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Home nasogastric tube care and gastrostomy nutrition support

Nasogastric Tube Care and Gastrostomy Home Nutrition Support

For patients with swallowing difficulty, the two biggest risks of tube feeding are a tube that has moved into the airway and choking on feed into the lungs. Both can be prevented with evidence-based nursing care. We arrange registered nurses in Hong Kong to visit the home. The nurse confirms tube position with pH strips before feeds, teaches the family a position that prevents aspiration, shows how to flush the tube with water to prevent blockage, and looks after gastrostomy sites. In situations such as end-stage dementia, we also discuss the pros and cons honestly with the family and do not push tube feeding.

  • Team of registered nurses in Hong Kong
  • Home visits across Hong Kong
  • Nurse $920 per hour · no minimum charge
  • pH position check · aspiration and blockage prevention
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Fees, who visits and how to book

The questions below are the ones that families ask most, answered together. For full fees, see the pricing page.

FeesRegistered nurse HK$920 per hour. By the hour booked: 4 hours at $400 per hour, 8 hours at $340 per hour, 12 hours at $300 per hour. No minimum charge, and single visits can be booked as needed.
Scope of serviceThe service includes inserting and changing nasogastric tubes (NGT) and confirming tube position with pH strips before each feed; cleaning the gastrostomy (PEG) site, checking how tight the external bumper is, and managing granulation tissue and leakage; teaching a feeding position that prevents aspiration (feed going down the wrong way) and a flushing method that prevents blockage; assessing the risk of refeeding syndrome; and teaching the family daily care skills step by step.
Service areasThe service covers Hong Kong Island, Kowloon and the New Territories, including private homes, residential care homes and hospitals.
Who visitsThe service is provided by registered nurses in Hong Kong who are registered with the Nursing Council of Hong Kong. They visit in person to assess the patient, give nursing care and guide the family.
How to bookEnquire or book by WhatsApp (5473 6204).

Common risks of tube feeding and nursing data

Feeding through a nasogastric tube or gastrostomy looks simple, but in clinical practice two safety risks must be guarded against strictly. The first is that the tube has moved, or even entered the airway, so that formula goes straight into the lungs. The second is that stomach contents flow back and are inhaled during feeding, causing aspiration pneumonia. Being careful is not enough to prevent either of these. An evidence-based nursing procedure has to be followed, and this is why registered nurses visit to carry out the care and teach the correct technique to the family.

≥30°
Angle to raise the upper body during feeding
The ASPEN guideline recommends that, in adults receiving enteral (tube) feeding, the head of the bed or the upper body should be raised to at least 30° (unless there is a clinical reason not to), to lower the risk of aspiration into the lungs (Boullata 2017, JPEN).
8% vs 34%
Hospital-acquired pneumonia, semi-recumbent vs lying flat (ICU study data)
A study in an intensive care unit (ICU) found that among ventilated patients, the rate of clinically suspected hospital-acquired pneumonia was 8% in those in a semi-recumbent position (≥45°), against 34% in those lying flat. These are ICU data. They mainly show that body position matters, and should not be taken as actual percentages for the home setting (Drakulovic 1999, Lancet).
pH ≤5.5
Gastric fluid pH that confirms the tube is in the stomach
Before every feed, a little gastric fluid must be drawn out and tested with pH indicator strips. A pH of 5.5 or below means the tube is in the stomach. The traditional method of listening with a stethoscope is not reliable (NICE CG32 / NPSA safety alert).
13–40% / 0.4–4.4%
Minor and serious complication rates after gastrostomy (PEG)
After PEG placement, minor complications occur in about 13–40% and serious complications in about 0.4–4.4%. The most common is skin infection around the stoma, at about 4–30% (Boeykens 2022, BMJ Open Gastro).

