International Journal of Nursing Studies 51 (2014) 14271433

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Reliability of pH measurement and the auscultatory method

to conrm the position of a nasogastric tube
Kurt Boeykens a,*, Els Steeman b, Ivo Duysburgh a
a
b

Nutrition Support Team, AZ Nikolaas, Sint-Niklaas, Belgium

Center for Health Services and Nursing Research, Leuven University, Belgium

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 27 October 2013
Received in revised form 14 March 2014
Accepted 17 March 2014

Background: Blind placement of a nasogastric feeding tube is a common nursing

procedure. Conrmation of the correct position in the stomach is warranted to avoid
serious complications such as misplacement in the lung. Testing pH of aspirate from a tube
is one of the techniques to conrm the tip position. The purpose of this study was to
evaluate the auscultatory method and pH measurement with a pH cut-off point of 5.5 after
tube insertion and to compare this with the gold standard: an abdominal X-ray.
Also the feasibility of the pH method was evaluated.
Materials and methods: Large prospective observational study in a general hospital. In
adult hospitalised patients, the positioning of 331 feeding tubes was tested using two
different methods to predict tube position in the stomach.
Results: In 98.9% (n = 178) of aspirate samples with a pH  5.5, the tube was located in the
stomach. If an aspirate could be obtained, the results of pH measurements showed a
sensitivity of 78.4% and a specicity of 85.7%. Obtaining aspirate initially after placement
was possible in approximately half of cases but after taking additional measures (including
administration of air into the tube, side-positioning of the patient and re-aspiration after
one hour) this increased to 81.6%. The sensitivity of the auscultatory method was 79%
while the specicity was 61%.
Conclusions: A pH of  5.5 from tube aspirate is adequate to check the position of the tube
in the stomach. Additional measures improve the success to obtain an aspirate from the
tube. The auscultatory method is unreliable.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Nasogastric tube
pH measurement
Auscultatory method
pH
Nasogastric feeding
X-ray

What is already known about the topic?

 There are multiple reports of death and harm caused by
misplacement of nasogastric feeding tubes.

 pH testing should be used as a rst line bedside method

but the auscultatory method, although proven unreliable, is still widely practiced.

What this paper adds

* Corresponding author at: AZ Nikolaas, Moerlandstraat 1, 9100 SintNiklaas, Belgium. Tel.: +32 3 7602745.
E-mail addresses: kurt.boeykens@aznikolaas.be,
kurtboeykens@telenet.be (K. Boeykens), els.steeman@aznikolaas.be
(E. Steeman), ivo.duysburgh@aznikolaas.be (I. Duysburgh).
http://dx.doi.org/10.1016/j.ijnurstu.2014.03.004
0020-7489/ 2014 Elsevier Ltd. All rights reserved.

 Aspirates from initially placed nasogastric tubes with a

pH of  5.5 are reliable to differentiate if the tube is in or
outside the stomach but this does not completely rule
out oesophageal placement.

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K. Boeykens et al. / International Journal of Nursing Studies 51 (2014) 14271433

