Thursday, March 1, 2018

Tips For A Successful NJ Tube Placement

Prior to undergoing surgery for a surgical GJ tube placed directly into my abdomen, I became quite acquainted with the dreaded nose hose, also known as the NJ tube. An NJ tube is a plastic feeding tube inserted into the nose, down the esophagus, through the stomach, past the duodenum, to feed liquid nutrition into the second portion of the small bowel, the jejunum.

Reasons for feeding tubes vary. There are many medical conditions that require them. Regardless of the illness, the main commonality is that feeding tubes provide nutrition to those unable to eat food orally.

For a more in-depth explanation of the various types of feeding tubes, read: What Is A Feeding Tube?

So, here are my top tips for a successful NJ tube placement!!

Remain calm and ask questions. 

Surrounded by equipment and supplies, walking into the interventional radiology room to have a NJ tube placed is kind of intimidating. The NJ tube was my "first-step," so to speak, in the medical world. I had scant experience with tubes and lines before then. I quickly learned that an immense part of remaining calm is knowing what to expect. Have someone explain the procedure as it is happening. Do not hesitate to ask questions. It is your body and you deserve the clarification. 

Here are the basics that I do elaborate on in the further sections of the post: 

  • Unless there are extenuating circumstances, anesthesia is not given. And if there is, it is typically only twilight drugs. 
  • First, the length of tube to be inserted is measured and marked for a stopping point.
  • A guide wire is put into the tube for placement, giving it the rigidity to guide the tube into the small bowel.   
  • The NJ is then inserted into the nose, down the throat, past the stomach, and into the small bowel. 
  • Placement is checked via x-ray/fluoroscopy with contrast (or 60 cc of air if allergic to contrast) and the tube is flushed with water to assure tube function.    
  • The tube is secured to the cheek or nose with tape. 

Request water for insertion. 

An NJ tube is placed using fluoroscopy to ensure the tube is eventually situated in the correct section of the GI tract, the jejunum. That does involve laying flat on a metal table with an x-ray above the abdomen area, but the beginning of the placement is more comfortable done sitting upright. 

While inserting the tube, the radiologist will likely tell you to swallow. The act of swallowing lessens the chance of the tube going into the trachea. If tolerated, drink a few small sips of water. It helps decrease the gaggy feeling. Repeating the swallowing motion sitting up is helpful just until the tube is in the stomach. 

Think about food

Once the tube is past the nasal cavity and into the stomach, it has to be threaded into the small bowel. The opening of the stomach (the pylorus) has to open for the tube to advance to the intestine. That can take some time, especially in patients who are prone to dismotility. One great way to speed up the process is to think about food. 

I know what you are probably thinking: "I cannot eat. I need a feeding tube for nutrition. Yet, this girl is telling me to think about food. How torturous!" 

Thoughts of food cue the body to prepare for digestion, causing the pylorus to open. I have had 4 NJ tubes. Placement time was cut in half when the radiologist made that suggestion. From that point on, I always dreamed of an apple cinnamon muffin for each consecutive placement. Yum! 

Lubrication or sterile water 

Lubrication jelly is typically offered for placements. It is not as painful if the tube is well lubricated because it has to be inserted into the sensitive nasal cavity. However, there are certain situations where jelly may not be an option, like in the case of allergies. Mast Cell Disease causes allergic reactions to many triggers. Lubrication jelly happens to be one of mine. I was not able to lubricate with the jelly for all of my NJ tube placements. The radiologist used sterile water instead—running it along the outside of the tube as it is advanced.

Adjust tube location and rotate tape. 

Immediately following insertion, nurses generally try to tape the tube to the front of the nose. Perhaps I was vain, but I wanted my NJ tube to look as inconspicuous as possible. Transforming my nose into a smaller version of an elephant trunk did not suit those desires, nor was it comfortable. I asked the nurse to relocate the position of the tube to the side of my cheek with clear Tegaderm. 

Unfortunately, my skin could not hold up with the adhesive. Rotating tapes prevented building up a sensitivity to any one products. I found paper tape to be the easiest on my sensitive skin. There were occasions where I was also successful with:

  • Tender Grips 
  • Duoderm 
  • 3M Micorpore 
  • Covidien 

Remember that the gag reflex does dissipate. 

Since the tube does go down the back of the throat, it does hit the gag reflex. During placement, I asked them to stop advancing the tube until I was able to adjust to the sensation enough to continue. Afterwards, the tube felt like I was choking on a giant spaghetti noodle. It did cause me to dry heave while swallowing. I spit my saliva into a cup for a few hours until the feeling passed.

Expect soreness in the nasal cavity and throat. 

The nasal cavity and throat are not accustom to a foreign object residing in such sensitive mucosa areas. There will likely be pain. 

Personally, my nose was not very sore initially. It built up over the duration of a couple of months. Using a saline spray in the evenings soothed nose pain caused from the friction and  dryness from the tube. 

Contrary to my nose, my throat did hurt extremely bad. The first placement had caused the worst sore throat I had ever had. It was comparable to swallowing needles. I gave the pain a week to dissipate prior to pulling the tube out at home. Within a few days after it was pulled, the threat pain subsided. The tube was replaced with a smaller pediatric size and I had no pain the second go. Swishing with 'Magic Mouthwash' or a combination of Maalox and Benadryl gives at least a little relief. I give the recipe in this video: Spooky Feeding Tube Experiences (NG/NJ/GJ).

Despite the brief physical discomfort of the procedure and the overwhelming emotions of adjusting to life with a feeding tube, I am immensely grateful. I learned love my NJ tube. Symptom wise, I felt better even 24 hours later. The plastic contraption was a symbol of healing by giving my body nutrition it needs to thrive.