Nasogastric / nasojejunal tube (and nasal bridle)

A feeding tube down the nose. Feeding one in the wrong place - the lung - is a Never Event. Before anything goes down it, confirm the tip with pH (1-5.5) or x-ray; a bridle holds the tube but does not confirm where it is.

Adult & paediatricGI & nutritionGuideline

Also called: NG tube, nasogastric tube, NGT, Ryle's tube, fine-bore feeding tube, NJ tube, nasojejunal tube, nasal bridle, nasal retention device, bridled NG

What it is

A nasogastric tube (NG) passes through the nose, down the oesophagus and into the stomach for feeding, fluids, medication or drainage. A nasojejunal tube (NJ) goes further, past the stomach into the jejunum, for patients who cannot tolerate gastric feeding. A nasal bridle is a retention device - a tape or clip looped behind the nasal septum - that stops a confused or at-risk patient pulling the tube out.

The reason this entry exists is a single lethal error: a feeding tube that has gone into the trachea and lung instead of the stomach, and is then fed through. The NHS classes Feeding into the lung, through a misplaced nasogastric tube is now a Never Event. The whole safety system is built to catch a misplaced tube before anything is put down it. The two facts that matter in the ED: confirm the tip before use, and know that an NJ cannot be checked by pH the way an NG can, and a bridle tells you nothing about the tip.

How to recognise it

A fine-bore tube taped at the nose, radio-opaque with length markings along it, running to a feeding port; an external length should be recorded and unchanged from insertion.
A nasojejunal tube looks similar at the nose but was placed radiologically or endoscopically and sits beyond the stomach - its position is confirmed by x-ray, not by pH.
A nasal bridle is a loop of tape or a small clip passing through and around the nasal septum, anchoring the tube - it reduces accidental removal but is not a confirmation of tube position.
A patient on home NG feeding usually arrives with documentation of the tube type, size, insertion length and feeding regimen.

What goes wrong

Misplaced in the lung (the Never Event)

A newly placed or displaced tube whose tip is in the trachea or a bronchus. There may be coughing or desaturation, but the guidance warns the absence of coughing does not exclude it.

Red flag
Do not put anything down it until the tip is confirmed. Feeding into the lung is fatal and is a Never Event. The safe check is pH or x-ray, never the look of the aspirate or a 'whoosh' of air: 'Whoosh' tests, acid/alkaline tests using litmus paper, or interpretation of the appearance of aspirate are never used to confirm nasogastric tube position as they are not reliable.

Displacement after initially correct placement

A tube that was confirmed earlier but where the external length has changed, the tape is loose, the patient has vomited, retched or coughed, or there are new respiratory symptoms.

Red flag
Any of these triggers a fresh position check before the next use - a tube can migrate up into the oesophagus (aspiration risk) or down into the lung. Re-confirm with pH or x-ray; a bridle does not prevent this: A nasal retention device to anchor the NGT at the nose does not prevent regurgitation of the tube to the oesophagus and pulmonary tree, but can reduce accidental removal.

An NJ tube checked as if it were an NG

A post-pyloric (jejunal) tube where someone aspirates and gets a pH above 5.5, and is unsure whether it is safe.

Red flag
Jejunal aspirate is not acidic, so the pH 1-5.5 rule does not apply to an NJ - a correctly placed NJ will usually read above 5.5. NJ position is confirmed radiologically. Do not reposition or re-use an NJ on pH logic; involve the team that placed it.

Nasal bridle pressure injury

A bridled tube with pain, bleeding or pressure damage at the nostril or septum.

Red flag
The bridle can cause septal pressure necrosis if too tight or left too long. Relieve the pressure and refer; but the bridle being intact still says nothing about whether the tip is correctly placed.

The first ten minutes

Before anything goes down the tube, confirm the tip is in the stomach - this is the whole game. pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe range.
If the pH is 5 to 6, do not guess - a second competent person checks any readings that fall within the pH range of 5 to 6; if it cannot be confirmed in range, use x-ray.
A pH in range is the first-line check but is not infallible - it does not even guarantee the tube is clear of the lung. The BAPEN NG-SIG paper is explicit: an accurate pH test read correctly of pH 5.5 only identifies gastric juice, not where that juice is (it found 6 tubes in the pulmonary tree despite a correct pH, 3 of them fatal), and NPSA adds that a pH between 1 and 5.5 does not necessarily confirm gastric placement of the nasogastric tube. Re-check on any change, and use x-ray whenever there is any doubt.
Use x-ray as the second-line test and read it properly: Does it cross the diaphragm in the midline?, Is the tip clearly visible below the left hemi-diaphragm?, and Proceed to feed only if all criteria are met. If in any doubt repeat x-ray or call for senior help.
For an NJ tube, do not rely on pH - confirm position radiologically and check with the placing team before use.
If you suspect a base-of-skull fracture, or an oesophageal abnormality such as a pharyngeal pouch, do not blindly pass a new tube: senior clinical help should be sought and nasogastric tube insertion should only be attempted under fluoroscopic control.

Do not

Do not feed, flush or give medication until the tip is confirmed.

Nasogastric tubes are not flushed, nor any liquid/feed introduced through the tube following initial placement, until the tube tip is confirmed by pH testing or x-ray, to be in the stomach. Feeding a lung-placed tube is the Never Event this entry exists to prevent.

Do not confirm position by the look of the aspirate, a 'whoosh' test, or litmus.

These methods have been discredited and are explicitly barred; a tube in the lung can fool all of them. Only pH 1-5.5 or a correctly interpreted x-ray is acceptable.

Do not apply the pH 1-5.5 rule to a nasojejunal tube.

Jejunal aspirate is not acidic, so a correctly placed NJ reads above 5.5. Using gastric pH logic will either wrongly reject a good tube or give false reassurance. NJ tubes are confirmed by x-ray.

Do not treat a bridle as proof the tube is correctly placed.

A bridle only reduces accidental removal; the tube can still migrate or regurgitate into the oesophagus or airway. Confirm the tip on its own merits before every use.

Who owns it

The nutrition support team / gastroenterology (and the paediatric team in children) own feeding-tube decisions; radiology places and confirms NJ tubes. Tell them the tube type (NG vs NJ), whether it is bridled, the external length and any change, the pH or x-ray result, and whether anything has been given through it.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first: Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established: Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours: Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought: Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud: The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it: Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways: The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

NTSP manual — Red flags · read in full

What the patient will be carrying

Home-feeding patients and carers usually know the tube type, size and insertion length and carry the feeding plan and the nutrition team's number; many are trained to check pH before each feed.

Scope of this page

This page covers the ED response to a patient who already has (or needs confirmation of) a nasogastric or nasojejunal tube: confirm the tip before use, read the x-ray criteria, recognise that NJ tubes and bridles change the rules. It follows the national NPSA guidance, reaffirmed by the 2016 NHS Improvement alert. It does not teach first NG insertion technique, the full bedside-chart documentation process, or neonatal NG feeding (a separate alert). Used in adults and children; neonatal feeding is out of scope.