 Additional measures can be implemented to increase the

success obtaining an aspirate from the nasogastric tube
after initial placement.
1. Introduction
Nasogastric (NG) intubation is a common procedure in
those patients who are not or not sufciently able to
swallow. The NG tube is used for the administration of
(additional) tube feeding, uids and medications. Even
though blind intubation is considered relatively harmless
and safe, incorrect positioning can have serious or even
lethal consequences (Metheny et al., 1990a,b; National
Patient Safety Agency (NPSA), 2011). The auscultation
method is often used to determine correct positioning of
the nasogastric tube (Metheny and Stewart, 2002; Simons
and Abdallah, 2012). Numerous studies indicate however
that this method may lead to false interpretations
(Metheny et al., 1990a,b; Neumann et al., 1995).
An abdominal X-ray remains the golden standard but Xray interpretation has to be performed by a competent
person and if there is any doubt of misinterpretation, the
advice of a radiologist should be sought. The NPSA reported
45 incidents of X-ray misinterpretation, 12 of which
resulted in the death of the patient. In their patient safety
alert they recommend that an X-ray should be used as a
second line test when no aspirate could be obtained or pH
indicator paper has failed to conrm the position of the
nasogastric tube. Other disadvantages are the costs, a lack
of or suboptimal radio-opacity in some tubes, sometimes
bad quality of X-ray, radiation exposure and more difcult
access for outpatients (requiring transportation) (Law,
2012; NPSA, 2011; Phang et al., 2004).
Testing the pH by aspirating a small amount of tube
secretions is a suitable alternative to determine correct
positioning (Gilbertson et al., 2011; Phang et al., 2004;
Taylor and Clemente, 2005). This is based on the fact that
pH testing can help to distinguish gastric placement (pH
usually range from 1 to 5) from respiratory, pleural or
intestinal placement (pH usually 6 or higher). At rst
glance, this seems to be an easy and reliable method but
there are some limitations to this method: the presence of
antacid medication and/or enteral feeding can raise gastric
pH (Lanas et al., 1995; Metheny and Stewart, 2002) and
integrating pH testing in care procedures is not always
obvious (Simons and Abdallah, 2012). The pH method is
not useful to detect placement in the oesophagus because
of gastric reux (more acid pH) or swallowed saliva (more
alkaline pH) and cannot be used to differentiate between
respiratory and intestinal placement (Metheny et al., 1993,
1994). Also when the NG tube is correctly placed in the
stomach, the pH method does not provide information on
the tip of the tube which can be in the fundus or near the
cardiac sphincter and this potentially could contribute to
complications associated with feeding.
Using a low (pH  4) cut-off level to conrm gastric
positioning is often identied as clinically impractical
because of poor sensitivity (Kearns and Donna, 2001;
Metheny and Titler, 2001; Metheny et al., 1994) but on the
other hand the risk of feeding in the oesophagus is almost
excluded (Hanna et al., 2010).

The NPSA (NPSA, 2011) and a National Dutch guideline

(V&VN, 2011) recommend (mostly based on consensus or
expert opinion) a pH between 1 and 5.5 to conrm correct
gastric positioning of the tube while a practise alert by the
American Association of Critical Care Nurses (AACN, 2010)
recommends an X-ray every time a new tube is inserted
prior to the administration of feeds, medications or uids.
However, large studies investigating reliability of
bedside pH measurement with CE (European Conformity)
marked pH paper with a cut-off point of  5.5, to
determine if the tube is located in or outside the stomach,
are lacking. The primary study objective was to test the
reliability of pH measurement (with a cut-off point
of  5.5, with or without antacids) and simultaneously
the auscultatory method against radiological verication.
A secondary study objective was to test the feasibility
(practicability) of the bedside pH-measurement.
2. Materials and methods
2.1. Patients
This prospective observational study was conducted
from September 2009 until the end of December 2012 at
the AZ Nikolaas Hospital in Sint-Niklaas (Belgium).
Preliminary ndings from this study were earlier published by Boeykens and Steeman (2012) in a Dutch
scientic nursing journal. A total of 331 nasogastric tubes
were placed in 314 patients (18 years) who had been
admitted to hospital and had no medical contra-indication
for a NG feeding tube. All nasogastric tubes were ordered
by the attending physician (for full or additional tube
feeding, water and/or medications) and placed and
controlled for positioning by, or placed and controlled
under supervision of the same advanced practice nurse.
The study was approved by the Ethical Committee of the
AZ Nikolaas Hospital in Sint Niklaas and all patients or their
legal representatives signed an informed consent.
2.2. Materials and protocol
All placed nasogastric tubes were single-port feeding
tubes made from radio-opaque polyurethane (PUR) 10 or
14 French (FR) with a guide wire (Flocare1, Nutricia). The
tubes were placed in conscious, somnolent or comatose
patients. Only those conscious patients who exhibited no
swallowing problems were asked to drink a sip of water
through a straw during placement of the tube to promote
the passing of the tube from the throat into the esophagus.
The length of tube to be passed was initially estimated
using the NEX-method (nose-earlobe-xiphoid). In this
method the distance between the nose and the earlobe and
the earlobe to the bottom of the xiphisternum is measured.
This insertion-length predictor remains the most commonly used method in clinical practise (NPSA, 2011; Ellett,
2012). After placement of the nasogastric tube the guide
wire was removed to facilitate aspiration. The nasogastric
tube was then xed to the nose. For aspiration a large
syringe (60 ml) with a conical end was used. Slow
aspiration using a large syringe, as opposed to a smaller
syringe, usually prevents the adhesion of the gastric

