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Original Research: Critical Care |

Comparison of a Self-Inflating Bulb Syringe and a Colorimetric CO2 Indicator With Capnography and Radiography to Detect the Misdirection of Naso/Orogastric Tubes Into the Airway of Critically Ill Adult PatientsVerifying Naso/Orogastric Tube Placement FREE TO VIEW

Nicholas A. Smyrnios, MD, FCCP; Richard Lenard, RRT-NPS, RPFT; Sunil Rajan, MD, FCCP; Michael S. Newman, DO; Stephen P. Baker, MScPH; Nehal Thakkar, MD, FCCP; Wahid Wassef, MD; Niraj K. Ajmere, MD; Richard S. Irwin, MD, Master FCCP
Author and Funding Information

From the University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, MA.

CORRESPONDENCE TO: Nicholas A. Smyrnios, MD, FCCP, University of Massachusetts Medical School, Division of Pulmonary, Allergy, and Critical Care Medicine, 55 N Lake Ave, Worcester, MA 01655; e-mail: Nicholas.Smyrnios@umassmemorial.org


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(6):1523-1529. doi:10.1378/chest.14-0663
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OBJECTIVE:  The objective of this study was to develop a mechanism of discovering misdirection into the airway of naso/orogastric (NG) tubes before they reach their full depth of placement in adults.

METHODS:  A prospective, observational study was performed in humans, evaluating both the self-inflating bulb syringe (SIBS) and a colorimetric CO2 detector. A prospective convenience sample of 257 NG tube placements was studied in 199 patients in medical ICUs of a tertiary care medical center. Findings were compared to a “standard” (ie, end tidal CO2 results of a capnograph and the results of a chest radiograph performed at the completion of the tube placement).

RESULTS:  On the first tube placement attempt in any patient, the SIBS had a sensitivity of 91.5% and a specificity of 87.0% in detecting nonesophageal placement, while the colorimetric device exhibited 99.4% sensitivity and 91.3% specificity. On subsequent insertions, the SIBS showed 95.7% sensitivity and 100% specificity, while the colorimetric device exhibited 97.8% sensitivity and 100% specificity. The colorimetric device was eight times more expensive than the SIBS.

CONCLUSIONS:  The SIBS and the colorimetric CO2 detector are very good at detecting NG tube malpositioning into the airway, although the colorimetric device is slightly more sensitive and specific. Neither method adds substantial time or difficulty to the insertion process. The colorimetric device is substantially more expensive. The decision as to which method to use may be based on local institutional factors, such as expense.

Figures in this Article

Naso/orogastric (NG) tubes are inserted in patients in the ICU for a variety of purposes, such as gastric decompression, administration of medications, and nutrition. The rate of misdirection of NG tubes into the airway is usually estimated as approximately 3% to 11%, with one prospective study reporting a rate as high as 27%.13 Rates of complication due to misdirection are reported to be as high as 3.2% of all tube placements.4 Intrathoracic complications include pneumonia, lung abscess, pneumothorax, bronchopleural fistula, atelectasis, hydrothorax, isocalothorax, empyema, subcutaneous emphysema, mediastinitis, pneumonitis, esophageal perforation, pulmonary hemorrhage, pleural knotted tube, bronchial suture line entrapment, and death.5,6

Different methods have been used to confirm reliably the placement of an NG tube. While auscultation of gas insufflation over the upper abdomen followed by a single chest radiograph is commonly used to confirm final tube placement, auscultation has been reported to be inaccurate in 20% of cases.7 Moreover, by the time the chest radiograph is obtained, the NG tube may have passed farther than 50 cm. At this depth, bronchial perforation and subsequent pneumothorax may have already occurred. Consequently, this commonly used method of NG tube placement is inadequate from a patient safety standpoint. The use of a two-step chest radiograph protocol, requiring the first chest radiograph to be obtained once the tube has been inserted up to 30 cm (where the primary carina is located in adults), has been proposed to rule out misdirection before assessing final tube placement in the stomach.5 However, this approach adds to the cost of the procedure and has been estimated to extend the time required for completion by nearly 3 h.2 In addition, each additional chest radiograph adds 0.1 mSv of radiation exposure to patients who are often already receiving high doses.

Other proposed methods have included placing each NG tube under direct visualization by fluoroscopy8 or endoscopy9 and aspiration of gastric contents10 with testing the pH of the aspirate.10 These methods each suffers from either lack of reliability or excessive cost and inconvenience.

