When a family member has had a stroke or surgery, or has a neurological condition, families most often ask: "Does the nasogastric tube have to stay in for life?" In fact most patients do not need to keep the tube permanently. A nasogastric tube (NG tube) is a temporary measure for the acute phase and is not a long-term plan. A speech therapist uses a systematic swallowing assessment to judge when the patient is ready to eat safely by mouth. The decision follows set criteria and procedures backed by research, and is not a matter of waiting to see how things go. This article explains the reasons for placing the tube, the risks of leaving it in long term, the three levels of assessment, the criteria for removal and the staged plan for returning to oral feeding, so that families understand each step.
Why is a nasogastric tube needed?
Clinically, a nasogastric tube is placed when swallowing is impaired, for example after an acute stroke, a head injury, weakness after severe pneumonia or surgery to the head and neck, and the patient cannot temporarily take in enough nutrition and fluid safely by mouth. Its purpose is to maintain calories and medication during the transition period, so that the patient does not become dehydrated or get worse during the acute phase.
A nasogastric tube is a bridge and not the end point. Once an assessment confirms that the patient's swallowing has recovered to a safe range, removing the tube and returning to eating by mouth is the aim of the medical team and also the wish of the patient and family. The focus is therefore never on whether the tube can be removed, but on when and how to remove it safely.
Risks of leaving a nasogastric tube in for a long time
Many families believe that having a tube in is the safest option, but leaving a nasogastric tube in for a long time carries several risks and can slow the recovery of swallowing. Research found that even with a nasogastric tube in place, the rate of pneumonia in patients with acute stroke was still as high as 44%, which shows that a nasogastric tube is not a reliable barrier against aspiration pneumonia (Dziewas 2004).
Effects on the nose and digestive tract
- The tube rubs the inside of the nose over a long time and causes pressure injury and ulcers of the nasal lining
- The tube blocks the drainage of sinus secretions, which makes acute or chronic sinusitis more likely
- Drainage from the Eustachian tube is blocked, which makes middle ear infection more likely
- It irritates the oesophagus and stomach and may cause stomach acid and food to flow back
Infection and lung risks
- Having a nasogastric tube in does not mean the patient cannot get pneumonia, and the patient is still at risk of aspiration pneumonia (Dziewas 2004)
- Secretions from the mouth and throat may run down along the tube and increase the chance of entering the airway
- The patient may pull the tube out, or the tube may move out of place, which is dangerous
- Not eating by mouth for a long time changes the balance of bacteria in the mouth, so pneumonia becomes more likely if the patient inhales saliva
Decline in swallowing function
- Without eating by mouth for a long time, the swallowing muscles weaken from lack of exercise and stimulation
- The patient may feel that the tube feeds them anyway and may be unwilling to practise swallowing
- Without food stimulating the mouth and throat for a long time, the swallowing reflex becomes slower
Effects on mood and quality of life
- The patient cannot sit down to eat with the family, which means less enjoyment and less time together
- Older people with a tube can easily feel low in mood and may even refuse rehabilitation training
- Cleaning the tube, changing the tape and watching that the patient does not pull the tube out every day adds to the carer's burden
Research also shows that stroke patients who depend on nasogastric tube feeding stay longer in hospital, have poorer functional outcomes and have a higher death rate (Schwarz 2018). Assessing as early as possible whether the tube can be removed is therefore a consensus across medical specialties, and is not a hasty step.
The speech therapist's three swallowing assessment methods
The key to deciding whether the tube can be removed is confirming that swallowing is safe. The speech therapist uses three levels of assessment. It starts with basic clinical observation at the bedside and moves up to instrument-based tests as the patient needs, choosing the method that best fits the condition.