Risk 1: confirming tube position with pH strips

After the tube is placed, daily activity can move it. If the position is not verified before feeding and formula is given into the airway and lungs by mistake, the result can be serious or even fatal pneumonia. The international guideline (NICE CG32, recommendation 1.7.17) states that after placement and before every use, the position of every nasogastric tube must be checked by aspirating gastric fluid and testing it with pH indicator strips, with an X-ray when needed. Only a pH of about 5.5 or below indicates that the tube is in the stomach (this threshold comes from an NPSA safety alert).

In the past a method known as the whoosh test (auscultation) was often used. Air is pushed down the tube and a stethoscope is used to listen for bubbling sounds over the abdomen. The medical literature has shown that this method is not reliable, because it cannot tell whether the tube is in the oesophagus, the stomach or the windpipe, and it should no longer be used to confirm position. The correct approach is to test gastric fluid with pH strips and to confirm with an X-ray when needed (Fan 2017; Boullata 2017).

Another common misunderstanding is that passing a nasogastric tube always makes swallowing worse. Research shows that when the tube is in the correct position it does not worsen swallowing disorders in patients with acute stroke. A tube in the wrong place, on the other hand, makes swallowing clearly worse. This again shows that placing the tube accurately and checking its position every time is the key, and it needs to be done carefully by a nurse with professional training (Dziewas 2008).

Steps to confirm tube position before every feed
  • Draw out a little gastric fluid with a syringe and drop it on a pH indicator strip to read the result
  • Confirm that the pH is 5.5 or below, which shows the tube is in the stomach, before starting the feed
  • If no gastric fluid can be drawn, or the strip reading is doubtful, pause feeding and arrange an X-ray to confirm position when appropriate
  • Check whether the length of tube outside the nostril and the securing mark have moved, to see whether the tube has shifted
  • Relying on the whoosh test (listening with a stethoscope) alone to decide where the tube is. This method has been shown to be unreliable

Risk 2: preventing aspiration with a set of nursing measures

Aspiration (food or liquid going down into the lungs) is the main reason tube feeding leads to pneumonia. Preventing it takes more than sitting a little higher. A whole bundle of measures has to be put in place, from feeding position and mouth care to monitoring how well the feed is tolerated, and none can be left out. The ASPEN safe practices guideline recommends that in adults receiving enteral feeding, the head of the bed or upper body should be raised to at least 30 degrees (unless there is a clinical contraindication). An intensive care study has also found that a semi-recumbent position reduces hospital-acquired pneumonia more than lying flat for long periods (these are ICU data, used to show that position matters, and should not be taken as exact percentages for ordinary home care).

Body position during and after feeding

  • Raise the patient's upper body to at least 30 degrees during feeding (as recommended by the ASPEN guideline, except where there is a clinical contraindication)
  • After feeding, keep the patient semi-reclined for a period of time, and do not lay the patient flat to sleep straight away
  • Staying semi-reclined helps to lower the risk of aspiration pneumonia (supported by ICU research, though the study figures are not exact numbers for the home setting)

Mouth care and watching the body's response

  • Clean the patient's mouth regularly to reduce secretions and bacteria in the mouth and throat
  • Before and after feeds, watch for signs of poor digestion such as abdominal bloating, vomiting or a large gastric residual volume
  • If coughing, breathlessness, fever or other signs of suspected aspiration appear, stop feeding at once and seek help from healthcare staff as soon as possible

Gastrostomy (PEG) care and common problems

If a patient is expected to depend on tube feeding for a long time (generally more than about 4 to 6 weeks), the international guideline (ESPEN home enteral nutrition) recommends changing from a nasogastric tube to a percutaneous endoscopic gastrostomy (PEG). This avoids long-term pressure and discomfort in the nose and throat, is less visible, and gives more stable feeding. PEG is a well-established technique, but the stoma still needs continuing professional care. The most common minor complication is infection around the stoma (about 4–30%). The rarer buried bumper mostly results from an external bumper that is too tight and cuts off the blood supply to the tissue, and it can only be prevented by regular checks and adjustment of the external bumper tension.

