs of evaluations (n=30) there was almost perfect agreement between the evaluators (k = 0.93; 95% CI: 0.65 - 0.99). Moreover, it was observed that the US was related to the abdominal X-ray, indicated by a perfect agreement (k=1.0; 95% CI: 0.77 - 1.00) between these exams.

There was only one case of disagreement between observers, when the nurse reported not seeing the NGT clearly. He attributed the difficulty to the interposition of gas, which generated artifacts and hindered to interpret the image with safety.

In seven other evaluations, the nurse reported some difficulty in performing the exam: two patients had a distended abdomen; in three patients, the delimitation of the structures was considered more difficult to obtain, also by gas interposition, increasing the duration of the evaluation; one of the patients had cough and another patient was confused and restless during the exam.

We highlight that, in the 30 evaluations, no tube was identified in a risk position for the administration of diet, which was corroborated by the X-ray examination.

DISCUSSION

The present study showed that a trained nurse can replicate the technique of verifying the NGT positioning, using US, with a low incidence of doubt in the interpretation of findings. Moreover, this investigation showed that US is related to X-ray findings.

The abdominal X-ray is the “gold standard” for checking NGT placement. However, it is a method that adds cost and time to the tube placement confirmation process. Furthermore, it exposes the patient to radiation and its interpretation also requires a trained professional, in order to avoid adverse events resulting from inadequate interpretation3^,26.

US is a promising alternative for checking the NGT positioning, as it can be performed at the bedside, quickly, safely and at low cost2. The use of US to guide procedures, whether when obtaining images in real time (dynamic form) or at certain moments of the procedure (static form), has been expanding. In both cases, it can increase assertiveness and safety in the execution27.

In the present study, US was used after the NGT insertion, evaluating the epigastric or subxiphoid region, therefore, in a static form. This was also the technique most frequently used in the studies that composed a systematic review that gathered 420 evaluated patients, mainly in the pre-hospital setting. The overall sensitivity and specificity were 93% (95% CI: 0.87 - 0.97) and 97% (95% CI: 0.23 - 1.00), respectively9.

In another systematic review, in which 545 patients were included, the US to assess the positioning of the enteral tube was used mainly in the ICU. The window used was also epigastric; sensitivity between 86 and 98% (95% CI: 0.50-1.00) and specificity between 67 and 100% (CI: 0.17-1.00) were identified, very variable values, which was attributed to heterogeneity of studies28.

However, among the works analyzed in both reviews, the evaluation was performed by nurses in only one of them9^,28. As US is an operator-dependent technique29, it is reinforced the importance of evaluating agreement between observers. However, the findings of this study are in line with data from the literature, which point out the potential of nurses in the use of US16^,30.

A systematic review that evaluated the use of US by nurses in emergency services included 16 studies and 2,245 evaluations; it was identified that even professionals without previous experience, after training, can use US to perform procedures (such as venipuncture and assessment of NGT placement) and to assist in the physical examination, in a precise and safe way30.

Evaluation of urinary retention (UR) with use of US is also a technique used by nurses. A study aimed at describe the incidence of urinary retention and the relationship between the patient’s complaint, physical examination and US performed by nurses found excellent agreement between observers, all nurses (k = 0.783; 95% CI: 0.703 - 0.996)7.

In the study about evaluation of UR, nurses were already experienced in this technique, while, in the present study, NGT placement evaluation was a newly acquired skill. This demonstrates that the training methodology used, in loco, positively interfered on the agreement obtained. This is relevant because, although the use of US by nurses is supported by COFEN, through Resolution 679/2021, there is no recommendation on the criteria for this training or its duration8.

Although the overall agreement was excellent, some difficulties were found by the nurse when interpreting the images obtained in the evaluations. The interposition of gas and the patient’s movement during the exam, due to cough or altered level of consciousness, which made the patient uncollaborative during the exam, were the biggest obstacles.

The interposition of gas is pointed out in several studies as a factor that can hinder to assess the gastrointestinal tract using US9^,10^,12^,20^,31^,32. This is due to the characteristics of US: high-frequency sound waves penetrate the tissues and are reflected by them. When returning to the transducer these waves are converted into images. Therefore, US penetrates better in solid structures, such as organs, or liquids, but has limitations when interacting with air, which is often present in the digestive tract. This can lead to dispersion of sound waves in different directions, reducing the return to the transducer and compromising the formation ofimages33.

To reduce this limitation, it has been suggested the use of saline solution9⁾ which generate a dynamic image at US, making it easier to visualization10. Due to the heterogeneity of the studies included in the systematic reviews, it became evident that US still does not have robust studies that support its use as a unique technique for verifying the placement of the enteral tube9^,18. In this sense, the instillation of saline solution, without being sure of the anatomical positioning of the tube, constitutes an additional risk and, therefore, was not used in this study.

The literature presents other factors that may hinder the use of the US technique, reducing its diagnostic accuracy. Such as the presence of obesity12^,31, painful or distended abdomen31, surgical wound, drains or open abdomen9, and patients who are confused or uncollaborative during the examination19.

Despite almost a third of the patients of the present study had a diagnosis of obesity, this was not identified as a hinder factor in the evaluations performed. Less encouraging results were obtained by other authors who were able to have the tube with US confirmed positioning in 49 of the 54 patients evaluated, and attributed their difficulty to the interposition of gas and obesity31.

The reduced number (n=30) of duplicate evaluations performed could constitute a possible limitation of the present study. However, previous research, with a similar number of participants, documented a learning curve with a mean of 25 to 50 evaluations for most US-guided procedures24^,25.

On the other hand, this study presents US as a technology reproducible by nurses, through training, which can increase access to safety practices in nutritional therapy. Although technical limitations may reduce the accuracy of US to identify NGT placement, many patients would still benefit from the use of this technology.

CONCLUSION

After undergoing a short-term training protocol, a nurse obtained similar results to those produced by an experienced physician when performing bedside US to identify NGT placement in critically ill adults. These findings suggest that the technique used is reproducible by nurses.

The main difficulties reported by the nurse were similar to those described in the literature, which suggests that this is a limitation of the method and not of the technology operator. Although more robust studies of diagnostic accuracy are still needed for the transposition of this technique to clinical practice, training nurses to apply US for the purpose of identifying the distal tip of the NGT can substantially improve the safety of the nutritional therapy process, reduce diet breaks, patient displacement to the radiology area and the hospital costs.

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Edited by

Associate editor

Graziella Badin Aliti

Editor-in-chief

João Lucas Campos de Oliveira

Publication Dates

• Publication in this collection
  28 Nov 2022
• Date of issue
  2022

History

• Received
  30 June 2022
• Accepted
  15 Sept 2022