Quantitative end tidal CO2 detection (capnography) has been shown to have near-perfect success in detecting both tracheal and esophageal location of endotracheal tubes.11 Some ICUs use capnography for routine monitoring of patients who are mechanically ventilated. In those ICUs, capnography may be an attractive approach for detection of NG tube malposition. However, in other ICUs, this approach has not been adopted, and for those institutions capnographs are expensive to acquire and require additional skill to operate.2 Their widespread application solely for this common procedure would dramatically increase its cost and slow its completion. Therefore, we believe that capnography is an excellent standard for comparison of other methods but may not be practical for routine use.

In contrast, a current “standard” for immediate determination of the accuracy of placement of endotracheal tubes is the colorimetric detector. Color change detected when the device is attached to the end of the endotracheal tube identifies the presence of CO2 and, therefore, a nonesophageal placement. This has been reported to have a sensitivity of 95.6% and a positive predictive value of 99.8% in detecting nonesophageal placement.12 Based upon experience with endotracheal tube placement, Burns et al3 demonstrated 100% correlation of the colorimetric indicator with capnography in a study of 195 patients in medical ICUs undergoing NG tube placement. In their study, no tube thought to be in the GI tract by capnography and colorimetric indicator was found to be in the respiratory tract by any other method, including chest radiography. The anesthesiology literature has also demonstrated the efficacy of another device known as the esophageal detector device (EDD) to identify endotracheal tubes misplaced in the esophagus.1315 One such EDD is a self-inflating bulb syringe (SIBS),13 shown in Figure 1. This exploits the fact that the SIBS will not inflate at all, or will inflate at a slower rate, when attached to a tube placed in the esophagus, because the esophageal wall will collapse around the tube due to the negative pressure applied.14 Several studies have shown this to be an effective method of confirming endotracheal tube placement. One study of 300 patients revealed 100% sensitivity of the EDD in detecting esophageal intubation, and a smaller arm of the same study showed the same accuracy for tracheal intubation.14 Several other studies have found similar results in patients undergoing endotracheal intubation.1618

Figure Jump LinkFigure 1 –  Self-inflating bulb syringe.Grahic Jump Location

We believed that the same principles could be used to determine the accuracy of placement of NG tubes. The absence of CO2 on the colorimetric device, or the delayed or absence of inflation of the SIBS, would indicate esophageal placement, while the presence of CO2 or rapid inflation of the bulb would suggest nonesophageal placement. Therefore, we sought to compare the accuracy of the SIBS and the colorimetric detector in confirming the placement of NG tubes in a study with two phases. We hypothesized that the SIBS and the colorimetric detector would provide equivalent earlier detection of malpositioned tubes and that the SIBS could provide an important cost advantage.

We first assessed the feasibility of the study in an animal model and then conducted the main study on adults in our medical ICUs. The animal study was approved by the University of Massachusetts Institutional Use and Animal Care Committee and the Human Study was approved by the Committee for the Protection of Human Subjects in Research at the University of Massachusetts Medical School (Docket No. 12871). The study was approved by expedited review. The study was judged to have minimal risk due to the lack of an intervention that would alter the patient’s care. Therefore, the need for written informed consent was waived. The study began enrollment in May 2008. Because of the date of beginning enrollment and because the study did not meet the definition of “any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome,”19 it was exempted from the clinical trials registry requirement based on the 2005 International Committee of Medical Journals Editors policy.

Preliminary Animal Study

Prior to initiating the human phase of the study, a preliminary investigation was performed on a pig model. This was performed as an addition to a study already being performed on those animals. Two pigs were used on each of two study days. Two Bard nasogastric sump tubes were inserted into each pig by the staff veterinarian using direct laryngoscopy. One tube was placed in the esophagus and one tube was placed in the trachea. One tube was marked “A” and the other was marked “B.” On each study day, 20 volunteers were invited to help test the SIBS. Volunteers included 10 ICU nurses, 12 resident physicians, four attending critical care physicians, three medical students, four critical care fellows, four gastroenterology fellows, one respiratory therapist, and two nurse practitioners.