K. Boeykens et al. / International Journal of Nursing Studies 51 (2014) 14271433

signicance level of P < 0.05 was used. A statistical

programme (IBM, SPSS Statistics version 211) was used
to analyse the results.

mucosa to the tip of the nasogastric tube (Burnham, 2000).

In those cases where no aspirate could initially be
obtained, slow aspiration was repeated several times. If
this was successful, a few drops of the aspirate were placed
on a pH testing strip intended to test human gastric
aspirate. (Merck1 pH indicator strip/pH 2.09.0,) with a
colour 0.5 pH units scale. When the pH was found to
be  5.5, it was assumed that the end of the nasogastric
tube was correctly situated in the stomach. When the
results showed a pH  6.0, the characteristics (colour and
consistency) of the aspirate were registered. Subsequently,
2030 ml of air was administered through the tube and a
stethoscope was used to listen for a whooshing sound
below the diaphragm. If a whooshing sound could be
heard, a subjective distinction was made between a loud
whooshing sound, some degree of whooshing sounds
(inconclusive) and no whooshing sound (see Fig. 1).
Another important aspect of the data collection was the
presence or absence (no intake in the previous 4 h) of
proton pump inhibitors (PPIs) or H2 receptor antagonists.
After including a rst group of patients (n = 59) we
concluded that it also would be of value to register if they
had a meal or drinks before placement. Fasting was dened
as no intake of solid food 4 h before intubation, 2 h for
liquids and one hour for enteral medications.

3. Results
3.1. Study population
The study included 331 intubations in 314 patients. An
X-ray was obtained in 301 intubations. A pH measurement
was performed in 270 intubations. The average age of the
participants was 69 years (range, 1894) (see Table 1).
3.2. Obtaining an aspirate from the nasogastric tube
In 48.6% (n = 161) intubations an aspirate could be
obtained immediately. The additional measures used
(including the aspiration of air into the tube, sidepositioning of the patient and re-aspiration after an hour)
increased the success rate by 33.5% leading to an aspirate
being obtained in 81.6% (n = 270) of intubations (see Fig. 2).
3.3. Use of gastric antacids
The majority of patients were taking antacids (H2
receptor antagonists or proton pump inhibitors). Especially in intensive care, nephrology and surgery the use of
these drugs was high, respectively 84.1% (n = 89), 80%
(n = 12) and 78.8% (n = 26). Without the use of antacids the
average pH was found to be 3.5 (SD: 1.8), with use of
antacids the average was 4.6 (SD: 1.7) (p < 0.05). Analysis
showed that if an aspirate could be obtained (in 270 out of

2.3. Statistical analysis

Descriptive statistics were used to express means,
standard deviations, percentages and frequencies. The Chisquared test was used to compare discontinuous variables
and the MannWhitney U for continuous variables. A

Prescription for nasogastric tube intubation

Estimation of internal tube length with the NEX-method

Intubation

Obtaining aspirate from the tube?

Yes

No

Take additional measures

pH measurement with strip

Yes

pH 5,5

pH 6

Administering (repeated) air

No

Auscultatory method

Yes

Yes

X-ray control
No

1429

Turn patient on the left side

No

Wait for minimum 1 hour

Fig. 1. Protocol for determining the tip position of the tube.