- 1Level 1: Clinical Bedside Swallowing AssessmentThe therapist first looks at the patient's alertness, attention and ability to follow instructions, then checks the strength and coordination of the lips, tongue, cheeks, soft palate and throat muscles and tests whether the cough reflex is strong enough. The therapist then gives the patient trial amounts of foods and liquids of different textures (for example 3–5 ml of iced water and pureed food) and observes the swallowing response, looking for signs such as coughing or choking, a wet voice or a drop in blood oxygen saturation. For most patients the bedside assessment is enough to judge whether the tube can be removed.
- 2Level 2: FEES, Flexible Endoscopic Evaluation of SwallowingThis test is done by a speech therapist or an ear, nose and throat doctor. A thin flexible endoscope is passed through the nose into the throat, so that the structure of the throat, vocal cord movement, any food left behind and any food going into the airway can be seen directly before and after the swallow. FEES involves no radiation and can be done at the bedside. It suits patients in whom silent aspiration is suspected but cannot be confirmed by bedside observation alone. A systematic review showed that FEES had higher sensitivity than VFSS for detecting aspiration (0.88) and penetration (0.97) (Giraldo-Cadavid 2017).
- 3Level 3: VFSS, Videofluoroscopic Swallowing StudyThis test is commonly called a swallowing X-ray study. The patient eats food mixed with contrast, and a radiologist and speech therapist watch the whole journey of the food from the mouth through the throat to the entrance of the oesophagus on moving X-ray images. VFSS shows every stage of the swallow in detail and suits more complex cases, but the patient has to be able to go to the radiology department and understand instructions well enough to cooperate with the test.
Conditions for judging whether the tube can be removed
Whether the tube can be removed successfully does not depend on one single indicator. Several conditions have to be met at the same time. The following are the criteria that speech therapists commonly check during a clinical assessment:
- Level of consciousness: the patient stays awake, can concentrate, and understands and carries out simple instructions
- Mouth muscle function: the lips can close fully, the tongue moves freely, and the patient can make a swallowing movement on their own
- Cough reflex: the patient has enough strength to cough, so that anything entering the airway by mistake can be coughed out
- Passes the water swallow test: under supervision, the patient drinks 3–5 ml of iced water with no coughing or choking, no drop in blood oxygen saturation and no wet voice
- Passes staged trial feeding: trial water, pureed food and then soft solid food in order, with no sign of food entering the airway at any stage
- Stamina and sitting posture: the patient has enough stamina to sit upright through a meal and is not so tired that swallowing safety is affected
- Cognition and cooperation: even with a slight decline in cognition, the patient can follow the pace of feeding and does not refuse food or swallow too fast
- Situations in which removal should wait: if the voice becomes wet, there are signs of silent aspiration, or blood oxygen saturation keeps dropping, removal should be postponed
Research found that important predictors of whether a nasogastric tube can be removed include functional status on admission (Barthel Index), the ability to close the lips, the cognitive ability to answer simple questions, and the level of function before the stroke (Lee 2021). Another study found that younger age, clearer improvement in motor function and recovery of language ability were each independent predictors of successful removal at 4 weeks (Li 2023).
Returning to oral feeding in stages according to IDDSI
Passing the assessment and having the tube removed does not mean the patient can go straight back to a regular diet. For safety the patient must return to eating in stages. The International Dysphagia Diet Standardisation Initiative (IDDSI) divides food textures into 8 standard levels (0–7), which gives a clear and objective basis for the progress of feeding.