Stoma skin and granulation care
The nurse uses a clean technique to care for the skin around the stoma, deals with redness, leakage and granulation tissue, and works to prevent the most common problem, infection around the stoma.
Monitoring external bumper tension (preventing a buried bumper)
The nurse regularly checks and adjusts how tight the external bumper is. If the bumper is too tight, the internal bumper can sink into the stomach wall (buried bumper). If it is too loose, feed can leak or the tube can move.
Keeping the tube clear and preventing blockage
The tube is flushed with water before and after every feed and every medicine to keep it clear. If a blockage occurs, it must be dealt with using the correct method, and the syringe must never be pushed hard.

How to prevent tube blockage

Blockage is the most common mechanical problem in tube feeding, and it is mainly caused by insufficient flushing and medicine residue. The way to prevent it is clear: flush the tube with water at regular times. This means every 4 hours during continuous feeding, before and after each feed, and after checking gastric residual volume, using about 30 mL of water. Before and after each medicine, about 15 mL of water is used. Medicines should be chosen in liquid form where possible and given one at a time, never mixed directly into the formula, to avoid precipitation (Boeykens 2022; Blumenstein 2014).

Key points for preventing tube blockage every day
  • Flush with about 30 mL of water every 4 hours during continuous feeding, before and after each feed, and after checking gastric residual volume
  • Flush the tube with about 15 mL of water before and after every medicine
  • Change medicines to liquid forms where possible, and give each medicine separately
  • Crushing tablets and mixing them directly into the formula to be given together. This easily forms precipitate that blocks the tube
  • Using vegetable or fruit juice or fizzy drinks to "clear" the tube. There is no medical evidence for this, and it may make the blockage worse

Refeeding syndrome and tube feeding in end-stage dementia

Our principle is to help the family make a medically informed choice, and not to place a feeding tube for every patient without good reason. The two clinical facts below must be explained honestly to the family beforehand.

Refeeding syndrome

  • If a patient has gone without food for a long time or is severely malnourished, giving too much too fast when feeding is first started carries a risk of refeeding syndrome
  • Blood tests show a very low phosphate level, and in severe cases this can cause problems such as an irregular heartbeat
  • The nurse assesses the patient against the NICE high-risk criteria, starts with a slow rate and small amounts, watches phosphate, potassium and magnesium levels, and increases the amount gradually once the patient is stable

Research on tube feeding in end-stage dementia

  • A Cochrane review of 7 observational studies found that tube feeding does not prolong life in end-stage dementia and does not improve other clinical outcomes
  • The ESPEN guideline also recommends that tube feeding should not be started in severe dementia, and that artificial nutrition is not recommended in the end stage
  • These are observational findings. They do not apply to patients with early to moderate dementia, or whose swallowing difficulty may improve, and such patients should be assessed individually

We respect each patient's clinical situation and the wishes of the family. For patients who have a real need and can benefit from tube feeding, the team provides safe and standardised tube care. In situations such as end-stage dementia, we go through the pros and cons honestly with the family and discuss care that puts the patient's comfort first, to help the family make an informed decision.

What happens at the first home visit

Every case starts with a full assessment, followed by specific safety measures and guidance for the family, with ongoing follow-up. The overall process is as follows.

  1. 1
    WhatsApp or phone enquiry
    We first find out about the patient's condition, the type of tube in use (NGT or PEG), the usual feeding arrangements and the home environment, and then give initial advice and a quote.
  2. 2
    First home assessment
    The nurse checks the position and securing of the tube, the condition of the skin around the stoma, and how the patient digests feeds. The nurse also assesses the risk of aspiration and refeeding, and checks whether the care supplies at home are suitable.
  3. 3
    Carrying out care and position checks
    The tube is inserted or changed according to the patient's actual needs. The tube position is confirmed with pH strips before every feed, and the stoma is cleaned and the tension of the external bumper adjusted.
  4. 4
    Hands-on teaching for the family
    On site, step by step, the family is taught how to place the patient in the feeding position, how to flush the tube with water, how to read the pH strip, and what signs of poor digestion or aspiration to watch for. Suitable care supplies are also prepared.
  5. 5
    Regular follow-up and adjustment
    The nurse follows up regularly on the patient's nutrition and stoma, deals with complications, and adjusts the feeding and care plan as the patient's condition changes.

