Accuracy of biochemical markers for predicting nasogastric tube placement in adults - A systematic review of diagnostic studies

Fernandez, Ritin S, Chau, Janita Pak-Chun, Thompson, David R, Griffiths, Rhonda and Lo, Hoi-Shan (2010) Accuracy of biochemical markers for predicting nasogastric tube placement in adults - A systematic review of diagnostic studies. International Journal of Nursing Studies, 47 8: 1037-1046. doi:10.1016/j.ijnurstu.2010.03.015

Author Fernandez, Ritin S
Chau, Janita Pak-Chun
Thompson, David R
Griffiths, Rhonda
Lo, Hoi-Shan
Title Accuracy of biochemical markers for predicting nasogastric tube placement in adults - A systematic review of diagnostic studies
Journal name International Journal of Nursing Studies   Check publisher's open access policy
ISSN 0020-7489
Publication date 2010-08
Year available 2010
Sub-type Critical review of research, literature review, critical commentary
DOI 10.1016/j.ijnurstu.2010.03.015
Volume 47
Issue 8
Start page 1037
End page 1046
Total pages 10
Editor Mary Fitzgerald
Sue Holmes
Ian Norman
Place of publication Bromley, United Kingdom
Publisher Elsevier
Collection year 2011
Language eng
Subject 110307 Gastroenterology and Hepatology
920203 Diagnostic Methods
Formatted abstract
The objective of this study was to investigate the diagnostic performance of
biochemical tests used to determine placement of nasogastric (NG) tubes after insertion in adults.

A systematic review of diagnostic studies was undertaken.

Data sources
A literature search of the bibliographic databases and the World Wide Web was performed to locate original diagnostic studies in English or Chinese on biochemical markers for detecting NG tube location.

Review methods
Studies in which one or more different tests were evaluated with a
reference standard, and diagnostic values were reported or could be calculated were
included. Two reviewers independently checked all abstracts and full text studies for
inclusion criteria. Included studies were assessed for their quality using the QUADAS tool. Study features and diagnostic values were extracted from the included studies.


Of the 10 studies included in this review, seven investigated the diagnostic
accuracy of pH, one investigated the diagnostic accuracy of pH and bilirubin respectively, two a combination of pH and bilirubin and one a combination of pH, pepsin and trypsin levels in identifying NG tube location. All studies used X-rays as the reference standard for comparison. Pooled results demonstrated that a pH of </= 4.0 had the ability to predict only 63% of the tubes located in the stomach. However, a pH value of </= 5.5 to determine gastric placement demonstrated a sensitivity of 0.89 (95% CI 0.82–0.94) and a specificity of 0.87 (95% CI 0.81–0.93). Bilirubin coupled with pH had a high specificity (0.99) which demonstrated the ability of the test to identify misplaced tubes in intestine. However, the ability of the test to correctly identify gastric placement of feeding tubes was relatively low (sensitivity <0.90).