| IDDSI 0–1 (thin liquids) | This is the starting stage of the assessment. The therapist first gives a trial of 3–5 ml of iced water, and once this is shown to be safe, gradually increases to drinking 30 ml and 60 ml of water in a row. Only when no water goes into the airway during this time can the patient move to the next stage. |
| IDDSI 3–4 (pureed food) | This food has a texture like pudding or smooth pureed meals. When swallowing this kind of food, the throat can sense the position of the food more easily and the risk of it entering the airway is lower, so it suits the start of returning to eating. Exercises such as the effortful swallow are practised at the same time. |
| IDDSI 5–6 (soft, minced food) | This food is like well-cooked vegetables, steamed fish or thick congee, and needs more chewing and coordination in the mouth. Once the patient is shown to eat food at this level safely, a transitional arrangement can be considered, for example eating by mouth during the day and keeping the nasogastric tube at night for extra nutrition. |
| IDDSI 7 (regular diet) | This is the final goal of returning to eating. Depending on the original condition and the speed of recovery of swallowing, some patients take several weeks to several months to eat regular meals again, and some need food of a particular texture for the long term. |
The speed of return to eating differs from person to person. In patients with an acute stroke, swallowing may improve within days to weeks, but after a brainstem stroke or in severe dementia progress may be very slow or may stop. The speech therapist decides when to change the food texture according to the result of each assessment. Family members must not skip the assessment and give the patient food that is harder to swallow on their own, because this can cause aspiration pneumonia.
A nasogastric tube does not fully prevent aspiration pneumonia
Many families think that a nasogastric tube makes everything safe. This is a common misunderstanding. Research has shown clearly that:
- A prospective study found that the pneumonia rate in acute stroke patients fed by nasogastric tube was still as high as 44% (Dziewas 2004)
- A study of 147 patients with swallowing difficulty showed no significant difference in the aspiration severity score with or without a tube (p = .50) (Kim 2018)
- The tube itself becomes a path for oropharyngeal secretions to run down the outside of the tube, which increases the chance of micro-aspiration
- Leaving the tube in for a long time means the patient does not clean the mouth, bacteria build up in the mouth, and the consequences are more serious once aspiration happens
- A systematic swallowing assessment finds silent aspiration, so that the decision to remove the tube rests on evidence and not on guesswork
- Swallowing training (effortful swallow, head lift exercise, EMST) strengthens the swallowing muscles and lowers the risk of aspiration
- Systematic mouth care reduces disease-causing bacteria in the mouth, so that even if a small amount is inhaled, the chance of pneumonia is lower
- Correct feeding posture and technique together with texture modification are a workable safeguard for safe eating
Points for carers helping the patient return to eating at home
Returning to eating successfully depends on carrying the hospital ward's standard of care into every meal at home. Carers do more than feed the patient. They carry out the therapist's plan at the dining table every day and act as the first-line observers.
- Prepare the environment—Before feeding, check that the patient is awake and sitting upright at about 90 degrees. Turn off the television during meals to avoid distraction, and prepare food at the IDDSI level set by the therapist without changing the texture on your own.
- Feeding technique—Give only small mouthfuls each time (about one teaspoon) and feed slowly, and make sure the previous mouthful is fully swallowed before giving the next. During feeding, watch whether the Adam's apple lifts, and watch for coughing, a wet voice or an unusual colour in the face. Do not rush the patient.
- Care after eating—After every meal, clean the patient's mouth straight away (brush the teeth or wipe with a mouth swab) and remove food residue to reduce bacterial growth. Keep the patient sitting upright for 20–30 minutes after the meal before lying down, to prevent food flowing back into the airway.
- Swallowing exercises—Each day, practise the swallowing exercises at home with the patient as taught by the therapist, for example the effortful swallow, head and neck movements or expiratory muscle strength training. The swallowing muscles improve only with regular exercise, and doing the exercises only now and then gives much poorer results.
- Warning signs—After eating, if the patient's voice becomes "wet", there is repeated coughing or choking, blood oxygen saturation drops, or there is an unexplained fever or fast breathing, stop oral feeding at once and contact the speech therapist or doctor for reassessment.
Frequently asked questions
For the full framework of swallowing assessment and for other speech and communication difficulties, see our pages on home speech therapy.
Worried that a family member's nasogastric tube is hard to remove? Our speech therapists can visit your home for a systematic swallowing assessment, judge the timing of tube removal, set an individual staged plan for returning to oral feeding, and demonstrate swallowing exercises that can be continued at home. Message us on WhatsApp for a quick reply, usually within 1 hour.
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