Diagnostic accuracy of end-tidal carbon dioxide detection in determining correct placement of nasogastric tube: An updated systematic review with meta-analysis

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Abstract

Background

Misplacement of the nasogastric tube in the respiratory tract could cause serious complications and even death. Thus, nasogastric tube verification is necessary for optimal patient safety and comfort. Although end-tidal carbon dioxide detection is considered an effective approach to determine nasogastric tube location, there is a paucity of up-to-date evidence.

Objectives

To review the diagnostic accuracy of end-tidal carbon dioxide detection in determining inadvertent airway intubation and verifying correct placement of nasogastric tubes.

Design

A systematic review and meta-analysis.

Methods

We searched clinical trials that evaluated the diagnostic accuracy of colorimetric capnometry or capnography in detecting nasogastric tubes located in the airway and differentiating between inadvertent airway intubation and correct nasogastric tube placement in any adult care setting. Four English language databases - Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL - and four Chinese language databases - China Biomedical Literature Database, WanFang Data, China National Knowledge Infrastructure, and Airiti Library - were searched from July 2009 to March 2021. Clinical trial registration databases and reference lists of included studies and relevant reviews were also searched. Two reviewers extracted the data of all included studies using a data extraction form. Two reviewers assessed the methodological quality independently with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted meta-analysis using the hierarchical bivariate model and estimated the pool sensitivity and specificity of capnography and colorimetric capnometry. Forest plots were generated to display the results. Heterogeneity was investigated by meta-regression. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluations framework.

Results

Of 1,155 records identified, seven new studies were added to this update and a total of 16 studies were analysed in the systematic review. The total absolute number of true positive, false negative, true negative, and false positive observations were 142, 6, 1,500, and 65 respectively. Low to very low certainty of evidence indicated that the use of colorimetric capnometry or capnography is potentially an effective method in differentiating between respiratory and nasogastric tube placement for critically ill adult patients. Pooled results (13 studies, 1,541 intubations) for sensitivity and specificity were 0.96 (95% confidence interval [0.88, 0.99]) and 0.99 (95% confidence interval [0.96, 1.00]), respectively.

Conclusions

Colorimetric capnometry and capnography may have the potential to be of high sensitivity and specificity for the detection of inadvertent airway nasogastric tube placements in critically ill adults. More evidence is required to generalize the updated findings to different types of patients and settings.

Section snippets

What is already known

  • It is vital to verify the placement of the nasogastric tubes immediately after insertion and prior to each feed and medication administration because inadvertent pulmonary placement of nasogastric tube results in serious pulmonary complications or even death.

  • A systematic review we conducted in 2011 concluded that there was evidence to support the use of colorimetric capnometry or capnography for the identification of nasogastric tube placement in mechanically ventilated patients.

  • Limitations

What this paper adds

  • Colorimetric capnometry and capnography may be of comparable diagnostic accuracy to radiography in their ability to differentiate between respiratory and gastrointestinal tube placement in critically ill adult patients, though the certainty of evidence was low or very low.

  • The limited number of studies conducted in general wards renders determination of diagnostic accuracy in this patient population uncertain.

Methods

This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement (Page et al., 2021) and the PRISMA of Diagnostic Test Accuracy (PRISMA-DTA) reporting guideline (Salameh et al., 2020).

Study selection

From 2009 to 2021, we identified 1154 records from the initial database search. A total of 939 records were screened after the removal of duplicates, of which 923 records were irrelevant and excluded (Cohen's kappa = 0.66). We identified one more record (an article in press) from an acute hospital in Hong Kong. Seventeen full-text articles were assessed for inclusion. One ongoing study (Samuele, November 2020—) and nine studies were further excluded (Cohen's kappa=0.77) due to ineligible

Summary of main results

Seven new trials were added to this update and a total of 16 trials were analysed in this systematic review. All of these trials investigated the diagnostic accuracy of colorimetric capnometry or capnography in detecting the positions of nasogastric tubes against reference standards (i.e., X-ray, aspiration of stomach contents, air auscultation, and capnography) in adults. The results of this updated review indicate that the use of colorimetric capnometry or capnography may be an effective

Conclusions

The use of colorimetric capnometry or capnography may have the potential to effectively differentiate inadvertent airway intubation from gastrointestinal nasogastric tube placement in critically ill adults. More evidence is required to generalize the updated findings to different types of patients and settings.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

No external funding.

References (54)

  • P. Meyer et al.

    Colorimetric capnography to ensure correct nasogastric tube position

    J. Crit. Care

    (2009)
  • S.Z. Mordiffi et al.

    Confirming nasogastric tube placement: is the colorimeter as sensitive and specific as X-ray? A diagnostic accuracy study

    Int. J. Nurs. Stud.

    (2016)
  • J.B. Reitsma et al.

    Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews

    J. Clin. Epidemiol.

    (2005)
  • J.A. Ryu et al.

    Clinical usefulness of capnographic monitoring when inserting a feeding tube in critically ill patients: retrospective cohort study

    BMC Anesthesiol

    (2016)
  • H.J. Schünemann et al.

    GRADE guidelines: 21 part 1. Study design, risk of bias, and indirectness in rating the certainty across a body of evidence for test accuracy

    J. Clin. Epidemiol.

    (2020)
  • H.J. Schünemann et al.

    GRADE guidelines: 21 part 2. Test accuracy: inconsistency, imprecision, publication bias, and other domains for rating the certainty of evidence and presenting it in evidence profiles and summary of findings tables

    J. Clin. Epidemiol.

    (2020)
  • N.A. Smyrnios et al.

    Comparison of a self-inflating bulb syringe and a colorimetric CO2 indicator with capnography and radiography to detect the misdirection of naso/orogastric tubes into the airway of critically ill adult patients

    Chest

    (2015)
  • K. Yolsuriyanwong et al.

    Update on endoscopic enteral access

    Tech. Gastrointest. Endosc.

    (2018)
  • C.E. Araujo-Preza et al.

    Use of capnometry to verify feeding tube placement

    Crit. Care Med.

    (2002)
  • P. Bossuyt et al.

    Interpreting results and drawing conclusions

  • P.M. Bossuyt et al.

    Developing criteria for including studies

    Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 0.4 [updated September 2008]

    (2008)
  • A.M. Bourgault et al.

    Migration of feeding tubes assessed by using an electromagnetic device: a cohort study

    Am. J. Crit. Care.

    (2020)
  • A.M. Bourgault et al.

    National survey of feeding tube verification practices: an urgent call for auscultation deimplementation

    Dimens. Crit. Care Nurs.

    (2020)
  • S.M. Burns et al.

    Detection of inadvertent airway intubation during gastric tube insertion: capnography versus a colorimetric carbon dioxide detector

    Am. J. Crit. Care.

    (2006)
  • S.M. Burns et al.

    Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurements

    Crit. Care Med.

    (2001)
  • P.P. Cheng et al.

    Colourimetric capnometry to verify nasogastric tube placement in patients at risk of mal-placement (article in press)

    Asian J. Gerontol. Geriatrics

    (2021)
  • Y. Comay et al.

    Case series: nasogastric (NG) feeding tube misplacement in critically ill tracheostomized patients

    Case Rep. Clin. Med.

    (2020)
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