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Table 1
Characteristics of study patients.
Number of patients
n

Total

314

100

Sex
Male

186

59.2

Medical discipline
Neurology
Intensive care
Geriatrics
Oncology
Pulmonary diseases
Nephrology
Surgery
Other
Gastric antacids

74
76
10
46
29
15
33
31
213

23.6
24.2
3.2
14.6
9.2
4.8
10.5
9.9
67.8

Consciousness
Comatose
Somnolent
Conscious

57
80
177

18.2
25.5
56.3

Charriere feeding tube

FR 10
FR 14
Swallowing dysfunction
X-ray

221
110
173
301

66.8
33.2
55.1
90.9

331 intubations), 77% (n = 208) of all pH results were  5.5.

In pH measurements without antacids 85.4% (n = 76)
was  5.5 as opposed to 72.9% (n = 132) with antacids
(P = 0.062). When pH was  6 there were 22% more false
negative results (tube located in the stomach) in the group
on antacids. The pH results with or without antacids are
illustrated in Fig. 3.
3.4. Fasting state
In a subgroup of 213 intubations where an aspirate
could be obtained, the effect of fasting on the pH cut-off
point was calculated. In fasting patients, 78.7% (n = 63) of

pH measurements was  5.5 as opposed to 76.6% (n = 102)

in patients without fasting. The possibility to obtain an
aspirate was 18.2% higher (95.3% versus 77.1%) in patients
who were not fasting (P < 0.01).
3.5. pH measurement versus radiological control
It was possible to obtain an aspirate from the
nasogastric tube in 270 of 331 intubations. However, as
previously indicated in the research method, a number of
patients (n = 29) had pulled out their NG tube or were not
deemed t enough to be transferred to radiology. That left
a total of 241 intubations in which the aspirate could be
compared to the X-ray results. One hundred eighty of these
pH measurements showed a pH  5.5. With this cut-off
point, the probability that the NG tube had been correctly
placed in the stomach was 98.9% (positive predictive
value). Two measurements showed a false positive test
(pH  5.5) with placement in the distal oesophagus (two
different intubations on the same patient on antacids). The
low pH measured in this patient was the result of the
existence of a large hiatal hernia (see Table 2). With a
pH  6, the probability that the tip of the NG tube was
located outside the stomach was 19.7% (negative predictive value). The results of pH measurements where an
aspirate could be obtained, showed a sensitivity (the
probability that pH results from aspirates correctly
identied that the NG tube had been placed in the
stomach) of 78.4% with a specicity (the probability that
pH results from aspirates correctly identied that the NG
tube was not in the stomach) of 84.6%. When you take into
account all attempts of aspiration (including those without
obtaining an aspirate) the sensitivity was 66% and the
specicity 93%.
With a pH  6 from a NG tube that was correctly
positioned in the stomach (n = 49), the characteristics of
the aspirate were documented to aid explanation. Following aspects were observed: off-white/containing sputum
(n = 16), dark green (n = 10), food-containing (n = 9), dark
brown (n = 7), yellow (n = 3), colourless (n = 3), grassy
green (n = 1).

Fig. 2. Obtaining an aspirate from the tube.

K. Boeykens et al. / International Journal of Nursing Studies 51 (2014) 14271433

1431

Fig. 3. pH-measurements (n = 272) with and without antacids.

case of hearing some degree of whooshing sounds, seven

tubes were located outside the stomach.

3.6. Auscultation versus radiological control

For all X-ray conrmed NG tubes (n = 301) the
auscultation method could be applied and compared
(see Table 2). After a loud whooshing sound, the
probability that the NG tube had been correctly placed
in the stomach was 94.7% (positive predictive value). The
probability that the absence or some degree of whooshing
sounds indicated that the NG tube had been positioned
outside the stomach (negative predictive value) was 25%.
The results of the auscultation method indicate a
sensitivity (the probability that the test correctly determines the gastric position of the NG tube) of 79% and a
specicity (the probability that the test correctly indicates
when the NG tube is placed outside the stomach) of 61%. In

3.7. Case examples

Two cases of misplacement in the lungs (both on the
same patient) were associated with an inconclusive
auscultation and an inability to obtain an aspirate from
the tube. The patient in question appeared perfectly lucid
and showed no signs or symptoms of respiratory distress
or coughing. Without X-ray visualisation this could
potentially have led to infusion of formula into the
patients lungs.
Another case involved a NG tube being placed in a
comatose patient. Upon auscultation, the assisting nurse