Who the service is for

Patients who depend on enteral (tube) nutrition because of swallowing difficulty are commonly found in the situations below, and a registered nurse can be arranged to visit for assessment and care in each of them.

Long-term illness or neurological conditions

  • Patients who can no longer eat safely by mouth because of a neurological condition such as stroke or Parkinson's disease
  • Patients with severe swallowing and eating difficulty because of a head and neck tumour, or the side effects of radiotherapy or chemotherapy
  • People who need long-term tube feeding and have already changed, or are considering changing, to a gastrostomy (PEG)

Short-term transition or families who need guidance

  • Patients who need a nasogastric tube for a while to take in nutrition after surgery
  • Family members who have just taken over care and feel unsure about feeding, flushing and checking tube position, and need a nurse to teach them hands-on
  • Patients whose risk of refeeding syndrome needs to be assessed, and who need healthcare staff to help plan how feeding is started

Frequently asked questions

Why must the position of the nasogastric tube be confirmed before every feed? Is listening to the abdomen with a stethoscope enough?
If the tube has moved, or has entered the airway by mistake, feeding formula into the lungs can cause serious pneumonia. According to the international guideline (NICE CG32), gastric fluid should be aspirated and tested with pH indicator strips before each use. A pH of about 5.5 or below indicates that the tube is in the stomach, and an X-ray is taken to confirm when needed. The traditional method of blowing air down the tube and listening (auscultation, or the whoosh test) has long been shown to be unreliable. It cannot tell whether the tube is in the oesophagus, the stomach or the airway, and it should not be used to confirm position. For this reason the registered nurses of our team always check the position with pH strips according to the standard, and never rely on listening alone.
How can choking on feed into the lungs (aspiration pneumonia) be prevented during NGT or gastrostomy feeding?
Prevention does not rest on a single action. It takes a whole bundle of measures. During feeding the upper body is raised to at least 30 degrees as recommended by ASPEN (unless there is a clinical reason not to), and the patient stays semi-reclined for a period after feeding before lying flat. Mouth care is also needed, together with attention to signs of intolerance such as abdominal bloating, vomiting and gastric residual volume. An ICU study found that a semi-recumbent position reduced hospital-acquired pneumonia more than lying flat for long periods, which confirms that position matters. The exact percentages, however, come from intensive care patients and cannot be applied directly as home figures. On a home visit the nurse first assesses the patient and then teaches the family to carry out the whole set of measures.
The nasogastric tube blocks often. How should it be handled, and how can blockage be prevented?
Blockage is the most common mechanical problem, and it usually comes from insufficient flushing and medicine residue. The most effective approach is to flush the tube with water at regular times: every 4 hours during continuous feeding, and before and after each feed and each medicine (about 15–30 mL of water each time). Liquid forms of medicine should be chosen where possible and given separately, never mixed directly into the feed. The nurse shows the family the correct flushing technique on the spot and helps to prepare suitable feeding syringes and flushing water.
What is the difference between a nasogastric tube (NGT) and a gastrostomy (PEG)? When is a switch to PEG needed?
A nasogastric tube is passed through the nostril and suits short-term use (generally within about 4 to 6 weeks). If tube feeding is expected to be long-term, the international guideline (ESPEN) recommends a percutaneous endoscopic gastrostomy (PEG) as the first choice. It avoids long-term pressure and discomfort in the nose and throat, is less visible, and gives more stable feeding. A PEG does need regular stoma care, including cleaning, monitoring the tension of the external bumper and preventing infection, and all of this falls within the home visit service of our registered nurses.
What complications can a PEG stoma have? Is it very dangerous?
PEG is a well-established technique and serious complications are not common (about 0.4–4.4%). Minor complications are more common (about 13–40%), and peri-stomal infection accounts for the largest share of these (about 4–30%), but most can be resolved with good care. A rarer complication that should not be overlooked is the buried bumper, which mostly results from an external bumper that is too tight and cuts off the blood supply to the tissue. For this reason the nurse checks regularly and adjusts the tension of the external bumper, and also looks after the stoma skin and any granulation tissue.
Must every older person or person with dementia have a feeding tube?
It depends on the individual condition and cannot be answered in general terms. For older people with severe or end-stage dementia, international evidence (a Cochrane review of 7 observational studies) shows that tube feeding does not prolong life or improve clinical outcomes. The ESPEN guideline on nutrition in dementia likewise recommends that tube feeding should not be started in severe dementia, and that artificial nutrition is not recommended in the terminal stage. This conclusion rests on observational evidence. It does not apply if the patient has early to moderate dementia, or if the swallowing disorder may be reversible, and such patients should be assessed separately. Our team goes through the pros and cons honestly with the family and discusses comfort-focused care, so that the family can make an informed decision, and we do not recommend tube feeding without good reason.
After a long period without normal eating, can tube feeding start at the full amount straight away?
Absolutely not. Patients who have fasted for a long time or are severely malnourished are prone to refeeding syndrome when feeding is restarted. Its biochemical hallmark is a low blood phosphate level, and in severe cases it can cause heart rhythm problems. Our nurses and team first assess the risk against the NICE high-risk criteria and start feeding slowly at a low amount. They monitor electrolytes such as phosphate, potassium and magnesium closely, and increase the amount step by step once the results are stable. Feeding is never started at full speed as soon as the tube is in.