Volunteers received brief instruction on evaluation parameters and then were asked to judge the location of one tube. Reinflation of the bulb syringe in < 5 s was considered to be consistent with nonesophageal placement. Inflation taking > 5 s or lack of inflation was considered to be consistent with esophageal placement. Volunteers were blinded to the location of the tubes. Each volunteer was randomly assigned to either tube A or tube B and attached the deflated bulb syringe to only their assigned tube. After using the bulb syringe, the volunteers were asked to make their assessment of where the tube was placed, either in the esophagus or in the trachea. At the conclusion of this study and the related studies being performed, esophagoscopy was performed to evaluate for esophageal mucosal damage that might have been caused by the negative pressure that was generated as the bulb syringe was trying to inflate.

Human Experimental Protocol

Eligible adult subjects were inpatients in a medical ICU, at least 18 years of age, and had a clinical need for an NG tube determined by bedside caregivers independent of the research team. Subjects were excluded from enrollment if they were pregnant, under the age of 18 years, prisoners, or had known esophageal disease such as severe erosions, esophageal varices, strictures, tumors, had previously undergone esophageal or fundoplication surgery, had tracheoesophageal fistula, or had excessive and unmanageable tracheal secretions.

Once a subject was enrolled, an NG tube was placed by a bedside clinical team member with a member of the research team in attendance who provided the SIBS, colorimetric detector, and capnograph. The side port of the NG tube was blocked with an occlusive plug to prevent entrainment of air from outside the patient’s body. The NG tube was placed to a depth of 30 cm by standard clinical procedure. A deflated 30-mL SIBS (Busse Hospital Disposables) (Fig 1) was attached to the proximal end of the tube. If the syringe fully inflated within 5 s, the tube was categorized as “reinflation/nonesophageal placement” by the bulb-syringe method. If the syringe did not fully inflate within 5 s, the patient was categorized as “no reinflation/esophageal placement” by the bulb-syringe method.

A colorimetric indicator (Covidien AG) was then attached to the gastric tube and the color response recorded. Change of the indicator color to purple was recorded as “color change/nonesophageal placement” by the colorimetric method. Absence of color change was recorded as “no color change/esophageal placement” by the colorimetric method. For either device, a “positive” test was defined as a test that detected a nonesophageal placement as defined in the previous sentences.

The colorimeter was removed and a capnograph was attached (BCI Capnocheck II 8401 capnograph; Turner Medical Inc). Elevated levels of CO2 suggested nonesophageal placement. Because of the absence of a well-defined external gold standard, and, in part, based on a report by Burns et al,20 which indicated that tracheally placed tubes revealed an end tidal Paco2 > 25 mm Hg, we defined the internal gold standard of true nonesophageal placement for statistical analysis as either an end tidal CO2 value ≥ 25 mm Hg or a chest radiograph, performed at the conclusion of the procedure, showing a malpositioned tube.20

Absence of elevated levels of CO2 suggested esophageal placement. For purposes of analysis, we defined true esophageal placement as either a chest radiograph that confirmed subdiaphragmatic intestinal placement or no chest radiograph was done and capnography detected CO2 levels < 25 mm Hg.

If CO2 of any value was observed, the clinical team member involved was advised of the finding. Final decision regarding removal of the tube was made by the clinical team member and no recommendation for maintenance or removal of the tube was made. Tubes not removed were advanced to a gastric location by usual ICU protocol.

If at any time during the procedure the patient developed new-onset respiratory or hemodynamic distress or instability, a chest radiograph was obtained immediately and, if necessary, the tube was removed.

Statistical Methods

Using a mid-range estimate of 10% nonesophageal placement, with 100% accuracy in detecting nonesophageal placement by bulb reinflation, and with 0% bulb reinflation when the tube is placed in an esophageal location, we estimated a need for 26 esophageal placements and 26 nonesophageal placements. However, given the expected rate of nonesophageal placement of 10%, we estimated that we would need 260 total placements to see the required number in each location.

Differences in proportions of misplacements between groups were evaluated using the Fisher exact test. Differences in rates of misplacements by methods were evaluated using the McNemar test. Differences in means for continuous random variables were evaluated using the Student t test or the Welch Aspin t test for equal variance or unequal variances scenarios, respectively. The predictive value of positive or negative tests was estimated using Bayes rule. Statistical analysis was performed using the SPSS Statistical Software Package, version 20 (IBM Inc).

Preliminary Animal Study

A total of 40 placement evaluations were completed over the course of two days of testing. Of the 40 trials, all 40 successfully identified whether the tube was placed in the esophagus or in the trachea, regardless of the professional discipline or level of training of the person performing the assessment. Endoscopy performed after all of the tests showed no visible abnormalities after the multiple trials, and biopsy showed no microscopic changes.

