Gastric Tube Placement – CXR

Table of Contents

Table of Contents

Published March 2021

Daniel Gergen, MD1
Samantha King, MD2
Expert review – pending
1 Fellow, Pulmonary and Critical Care Medicine, University of Colorado
2 Chief Medical Resident, Internal Medicine, University of Colorado.


  1. Use two rules to determine the appropriate placement of a nasogastric or orogastric tube on chest x-ray.

Teaching Instructions

Plan to spend 5-10 minutes familiarizing yourself with the animations of the PowerPoint and the key findings of this chest X-ray.

Instructions: Present the image either by expanding the window (bottom right) in a browser or downloading the PowerPoint file (downloading is recommended.  Have the image pulled up in presenter mode before learners look at the screen to avoid revealing the diagnosis.  Ask a learner to provide an overall interpretation.  Then advance through the animations to prompt learners with key questions and reveal the findings, diagnosis, and teaching points.  You can go back to prior graphics and questions by using the back arrow or scrolling back on the mouse wheel.

Official CXR Read: Extensive bilateral multifocal alveolar opacities. A new weighted tip feeding tube appears to course through the left mainstem bronchus, with tip projecting over the lateral left lung.  This may be in the pleural space. Endotracheal tube tip projects over the mid intrathoracic trachea.  Right IJ central venous catheter tip projects over the superior vena cava.

Diagnosis: Mispositioned weighted feeding tube requiring removal and replacement


  • The radiograph demonstrates multifocal alveolar opacities due to ARDS.
  • The right internal jugular central venous catheter terminates at the cavoatrial (superior vena cava and right atrial) junction.
  • The endotracheal tube (ETT) terminates approximately 4 cm above the carina (goal of 2-5cm).
  • Gastric tubes (nasogastric, orogastric) are commonly placed for enteral access for medication administration and nutrition along with gastric decompression.

A 2-step process for determining appropriate gastric tube placement:

    1. Does the portion of the tube above the diaphragm remain midline? The esophagus is a midline structure. Any deviation of the enteric tube from the midline should raise suspicion for misplacement (i.e. trachea/bronchi) or curling within the esophagus.
    2. Does the tube end below the diaphragm/cardiac silhouette? An enteric tube that ends above this level is likely not in the stomach, which increases the risk of aspiration.
    3. (optional) Is the tip of the tube pointing towards the pylorus

Presentation Board

Take Home Point

When determining if a gastric (enteric) tube is in the stomach, ask:

  1. Does the portion of the tube above the diaphragm remain midline?
  2. Does the tube end below the diaphragm/cardiac silhouette?

Goodman, L. R. (2019). Felson's Principles of Chest Roentgenology E-Book: A Programmed Text. Netherlands: Elsevier Health Sciences.

Share on facebook
Share on twitter
Share on linkedin

Comment on this article