Would you like a registered nurse in Hong Kong to visit and handle nasogastric tube or gastrostomy feeding safely, with prevention of aspiration and blockage? Message us on WhatsApp to find out about the service and get a quote straight away (5473 6204).

WhatsApp for a free enquiry and quote

Disclaimer: This article is general health information and is not professional medical advice. If you have any health concerns, please consult a qualified healthcare professional.

References

  1. National Institute for Health and Care Excellence (NICE). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline CG32 (2006; updated 2017), rec 1.7.17. nice.org.uk
  2. Boullata, J. I., Carrera, A. L., Harvey, L., et al. (2017). ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr, 41(1), 15–103. PubMed
  3. Bischoff, S. C., Austin, P., Boeykens, K., et al. (2020). ESPEN guideline on home enteral nutrition. Clin Nutr, 39(1), 5–22. PubMed
  4. Volkert, D., Chourdakis, M., Faxén-Irving, G., et al. (2015). ESPEN guidelines on nutrition in dementia. Clin Nutr, 34(6), 1052–1073. PubMed
  5. Drakulovic, M. B., Torres, A., Bauer, T. T., et al. (1999). Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet, 354(9193), 1851–1858. PubMed
  6. Boeykens, K., Duysburgh, I., & Verlinden, W. (2022). Prevention and management of minor complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol, 9(1), e000975. PubMed
  7. Blumenstein, I., Shastri, Y. M., & Stein, J. (2014). Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol, 20(26), 8505–8524. PubMed
  8. Sampson, E. L., Candy, B., & Jones, L. (2009). Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev, (2), CD007209. PubMed
  9. Dziewas, R., Warnecke, T., Hamacher, C., et al. (2008). Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurol, 8, 28. PubMed
  10. Mehanna, H. M., Moledina, J., & Travis, J. (2008). Refeeding syndrome: what it is, and how to prevent and treat it. BMJ, 336(7659), 1495–1498. PubMed
  11. Fan, E. M. P., Tan, S. B., & Ang, S. Y. (2017). Nasogastric tube placement confirmation: where we are and where we should be heading. Proc Singap Healthc, 26(3), 189–195. DOI