Table 2
Radiological position of the tubes and results of pH-measurement and the auscultatory method.
Stomach

Oesophagus

Lung

Duodenum

Throat

Total

pH  5.5

n=
%

178
(98.9)

2
(1.1)

0
(0)

0
(0)

0
(0)

180

pH  6

n=
%

49
(79)

2
(3.2)

2
(3.2)

7
(11.3)

1
(1.6)

61

No pH

n=
%

44
(73.3)

9
(15)

1
(1.7)

1
(1.7)

5
(8.3)

60

Loud
Whooshing sound

n=
%

213
(94.2)

5
(2.2)

0
(0)

6
(2.7)

1
(4)

225

Inconclusive
Whooshing sound

n=
%

26
(78.8)

3
(9.1)

2
(6.1)

1
(3)

1
(3)

33

No
Whooshing sound

n=
%

31
(72.1)

6
(14)

1
(2.3)

1
(2.3)

4
(9.3)

43

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K. Boeykens et al. / International Journal of Nursing Studies 51 (2014) 14271433

was certain that the NG tube had been placed correctly.

The advanced practice nurse disagreed. It was not possible
to obtain an aspirate. An X-ray showed the NG tube to be
completely curled up in the patients throat.
4. Discussion
Several studies have been published in the literature
investigating the diagnostic accuracy of different pH cutoff points. The majority of these studies used pH
measurement (alone or in combination with other
biochemical markers) to differentiate between gastric
and intestinal placement to conrm tube position. There
are a few studies where pH measurement was used to
differentiate if the tube was located in or outside the
stomach. In a study where a cut-off point of  4 was used,
besides three other methods for tip localisation (n = 134;
365 assessments), only 56% of the NG tubes were correctly
determined to be in the stomach. The sensitivity of the pH
test to identify misplaced tubes was 82%, the specicity
was 55% and this was due to the fact that in only one out of
eleven misplaced tubes (where the tip of the tube was
above the diaphragm) an aspirate could be obtained
(Kearns and Donna, 2001). In a second study in 280
intensive care patients, at pH < 4, the sensitivity was 49%
and the specicity 74%. Using a higher cut- off point of
pH < 5, a more recent smaller study in 44 intensive care
patients showed 90.4% of the NG tubes to be correctly
identied in the stomach (Turgay and Khorshid, 2010).
Metheny et al. (1989) used a pH  5.5 as a cut-off point to
determine gastric placement. Aspirates were obtained
from 94 nasogastric and 87 nasointestinal tubes after
initial placement and after two-days of feeding. Approximately 81% of the aspirates from nasogastric tubes had pH
values ranging from 1 through 4. In a subgroup of patients,
a pH of  5.5 was able to predict 91% of gastric positioning
among patients who received acid inhibitors compared to
87% who did not (Fernandez et al., 2010).
Simultaneously with the pH method, results of the
auscultatory method have been reported in the literature.
Because it seems very difcult to detect misplaced tubes
with this method, several studies report a poor interobserver validity or a very low specicity and a high
sensitivity (Metheny et al., 1990b; Neumann et al.,
1995; Seguin et al., 2005)
According to our data, the current study is the rst large
scale study in adult hospital patients using the pH method
(with CE marked testing strips) with a pH cut-off point
of  5.5 to determine whether a NG tube has been
successfully placed in or outside the stomach, immediately
after placement. To limit as much as possible placement
bias (for example differences in tube length measurement
and/or intubation technique) and interobserver variability
in the auscultation and/or pH method, all NG tubes were
placed, or the placement supervised, by the same
experienced advanced practice nurse. We assume that
this was an advantage because pH readings can be
misinterpreted (Clemente, 2009). An additional strength
of this study was that simultaneously several measures
were tested to increase the number of aspirates. This study
demonstrated that a pH cut-off point of  5.5 is absolutely

