Bedside Ultrasonography-Guided Nasogastric Tube Placement: A Narrative Review

1. Introduction

Patient safety remains a global concern, with millions of adverse events each year leading to preventable harm and deaths [1]. Among these, the blind insertion of a nasogastric tube (NGT) is a common nursing procedure associated with potentially life-threatening complications, including aspiration and pneumothorax [2,3]. Misplacement rates vary from 0.3% to 8% [4], and in the United Kingdom, undetected malposition is classified as a “never event” because of its serious consequences [5].

Traditional bedside verification methods, such as auscultation, have long been used but are now recognized as unreliable. Guidelines caution against this practice [6], yet studies show that many nurses continue to rely on it, often unaware of its limitations [7]. Radiography remains the gold standard, providing accurate confirmation of tube position [8]. However, routine use is not without challenges: repeated exposure to ionizing radiation, delays in feeding or medication administration, and additional costs to health systems [9,10].

Ultrasonography has emerged as a promising alternative. It allows real-time visualization of the tube during or after insertion, avoids radiation, and can reduce delays in care [11,12]. For nurses, point-of-care ultrasonography offers the possibility of immediate bedside confirmation, supporting safer and more timely clinical decisions [13,14]. Its main limitation is the need for specific training and standardized protocols, but growing evidence supports its feasibility in clinical practice.

Ongoing education and competency in NGT insertion and verification are essential to prevent adverse events and to ensure evidence-based nursing care [15,16]. In this context, ultrasonography represents an important opportunity to enhance safety and autonomy in nursing practice.

Despite growing interest in point-of-care ultrasonography, there is currently no comprehensive review mapping the procedures employed to guide NGT insertion in clinical practice. By synthesizing available evidence, this study addresses a critical gap in the literature. Its findings can inform nursing education, support the development of standardized protocols, and guide the safe integration of ultrasonography into routine care. In doing so, it contributes to advancing nursing knowledge, strengthening patient safety, and enhancing the quality of enteral care delivery.

The aim of this review was to explore the procedures used for bedside ultrasonography-guided nasogastric tube insertion in adult patients.

2. Materials and Methods

This narrative review was guided by Jones’s review process [17], which involves several key steps: (1) defining the research question or topic to be explored; (2) consulting a biomedical librarian for assistance with database navigation; (3) identifying relevant databases; (4) conducting searches using keywords and synonyms, combined with Boolean operators; (5) narrowing the topic to establish a framework for the review; (6) setting criteria for study selection; (7) organizing publications into thematic categories; (8) noting the research methods employed (quantitative, qualitative, or mixed); (9) synthesizing findings by comparing results, identifying patterns, and analyzing consistencies or contradictions; and (10) drawing conclusions by summarizing current knowledge, highlighting inconsistencies and gaps, and suggesting directions for future research.

This narrative review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) [18].

The research question guiding this review was: What procedures are used to insert and confirm a nasogastric tube with the guidance of bedside ultrasonography in adult patients?

The search was conducted across major health science databases, including CINAHL (via EBSCOhost), Embase (via Elsevier), LILACS (via BVS), PubMed via National Institutes of Medicine), and Scopus (via Elsevier). Additional sources consulted included gray literature (Google Scholar and ProQuest Dissertation & Thesis Global), and both national and international guidelines. No restrictions were applied regarding publication date or language.

Eligible sources included primary studies and clinical guidelines that focused on the procedures used for bedside ultrasonography-guided nasogastric tube insertion in adult patients (≥18 years). Exclusion criteria included: studies that did not address the research question; studies that investigated the use of PoCUS solely for gastric residual volume (GRV) assessment; studies involving children or animals; reviews, abstracts, letters, expert opinion; study protocols, trial registrations; studies involving nasoenteric tubes or long-term feeding tubes; studies published in languages that do not use the Latin-Roman alphabet—modern Latin alphabet.

The controlled vocabulary terms available in the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) were implemented and keywords were used with the Boolean operators AND and OR. Therefore, the search strategy carried out in June 2024 and updated on August 2025 was: (Ultrasonography OR “Point of Care” OR “Point-of-Care” OR POCUS OR “Point-of-care ultrasonography” OR “Point of care ultrasonography” OR “Point-Of-Care Ultrasound” OR “Point Of Care Ultrasound” OR Ultrasso*) AND (“Intubation, Gastrointestinal” OR “Nasogastric Intubation” OR “Nasogastric Tube” OR “Nasogastric Feeding Tube” OR “Nasogastric Tube Placement” OR “Nasogastric Tube insertion”) AND (Adult) (Table S1).

