Both methods of nasogastric tube placement were used in our department. This protocol was carried out as part of the baseline audit spiral. Fully informed consent was obtained from all participants.
Inpatients requiring nasogastric feeding tubes were identified following assessment by the multidisciplinary head and neck team. Thirty-five consecutive patients with head and neck carcinoma were included. The comparative audit took place at the UCLH Head and Neck Unit, London. All patients had failed traditional insertion methods after 2 attempts and were therefore eligible for inclusion.
Nasogastric tube insertion was attempted using an established blind technique whereby a fine bore nasogastric feeding tube is passed into the nose and the patient asked to swallow a small volume of water. The tube is simultaneously advanced into the oesophagus and the position confirmed using pH testing of aspirate and/or chest X-ray.
Following 2 failed attempts, patients were then randomised to undergo insertion of feeding tube with the aid of the flexible nasendoscope alone (Group A) or with the flexible nasendoscope and gel cap combined (Group B), (Figure 1). Patients were randomized using a computerized random number generator (0-100) where even numbers were allocated to Group A, and odd numbers to Group B. The randomization was implemented by the clinician performing the procedure immediately before insertion (Figure 2).
All patients received 3 metered doses of co-phenylcaine (lignocaine 5% with phenylephrine) nasal spray with a further 2 doses after an interval of 5 minutes to the side of the nose identified as clearer by the clinician performing the procedure. Water based lubricants were used in both sample groups.
Patients in Group A underwent insertion of the flexible nasendoscope and when an adequate view was achieved, the nasogastric tube was then passed over the endoscope until the tip of the tube was visible in the nasopharynx. The tube could then be advanced and observed to pass into the oesophagus under direct vision. Patients in Group B underwent simultaneous insertion of flexible nasendoscope and feeding tube. The tip of the feeding tube and the tip of the flexible nasendoscope were inserted together into a gel cap (Figure 1). The feeding tube and nasendoscope were then passed together through the nose and directly into the pyriform fossa and advanced into the oesophagus. Both were then left in place for 30 seconds (the average time taken for easy separation of the gel cap in a pre-study sample of 20 gels caps) before the endoscope was withdrawn and the feeding tube advanced into the stomach. There were no adverse events in either group.
The outcome measures recorded by medical staff were ease of procedure (graded 0-100 on a visual analogue scale (VAS) where 0 is very easy and 100 is very difficult), perceived patient discomfort (VAS 0-100 where 0 is no discomfort and 100 is very uncomfortable), length of procedure (seconds) and number of assistants required to facilitate insertion. All procedures were carried out by one of two clinicians experienced in using both techniques.
Following insertion, patients were asked to complete a further VAS to grade their pain score (VAS 0-100; 0 is no pain and 100 is worst pain ever) and discomfort (VAS 0-100; 0 is no discomfort and 100 is most uncomfortable thing ever). The clinician performing the follow-up patient questionnaire was blind to the technique used in order to reduce bias whilst collecting results. The data was normally distributed having passed normality testing (alpha = 0.05).