Human Study

We evaluated the SIBS and the colorimetric device on a prospective convenience sample of 260 NG tube insertions on 202 different subjects. Three subjects (and three tube placements) were excluded due to lack of data. A description of the population studied is presented in Table 1. Fifty-eight percent of the subjects were tracheally intubated and receiving mechanical ventilation. The primary diagnoses at admission for the patients studied are listed in Table 2.

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Study Cohort

Data given as mean No. (%) unless otherwise specified. APACHE = Acute Physiology and Chronic Health Evaluation; GCS = Glasgow Coma Scale.

Table Graphic Jump Location
TABLE 2 ]  Primary Diagnosis at Time of Admission

The incidence of misplacements was greater among subsequent insertions compared with first insertions, although that difference did not reach statistical significance. Of the 202 first tube insertions on these 202 patients, 199 had either chest radiograph or capnographic data that met our standard for comparison. For first insertions, 23 of 199 (11.6%) were misdirected into the trachea, whereas 12 of 58 (20.7%) subsequent insertions were misdirected into the trachea (P = .084). For the 220 total insertions that were defined as appropriate by capnography, 219 had a chest radiograph performed; of those, 217 (99.1%) were found to be in the correct position. There was no significant difference in the rate of nonesophageal placements between tubes placed nasally and those placed orally. These results are presented in Tables 3 and 4.

Table Graphic Jump Location
TABLE 3 ]  Result of Self-Inflating Bulb Syringe for Detecting Gastric Tube Misplacement
a 

First refers to first tube placement in that individual patient; tube placement second or more refers to second or subsequent tube placement in that individual patient.

b 

Yes = self-inflating bulb syringe reinflates within 5 s of attachment to the gastric tube; no = self-inflating bulb syringe did not reinflate within 5 s of attachment to the gastric tube.

c 

Misplacement: placement met the capnographic or radiographic definition for placement outside of the GI tract.

d 

Esophageal placement: placement met the capnographic or radiographic definition for placement in the GI tract.

Table Graphic Jump Location
TABLE 4 ]  Result of Colorimetric CO2 Detector for Detecting Gastric Tube Misplacement
a 

First refers to first tube placement in that individual patient; second or greater refers to second or subsequent tube placement in that individual patient.

b 

Yes = colorimetric device changed color when attached to the gastric tube; no = colorimetric device did not change color when attached to the gastric tube.

c 

Misplacement: placement met the capnographic or radiographic definition for placement outside of the GI tract.

d 

Esophageal placement: placement met the capnographic or radiographic definition for placement in the GI tract.

We analyzed the sensitivities and specificities of the SIBS and the colorimetric device both for first insertions on each patient and for second and additional insertions. Those results are provided in Table 5, as are the predictive values of a positive and a negative test for both the SIBS and the colorimetric device, and the sensitivity and specificity of initial and subsequent insertions taken together. Because the use of both the SIBS and the colorimetric device together yielded a result that was identical to that of the colorimetric device, we have not provided detailed analysis of that information.

Table Graphic Jump Location
TABLE 5 ]  Sensitivity, Specificity, and Predictive Values of the Self-Inflating Bulb Syringe and the Colorimetric Detector for Identifying Nonesophageal Placement of Naso/Orogastric Tubes

Data given as % (95% CI) unless otherwise indicated. NPV = negative predictive value; NS = not statistically significant; PPV = positive predictive value.

Using the previously described rate of tube malpositioning for first insertions of 11.6% and the test sensitivities described in Table 5, we estimated the number of insertions needed to be evaluated to detect a single malpositioned tube. This was 9.4 for the SIBS and eight for the colorimetric device. The estimated cost of the SIBS at this writing is $1.45 and the cost of the colorimetric device is $11.44. Using those estimates, we calculated a cost to detect a single malpositioned tube of $13.63 for the SIBS and $91.52 for the colorimetric device.

There were no significant differences in sex, endotracheal intubation status, presence of ARDS, or APACHE (Acute Physiology and Chronic Health Evaluation) IV score between patients found to have tracheal or esophageal placement. The average age of patients with tracheally misdirected NG tubes was 69.3 years vs 62.9 years for patients with esophageally positioned tubes (P = .007). There were no adverse events associated with the use of either device.