Due to the heterogeneity of the studies and small sample sizes, conclusions about the diagnostic performance of the different tests cannot be drawn. Better designed studies exploring the accuracy of diagnostic tests are needed to improve the diagnostic policy. Until stronger evidence becomes available practice related to the diagnostic tests used within the clinical setting will continue to be dictated by local preferences and cost factors.
Keyword nasogastric tubes
diagnostic accuracy
systematic review
References Bossuyt, P.M., Reitsma, J.B., Bruns, D.E., Gatsonis, C.A., Glasziou, P.P., Irwig, L.M., Lijmer, J.G., Moher, D., Rennie, D., de Vet, H.C., 2003. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. BMJ: British Medical Journal 326 (7379), 41–44 (see comment). Bradley, J.S., Phillips, J.O., Cavanaugh, J.E., Metzler, M.H., 1998. Clinical utility of pH paper versus pH meter in the measurement of critical gastric pH in stress ulcer prophylaxis. Critical Care Medicine 26 (11), 1905–1909. Burns, S.M., Carpenter, R., Truwit, J.D., 2001. Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurements. Critical Care Medicine 29 (5), 936–939. Chen, Y.C., Chou, S.S., Lin, L.H., Wu, L.F., 2006. The effect of intermittent nasogastric feeding on preventing aspiration pneumonia in ventilated critically ill patients. Journal of Nursing Research 14 (3), 167–180. Conner, T.M., Carver, D., 2005. The role of gastric pH testing with smallbore feeding tubes: in the intensive care unit. DCCN: Dimensions of Critical Care Nursing 24 (5), 210–214. Hart, S., 2006. Ionising radiation: promoting safety for patients, visitors and staff. Nursing Standard 20 (47), 47–57 (quiz 58, 60). Howes, D.W., Shelley, E.S., Pickett, W., 2005. Un detecteur colorimetrique de gaz carbonique pour determiner la mise en place endotracheale accidentelle d’un tube d’alimentation.(Colorimetric carbon dioxide detector to determine accidental tracheal feeding tube placement). Canadian Journal of Anesthesia 52 (4), 428–432. Kearns, P.J., Donna, C., 2001. A controlled comparison of traditional feeding tube verification methods to a bedside, electromagnetic technique. JPEN: Journal of Parenteral and Enteral Nutrition 25 (4), 210–215. Kindopp, A.S., Drover, J.W., Heyland, D.K., 2001. La capnographie permet de confirmer la position appropriee de la sonde d’alimentation chez les patients de l’unite des soins intensifs.(Capnography confirms correct feeding tube placement in intensive care unit patients). Canadian Journal of Anesthesia 48 (7), 705–710. Leder, S.B., Suiter, D.M., 2008. Effect of nasogastric tubes on incidence of aspiration. Archives of Physical Medicine and Rehabilitation 89 (4), 648–651. McClave, S.A., 2009. What does it mean to own feeding tubes? Nutrition in Clinical Practice 24 (4), 430–432. Medicines Healthcare products Regulatory Agency (MHRA), 2004. Enteral Feeding Tubes (Nasogastric). Medicines and Healthcare products Regulatory Agency (MHRA), London. Metheny, N., Reed, L., Berglund, B., Wehrle, M.A., 1994. Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Nursing Research 43 (5), 282–287. Metheny, N., Reed, L., Wiersema, L., McSweeney, M., Wehrle, M.A., Clark, J., 1993. Effectiveness of pH measurements in predicting feeding tube placement: an update. Nursing Research 42 (6), 324–331. Metheny, N., Williams, P., Wiersema, L., Wehrle, M.A., Eisenberg, P., McSweeney, M., 1989. Effectiveness of pH measurements in predicting feeding tube placement. Nursing Research 38 (5), 280–285. Metheny, N.A., Schnelker, R., McGinnis, J., Zimmerman, G., Duke, C., Merritt, B., Banotai, M., Oliver, D.A., 2005. Indicators of tubesite during feedings. Journal of Neuroscience Nursing 37 (6), 320–325. Metheny, N.A., Smith, L., Stewart, B.J., 2000. Development of a reliable and valid bedside test for bilirubin and its utility for improving prediction of feeding tube location. Nursing Research 49 (6), 302–309. Metheny, N.A., Spies, M.A., Eisenberg, P., 1988. Measures to test placement of nasoenteral feeding tubes. Western Journal of Nursing Research 10 (4), 367–379. Metheny, N.A., Stewart, B.J., 2002. Testing feeding tube placement during continuous tube feedings. Applied Nursing Research 15 (4), 254–258. Metheny, N.A., Stewart, B.J., Smith, L., Yan, H., Diebold, M., Clouse, R.E., 1999. pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Nursing Research 48 (4), 189–197. Metheny, N.A., Stewart, B.J., Smith, L., Yan, H., Diebold, M., Clouse, R.E., 1997. pH and concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube placement. JPEN: Journal of Parenteral and Enteral Nutrition 21 (5), 279–285. Phang, J.S., Marsh, W.A., Barlows III, T.G., Schwartz, H.I., 2004. Determining feeding tube location by gastric and intestinal pH values. Nutrition in Clinical Practice 19 (6), 640–644. Portney, L.G., Watkins, M.P., 2000. Foundations of Clinical Research: Applications to Practice. Prentice Hall Health, Upper Saddle River. Rakel, B.A., Titler, M., Goode, C., Barry-Walker, J., Budreau, G., Buckwalter, K.C., 1994. Nasogastric and nasointestinal feeding tube placement: an integrative review of research. AACN Clinical Issues in Critical Care Nursing 5 (2) 194–206, 218–199, 223. Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., Haynes, R.B., 2000. Evidence-based Medicine: How to Practice and Teach EBM. Churchill Livingstone, New York. Simel, D.L., Samsa, G.P., Matchar, D.B., 1991. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. Journal of Clinical Epidemiology 44 (8), 763–770. Swiech, K., Lancaster, D.R., Sheehan, R., 1994. Use of a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral feeding tubes. Applied Nursing Research 7 (4), 183–189. Taylor, S.J., Clemente, R., 2005. Confirmation of nasogastric tube position by pH testing. Journal of Human Nutrition and Dietetics 18 (5), 371–375. Tobin, R.W., Gonzales, A.J., Golden, R.N., Brown, M.C., Silverstein, F.E., 2000. Magnetic detection to position human nasogastric tubes. Biomedical Instrumentation & Technology 34 (6), 432–436. Weinberg, L., Skewes, D., 2006. Pneumothorax from intrapleural placement of a nasogastric tube. Anaesthesia and Intensive Care 34 (2), 276–279. Whiting, P., Rutjes, A.W., Reitsma, J.B., Bossuyt, P.M., Kleijnen, J., 2003. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology 3, 25. Wu, P.Y., Kang, T.J., Hui, C.K., Hung, M.H., Sun, W.Z., Chan, W.H., 2006. Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis. Journal of the Formosan Medical Association 105 (1), 80–85. Zamora, J., Abraira, V., Muriel, A., Khan, K., Coomarasamy, A., 2006. Meta- DiSc: a software for meta-analysis of test accuracy data. BMC Medical Research Methodology 6, 31.
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status Non-UQ

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Sub-type: Critical review of research, literature review, critical commentary
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Created: Thu, 29 Jul 2010, 15:22:28 EST by Vicki Percival on behalf of School of Nursing, Midwifery and Social Work