For the purposes of this narrative review, PoCUS was defined as the use of portable ultrasound performed directly by a healthcare provider at the point of care, for real-time diagnostic or clinical monitoring purposes [19]. Nasogastric tube was defined as a short-term feeding device, intended for use up to 4–6 weeks, inserted through the nose and positioned in the stomach [20].

Following the search strategy, all retrieved articles were exported to EndNote^® for duplicate removal. The remaining articles were then uploaded to the Rayyan^® platform, where two reviewers independently applied the inclusion and exclusion criteria in two stages: initial screening by title and abstract, followed by full-text review. Discrepancies were resolved through consensus, with a third reviewer consulted when necessary.

A descriptive synthesis was undertaken, with results organized thematically using the I-AIM framework (Indication, Acquisition, Interpretation, and decision-Making) [21]. To enhance interpretation, narrative and tabular presentations were complemented with visual tools (infographics and schematic figures) that highlighted procedural variations, recurring patterns, and gaps in practice.

Generative artificial intelligence (ChatGPT, OpenAI, San Francisco, CA, USA) was used in this study to support English language revision for clarity and proficiency and to assist in the conceptual organization and graphical design of Figure 6. The AI tool was not used to generate original data, perform data analysis, interpret results, or draw scientific conclusions. All content was critically reviewed, edited, and validated by the authors, who take full responsibility for the integrity and accuracy of the manuscript.

3. Results

The database search identified 3,815 records, with two additional sources retrieved through other means. After removing duplicates and applying eligibility criteria, 29 studies were included (Figure 1).

Studies were geographically diverse, most conducted in China [22,23,24,25], Brazil [12,26,27], and France [28,29,30,31], with one binational investigation from Italy and Switzerland [32] (Figure 2).

Sample sizes ranged from single-case reports to multicenter cohorts involving over 500 patients, reflecting the heterogeneity of the available evidence (Table 1).

Legend: BUS: Bedside Ultrasound; EC: Enteral Catheter; ED: Emergency Department; ICU: Intensive Care Unit; LMAs: Laryngeal Mask Airways; NGT: Nasogastric Tube; US: Ultrasound.

3.1. Clinical Settings

Most investigations were conducted in intensive care units (ICUs), followed by emergency departments and, less frequently, other clinical environments such as isolation wards or prehospital contexts (Figure 3).

This distribution reflects the procedure’s relevance in critically ill or unstable patients, but also highlights the need for validation in general wards where nurses perform the majority of NGT insertions.

3.2. Indication (I)

Across studies, ultrasound was primarily employed for confirmation of NGT placement in the context of enteral nutrition [12,23,24,25,31,32,34,36,37,38,39,40,41,44,45,46] and gastric decompression [23,24,28,29,30,32,33,38,39,40,42,43,45,46,47,48]. Drug administration [4,32,40,42,43,46], lavage [32,42,43], and diagnostic monitoring [32,38,43] were less frequently cited. This suggests that nutritional safety is the dominant clinical driver for using ultrasound in this domain.

3.3. Acquisition (A)

Protocols varied considerably across studies, underscoring a lack of standardization. Most examinations were performed in the supine position [4,12,22,23,24,25,26,27,29,30,31,32,33,34,35,36,37,38,39,40,43,45,46,47,48], employing convex probes [23,24,26,27,28,29,31,32,33,34,35,36,37,38,39,42,43,44,45,46,47] for abdominal windows and linear probes for cervical windows [4,22,23,36,38,40,43,46,47,49] (Figure 3). The epigastric/subxiphoid region and cervical esophagus were the most frequent acoustic windows [22,24,25,28,33,36,38,42,43,46,47,48] (Figure 4A and 4B), with the gastric antrum often described as the key sonoanatomical landmark (Figure 4B).

Details regarding windows and imaging planes were inconsistently reported. These variations are summarized in Figure 4, which consolidates technical specifications reported across studies.

3.4. Interpretation (I)

Correct NGT placement was most commonly interpreted through direct visualization of the tube as a hyperechoic structure within the stomach [12,23,24,25,32,33,36,39,42,43,44,45] (Figure 3B). Indirect techniques, such as dynamic “fogging” after air injection [22,23,28,33,36,37,39,46,47], were widely reported, while saline injection and color Doppler were less common [23,34,45]. Comparator tests included chest radiography, gastric aspirate pH, and auscultation, with radiography remaining the reference standard in over 90% of studies.

3.5. Decision-Making

Despite its feasibility as an immediate bedside tool, ultrasound rarely replaced radiography in clinical decision-making. In most reports, feeding or medication administration was withheld until radiographic confirmation. Exceptions included selected studies where ultrasound was used as the sole confirmation method when other techniques were impractical, such as in COVID-19 isolation wards [24]. Overall, ultrasound contributed to timelier assessments but did not supplant radiography as the gold standard for clinical decisions.

