Ultrasonography for confirmation of gastric tube placement

Abstract

Background: Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.

Objectives: To assess the diagnostic accuracy of ultrasound for gastric tube placement confirmation.

Search methods: We searched the Cochrane Library (2016, Issue 3), MEDLINE (to March 2016), Embase (to March 2016), National Institute for Health Research (NIHR) PROSPERO Register (to May 2016), Aggressive Research Intelligence Facility Databases (to May 2016), ClinicalTrials.gov (to May 2016), ISRCTN registry (May 2016), World Health Organization International Clinical Trials Registry Platform (to May 2016) and reference lists of articles, and contacted study authors.

Selection criteria: We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies, and case-control studies. We excluded case series or case reports. Studies were excluded if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.

Data collection and analysis: Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted authors of the included studies to obtain missing data.

Main results: We identified 10 studies (545 participants and 560 tube insertions) which met our inclusion criteria.No study was assigned low risk of bias or low concern in every QUADAS-2 domain. We judged only three (30%) studies to have low risk of bias in the participant selection domain because they performed ultrasound after they confirmed correct position by other methods.Few data (43 participants) were available for misplacement detection (specificity) due to the low incidence of misplacement. We did not perform a meta-analysis because of considerable heterogeneity of the index test such as the difference of echo window, the combination of ultrasound with other confirmation methods (e.g. saline flush visualization by ultrasound) and ultrasound during the insertion of the tube. For all settings, sensitivity estimates for individual studies ranged from 0.50 to 1.00 and specificity estimates from 0.17 to 1.00. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (four studies, 305 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide confidence intervals.For the studies using ultrasound alone (four studies, 314 participants), sensitivity estimates ranged from 0.91 to 0.98 and specificity estimates from 0.67 to 1.00.

Authors' conclusions: Of 10 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Conflict of interest statement

HT: none known.

YT: none known.

YN: none known.

MA: none known.

YK: none known.

Figures

1

Study flow diagram.

2

Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.

3

Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study.

4

Forest plot of diagnostic accuracy of ultrasound in different ways. Four studies reported the diagnostic accuracy of ultrasound (Brun 2012; Chenaitia 2012; Gok 2015; Radulescu 2015), while the others reported the diagnostic accuracy of ultrasound combined with other methods. Gok 2015 reported the diagnostic accuracy of ultrasound during tube insertion (ultrasound‐guide insertion). We found three visualization methods (echo window) of ultrasound: neck (Gok 2015), epigastric (Brun 2012; Chenaitia 2012; Kim 2012; Lock 2003; Vigneau 2005), and a combination (Brun 2014; Radulescu 2015). Studies used air injection during ultrasound (Basile 2015; Brun 2014), saline injection (Vigneau 2005), both air and saline injection (Kim 2012), and dextrose and air injection (Nikandros 2006). Two studies did not report the echo window (Basile 2015; Nikandros 2006).

References

References to studies included in this review Basile 2015 {published and unpublished data}

Brun 2012 {published data only (unpublished sought but not used)} Brun 2014 {published data only} Chenaitia 2012 {published data only} Gok 2015 {published and unpublished data} Kim 2012 {published data only} Lock 2003 {published data only} Nikandros 2006 {published and unpublished data} Radulescu 2015 {published data only} Vigneau 2005 {published data only} References to studies excluded from this review Blaivas 2012 {published data only} Dagli 2015 {published data only} Greenberg 1993 {published data only} Hernandez‐Socorro 1996 {published data only} Kerforne 2013 {published data only} Lock 1997 {published data only} Tamhne 2006 {published data only} Wagai 1981 {published data only} Xiao‐feng 2015 {published data only} Additional references AACCN 2009 Berrington 2004 Beynon 2013 Bossuyt 2008 Bourgault 2009 CNSC 2013 de Vet 2008 Deeks 2010 Deeks 2013 Der Kureghian 2011 ECRI and ISMP 2006 ENA 2015 ESPEN Guidelines 2009 Frush 2003 Glas 2003 Harbord 2009 Higgins 2011 Holland 2013 Irving 2014 JSPEN Guideline 2013 Kawati 2005 Lamont 2011 Mariani 2010 Metheny 1999 Milsom 2015 Ministry of Economy, Trade and Industry 2013 National Patient Safety Agency 2011 NICE 2006 Reitsma 2005 RevMan 2014 [Computer program] Samuels 2013 SCCM and ASPEN Guidelines 2016 Schattner 1997 Simons 2012 Takwoingi 2013 Thomson 2000 Whiting 2011