From this study, the following three findings emerged. First, both the SIBS and colorimetric detector performed with a high degree of sensitivity and specificity in our sample of patients in the medical ICU, although the colorimetric device was slightly more sensitive and specific. Taken together with the excellent negative predictive value demonstrated, we believe the high degree of sensitivity and specificity makes the colorimetric device acceptable to make clinical decisions to maintain or remove NG tubes based on either of these devices.

Second, in an era of intense focus on medical costs, these two approaches are examples of simple, low-cost interventions that can improve quality of care without significantly adding to hospital cost. They are able to accomplish the same result as alternative approaches that are much more time consuming and expensive. This should reduce the rates of life-threatening complications such as pneumothorax, bronchopleural fistula, atelectasis, hydrothorax, isocaolothorax, empyema, subcutaneous emphysema, mediastinitis, pneumonitis, esophageal perforation, and pulmonary hemorrhage. Further study will be necessary to confirm that such complications are, in fact, reduced.

Third, both the colorimetric device and the SIBS are safe, with no adverse events associated with their use. We do not envision that events will emerge during widespread use, because each device is noninvasive, and the time taken to apply each adds a negligible amount to the time to the procedure itself.

Our study has several potential limitations. First, these patients were recruited from a single institution and exclusively in a medical ICU population. Although it is reasonable to think that the same results would be obtained in other populations, that assumption should be tested. Second, it is unclear from our data whether the colorimetric device is equal or superior to the SIBS. Although sensitivity appears to be greater for the colorimetric device in first insertions, there was no difference in sensitivity for second or subsequent insertions and no difference in specificity at any point. This is a potentially important issue to resolve because an institution would spend approximately $10,000 more per 1,000 NG tubes placed using the colorimetric device rather than the SIBS. It may require additional study to determine whether the additional cost is worth spending.

Third, our study suffered from the lack of a true gold standard (eg, chest radiography) for detection of tube position at 30 cm depth in all of the patients. Because we found it unacceptable to shield bedside caregivers from knowledge of elevated Pco2 levels on capnography, many tubes were removed before radiographs were done. Therefore, we had to use the capnograph-derived Pco2 level as a definition of malpositioning in those placements even when there was no other clinical indicator of adverse effects. It may be valuable in future study to include a chest radiograph at 30 cm as a gold standard for comparison.

Fourth, it is not known what the expected result is on either SIBS or colorimetric detector of an NG tube whose tip is coiled in the neck. We encountered this only once and it was not detected as abnormal by either the SIBS or the colorimetric detector. We include this because we believe this is a situation occasionally encountered by most clinicians. We will be interested to see what further experience with these devices demonstrates.

Fifth and finally, our measurements were not used for clinical decision-making in either a randomized manner or in a uniform manner. Therefore, there could have been a bias in deciding which tubes were removed and which were kept in place.

Nevertheless we do not believe that any of these limitations detract from the major findings of the study. Both the SIBS and the colorimetric device performed well in the situations in which they were used. This was true in all placements, but was particularly true in first placements when the studies did not detect malpositioning. In that situation, the negative predictive value of the SIBS was 98.2% and of the colorimetric CO2 detection was 99.9%. It was also particularly true in second and subsequent placements where the sensitivities were 95.7% and 97.8%, respectively. Both of these suggest that a clinician could be confident that an NG tube placed without abnormal findings on either device was highly likely not to be malpositioned and, therefore, highly likely not to lead to complications described previously. Those findings alone provide a rationale for the application of such devices. Those findings also support our choice of 25 mm Hg Pco2 as the threshold for determining nonesophageal placement. Future studies may allow us to redefine that cutoff value.

Our data suggest that the use of either the colorimetric CO2 detector or the SIBS is a reliable way of discovering respiratory tract placement of an NG tube and potentially reducing associated complications. Use of a SIBS is a safe alternative to a colorimetric detector or capnography when either is too expensive or not available. Application of a SIBS or colorimetric device does not eliminate the need for a radiograph to confirm tube placement at the conclusion of the placement and before anything is infused into the tube. Neither the SIBS nor the colorimetric device can determine the ultimate location of the tip and side port of the tube in the GI tract. Therefore, we continue to advocate for and adhere to the practice of obtaining a chest or abdominal film at the completion of the procedure.