Figure 5 summarizes key recommendations, emphasizing standardized protocols, structured nurse training, and the need for multicenter trials to strengthen the evidence base

4. Discussion

This narrative review synthesizes evidence on ultrasonography-guided NGT placement using the I-AIM framework [21], highlighting both opportunities and challenges for nursing practice. The findings confirm that ultrasonography is a safe, non-invasive, and rapid bedside method [23], but its use remains inconsistent [50], with radiography still the gold standard [12,38].

For nurses, who are often responsible for NGT insertion, the ability to perform ultrasound verification has transformative potential. Studies show that, after structured training, nurses achieve diagnostic accuracy comparable to physicians, even in intensive care and emergency settings [22,27,37]. This supports international calls to expand nursing autonomy in PoCUS [51,52] and integrate it into clinical education [53,54]. By reducing reliance on chest X-rays, ultrasound can shorten delays in initiating feeding [55], avoid unnecessary transfers [12], and address the limitations of auscultation, a method still used despite guideline warnings of poor reliability [56].

The evidence base is dominated by observational, single-center studies with small samples (Figure 3). Although randomized trials and multicenter cohorts provide encouraging results, heterogeneity in protocols—ranging from probe choice to imaging windows and interpretation criteria—prevents definition of a standardized best practice and explains why radiography remains prioritized for clinical decisions. Feasibility also varies by patient group: visualization is often poorer in individuals with obesity, excessive gastric gas, or altered anatomy [57], and some protocols require two operators [32,49], limiting scalability.

Additional study-specific limitations further constrain applicability. Several investigations underreported key technical details including the type of probe used [12,25,30], probe frequency [12,24,25,30,42], and patient position [42,44]. Moreover, only three studies specified the depth used for ultrasound confirmation of nasogastric tube placement [26,31,45], reducing reproducibility. Populations with obesity [26,35], tracheostomies [26,33], or recent abdominal surgery [26,33]—common in clinical practice—were frequently excluded. Nurse-led research remains underrepresented [12,22,23,25,27,32,39,43,46,49], with most studies conducted by physicians, and outcomes were largely restricted to diagnostic accuracy [23,34,36,40,43,45,46] rather than patient safety, timeliness, or cost-effectiveness.

These gaps indicate clear priorities for future research. Large multicenter trials should validate accuracy and safety across diverse settings, while standardized protocols must be established for patient positioning, probe selection, and adjunctive techniques such as dynamic fogging or Doppler. Studies should evaluate nurse-performed ultrasonography more explicitly, testing training programs, competency frameworks, and simulation-based education. Inclusion of complex patient groups will improve generalizability, and research should extend to clinical and economic outcomes, such as reduced delays, decreased radiation exposure, adverse event prevention, and cost savings. Emerging technologies, including artificial intelligence–assisted interpretation and digital decision support, also warrant investigation.

The implications for nursing practice are substantial. By adopting ultrasonography, nurses can move away from unsafe methods and reduce dependence on radiography, promoting faster, safer, and more patient-centered care. Integrating this technique into nursing workflows enhances professional autonomy and positions nurses as key actors in advancing bedside diagnostics. To achieve this safely, standardized training, competency models, and evidence-based guidelines must be developed and rigorously evaluated.

5. Conclusions

This narrative review demonstrates that ultrasonography is a safe, rapid, and radiation-free method for verifying NGT placement, with clear potential to complement or, in selected contexts, replace radiography. Evidence synthesized through the I-AIM framework shows that ultrasound enables real-time confirmation at the bedside, reduces reliance on unreliable methods such as auscultation, and minimizes delays that compromise timely initiation of enteral nutrition. Although the current evidence base is dominated by small observational studies with methodological heterogeneity, findings consistently highlight the feasibility of nurse-performed ultrasonography, with diagnostic accuracy comparable to physicians when structured training is provided.

For nursing practice, these results underscore the opportunity to integrate ultrasonography into everyday workflows, strengthening professional autonomy and enhancing the safety of one of the most frequent and high-risk procedures in hospital care. To achieve this, standardized protocols, competency frameworks, and inclusion of ultrasound training in nursing curricula are essential.

Future research should focus on robust multicenter trials, standardization of acquisition and interpretation techniques, evaluation of nurse-led implementation, and assessment of clinical and economic outcomes beyond diagnostic accuracy. By addressing these gaps, ultrasonography can be fully established as a reliable, evidence-based tool that empowers nurses, improves patient safety, and advances the quality of enteral care delivery.