safe in excluding lung placement but did not completely

rule out oesophageal placement. Feeding in the oesophagus will increase the risk of pulmonary aspiration so we
can certainly support X-ray conrmation in high risk
patients (diagnosed gastroesophageal reux disease or
hiatus hernia, oesophageal or gastric abnormalities, former
upper gastrointestinal surgery, patients nursed in a supine
position, and patients with a high risk of aspiration for
example unconscious patients and those with altered
cough and/or gag reexes).
Acid inhibition produced more false negatives pH tests,
which was also demonstrated in the study by Taylor and
Clemente (2005), leading per protocol to more X-ray
controls. Also interesting to notice is, that when an aspirate
could not be obtained (n = 60), sixteen tubes were located
outside the stomach. Visualizing aspirates with a pH > 6
was of little value in differentiating between gastric
placement or not because of overlapping colour and
physical characteristics. Many nursing textbooks still
recommend the auscultatory method (some of them as
only method) of verifying tube placement (Simons and
Abdallah, 2012). That this is potentially dangerous was also
demonstrated in this study (see also case examples).
Because of the subjectivity of interpreting whooshing
sounds (certainly with hearing some degree of whooshing
sounds) one could wrongly judge that a tube is in the
correct position.
This study does have some limitations. Intubation by, or
in the presence of, the same practitioner does not
completely reect current daily practice. We could have
designed the study to allow department nurses to place the
NG tubes and perform subsequent tests without direct
supervision. This however would have required an in
depth knowledge and uniform performance of the
procedure by many nursing staff, which, at the start of
the study, was not the case. But also in other hospitals pH
testing seems not to be a part of nursing policy (Simons and
Abdallah, 2012).
We also did not distinguish between proton-pomp
inhibitors (PPIs) and H2 receptor antagonists while
registering the use of antacids, although from our
experience we can declare that most patients in our
hospital are using PPIs. Especially PPIs can increase the
number of patients with a pH > 6 (Lanas et al., 1995).
With regard to measurement of the insertion-length of
the tube, research indicates that using the NEX method, not
always leads to correct internal tube lengths which can
inuence aspiration from the tube (Hanson, 1979). The
principle of the NEX-method was rst described in an old
study in 30 premature infants and later extrapolated to
adults and further cited in many nursing textbooks (Ellett,
2012; Royce et al., 1951). A better alternative could have
been to use a conversion chart to determine the real
required length (Hanson, 1979; V&VN, 2011).
5. Conclusions
An aspirate pH of  5.5 appears to reliably reect
correct gastric positioning of the NG tube, even if antacids
are used. Although in this study pH measurement with a
pH  5.5 distinguished gastric from respiratory placement,

K. Boeykens et al. / International Journal of Nursing Studies 51 (2014) 14271433

there is still a small chance that the tube is positioned in

the oesophagus. The bedside pH method reduces the need
for costly X-ray, decreases radiation exposure and offers
advantages for outpatient care. Extra measures can
signicantly increase the success rate for obtaining an
aspirate from the NG tube. In cases where the risk for
aspiration is high, where no aspirate can be obtained or
where the pH tested  6, radiological verication should be
performed. Even though the auscultation method allows
for good assessment of gastric placement, the use of this
method should be discouraged as it does not reliably allow
for detection of the NG tube outside the stomach.
Statement of authorship
All authors state that they have made substantial
contributions and nal approval of the conceptions,
drafting and nal version of the manuscript.
Conict of interest
We have no conict of interest to declare.
Funding
No funding.
Ethical approval
The study was approved by the Ethical Committee of
the AZ Nikolaas Hospital in Sint Niklaas and all patients or
their legal representatives signed an informed consent.
Acknowledgements
K. Boeykens wishes to thank the nutrition support
nurses and nursing organisations in Belgium and especially
The Netherlands for their networking, publications and
efforts to stimulate the use of pH measuring after
nasogastric intubation in clinical practise.
This paper includes some data previously reported in a
Dutch language journal: Boeykens, K., Steeman, E., 2012.
Betrouwbaarheid van de pH-meting en de auscultatiemethode om de positie van een neusmaagsonde te
bepalen. Verpleegkunde 4, 49.

Appendix A. Supplementary data

Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.ijnurstu.2014.03.004.
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