Author contributions: N. A. S. and S. P. B. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. R. L. and R. S. I. contributed to the study concept; N. A. S., N. T., W. W., N. K. A., and R. S. I. contributed to the study design; S. R., M. S. N., N. T., and N. K. A. contributed to data collection; S. P. B. performed the data analysis; N. A. S. wrote the manuscript; and N. A. S., R. L., S. R., M. S. N., S. P. B., N. T., W. W., N. K. A., and R. S. I. reviewed, edited, and approved the final manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Although Dr Irwin is Editor in Chief of CHEST, the entire review process and decision regarding publication of this manuscript were carried out independently of him. The remaining authors have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

EDD

esophageal detector device

NG

naso/orogastric

SIBS

self-inflating bulb syringe

Harris MR, Huseby JS. Pulmonary complications from nasoenteral feeding tube insertion in an intensive care unit: incidence and prevention. Crit Care Med. 1989;17(9):917-919. [CrossRef] [PubMed]
 
Kindopp AS, Drover JW, Heyland DK. Capnography confirms correct feeding tube placement in intensive care unit patients. Can J Anaesth. 2001;48(7):705-710. [CrossRef] [PubMed]
 
Burns SM, Carpenter R, Blevins C, et al. Detection of inadvertent airway intubation during gastric tube insertion: Capnography versus a colorimetric carbon dioxide detector. Am J Crit Care. 2006;15(2):188-195. [PubMed]
 
Ghahremani GG, Gould RJ. Nasoenteric feeding tubes. Radiographic detection of complications. Dig Dis Sci. 1986;31(6):574-585. [CrossRef] [PubMed]
 
Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med. 1989;149(1):184-188. [CrossRef] [PubMed]
 
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Figures

Figure Jump LinkFigure 1 –  Self-inflating bulb syringe.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Study Cohort

Data given as mean No. (%) unless otherwise specified. APACHE = Acute Physiology and Chronic Health Evaluation; GCS = Glasgow Coma Scale.

Table Graphic Jump Location
TABLE 2 ]  Primary Diagnosis at Time of Admission
Table Graphic Jump Location
TABLE 3 ]  Result of Self-Inflating Bulb Syringe for Detecting Gastric Tube Misplacement
a 

First refers to first tube placement in that individual patient; tube placement second or more refers to second or subsequent tube placement in that individual patient.

b 

Yes = self-inflating bulb syringe reinflates within 5 s of attachment to the gastric tube; no = self-inflating bulb syringe did not reinflate within 5 s of attachment to the gastric tube.

c 

Misplacement: placement met the capnographic or radiographic definition for placement outside of the GI tract.

d 

Esophageal placement: placement met the capnographic or radiographic definition for placement in the GI tract.

Table Graphic Jump Location
TABLE 4 ]  Result of Colorimetric CO2 Detector for Detecting Gastric Tube Misplacement
a 

First refers to first tube placement in that individual patient; second or greater refers to second or subsequent tube placement in that individual patient.

b 

Yes = colorimetric device changed color when attached to the gastric tube; no = colorimetric device did not change color when attached to the gastric tube.

c 

Misplacement: placement met the capnographic or radiographic definition for placement outside of the GI tract.

d 

Esophageal placement: placement met the capnographic or radiographic definition for placement in the GI tract.

Table Graphic Jump Location
TABLE 5 ]  Sensitivity, Specificity, and Predictive Values of the Self-Inflating Bulb Syringe and the Colorimetric Detector for Identifying Nonesophageal Placement of Naso/Orogastric Tubes

Data given as % (95% CI) unless otherwise indicated. NPV = negative predictive value; NS = not statistically significant; PPV = positive predictive value.

References

Harris MR, Huseby JS. Pulmonary complications from nasoenteral feeding tube insertion in an intensive care unit: incidence and prevention. Crit Care Med. 1989;17(9):917-919. [CrossRef] [PubMed]
 
Kindopp AS, Drover JW, Heyland DK. Capnography confirms correct feeding tube placement in intensive care unit patients. Can J Anaesth. 2001;48(7):705-710. [CrossRef] [PubMed]
 
Burns SM, Carpenter R, Blevins C, et al. Detection of inadvertent airway intubation during gastric tube insertion: Capnography versus a colorimetric carbon dioxide detector. Am J Crit Care. 2006;15(2):188-195. [PubMed]
 
Ghahremani GG, Gould RJ. Nasoenteric feeding tubes. Radiographic detection of complications. Dig Dis Sci. 1986;31(6):574-585. [CrossRef] [PubMed]
 
Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med. 1989;149(1):184-188. [CrossRef] [PubMed]
 
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