Guideline for Insertion of a Nasal Bridle retaining loop
Version
3
Name of responsible (ratifying) committee
Nutrition Support Group
Date ratified
25.07.13
Document Manager (job title)
Jo Pratt Lead Clinical Nutrition Nurse Specialist
Date issued
09/08/2013
Review date
June 2015
Electronic location
Corporate Clinical Guidelines
Related Procedural Documents
Policy for the Insertion and Maintenance of Fine Bore
Nasogastric Feeding Tubes in Adults
Key Words (to aid with searching)
NGT Fixation; Nasal Bridle; Nasal Loop Forcible
feeding; Feeding practices; Feeding behaviour; Ethnic
differences; Cultural factors; Patient restraint; Patient
compliance; Patient cooperation; Artificial feeding;
Parenteral feeding
1Guideline for Insertion of a Nasal Bridle retaining loop
(Review date June 2015)
12/02/2016
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CONTENTS:
1. QUICK REFERENCE GUIDE
2. INTRODUCTION
3. PURPOSE
4. SCOPE
5. DEFINITIONS
6. DUTIES AND RESPONSIBILITIES
7. PROCESS
8. TRAINING REQUIREMENTS
9. ASSOCIATED DOCUMENTATION
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
APPENDICES:
1.
2.
3.
INDICATIONS/ CONTRAINDICATIONS /CONSIDERATIONS
PICTURES DEMONSTRATING NASAL BRIDLE INSERTION
NASAL BRIDLE CARE PLAN
1. QUICK REFERENCE GUIDE
1. Patients who repeatedly remove naso-enteric feeding tubes, or have a feeding tube that
was placed radiographically/endoscopically and/or would be problematic to replace, are
referred to the CNNS team for assessment for Nasal Bridle insertion.
2. Nasal Bridles are inserted by the CNNS team, if deemed appropriate, following
assessment.
3. Appropriate consent is obtained prior to Nasal Bridle insertion and is documented in the
patient’s medical notes.
4. Ward staff are issued with Nasal Bridle care guidelines.
5. All patients with a Nasal Bridle in-situ are reviewed weekly by CNNS team
6. A Nasal Bridle can be removed if absolutely necessary to prevent damage to the nasal
septum
Guideline for Insertion of a Nasal Bridle retaining loop
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2. INTRODUCTION
The use of naso-enteric feeding tube is a common procedure across many different specialties.
Naso-enteric tubes become displaced for a variety of reasons and a small group of patients
appear to be particularly intolerant of the tube and require a tube to be re-passed frequently.
This can be distressing for the patient, their family and detrimental to their recovery and/or
treatment.
An alternative fixing device has been developed called the Nasal Bridle. This provides a means
of securing the naso-enteric feeding tube to prevent accidental or intentional tube removal by
the patient.
Using this device is potentially an ethically sensitive decision and is recognised as a form of
restraint. This guideline has been written to enable the Clinical Nutrition Nurse Specialists to
follow an agreed decision making, assessment and procedural process.
3. PURPOSE
This guideline is designed to enable Clinical Nutrition Nurse Specialists (CNNS) to place Nasal
Bridles in patients who repeatedly remove naso-enteric feeding tubes. A Nasal Bridle may also
be used where a naso-enteric tube has required radiologic or endoscopic insertion and/or
where a tube would be difficult to replace.
4. SCOPE
The Nasal Bridle will be inserted by the CNNS who will act as gatekeepers for this procedure.
Supplies of this device are held only by the CNNS. Insertion will follow assessment and
multidisciplinary consultation.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it
may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety’
5. DEFINITIONS
Nasal Bridle: Is a method of preventing inadvertent displacement or removal of naso-enteric
feeding tubes in patients requiring enteral administration of feed, fluid or medication. It
comprises of a rigid probe and a flexible probe with a tape attached. The flexible probe has a
removable guidewire. Each probe has a magnet at the end. The probes are inserted into each
nostril until the magnets join at the back of the nose. The rigid probe is then pulled out of the
nostril bringing the flexible probe and the loop of tape around the back of the nasopharynx and
exiting from each nostril. The tapes from each nostril are then secured to the naso-enteric tube
with a clip, reducing the risk of inadvertent removal. The Nasal Bridle stocked by the CNNS
team accommodates an 8fg feeding tube (although larger sizes are available to order if
specifically requested).
Naso-enteric feeding tube: most commonly a naso-gastric tube but may be a naso-jejunal tube.
At PHT an 8fg diameter tube is recommended for feeding and must be used if a bridle is
required.
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
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6. DUTIES AND RESPONSIBILITIES
Doctors: It is a medical decision to commence enteral feeding.
Healthcare professionals: It is the responsibility of those caring for the patient to assess
whether they have capacity to consent for this procedure. If the patient is deemed to lack
capacity then a best interests decision should be made and documented in the patients medical
notes.
Registered Nurse: It is the nurses’ responsibility to care for the Nasal Bridle as per Trust
Guideline and assist the CNNS in Nasal Bridle placement if required.
CNNS: It is the CNNS responsibility to assess the patient for Nasal Bridle insertion and
maintain competency in insertion. CNNS must obtain consent from the patient, or make a best
interests decision in those patients who lack capacity to consent, which must be documented in
the patients medical notes. CNNS will provide a care plan for each patient with a Nasal Bridle
in-situ.
All patients with a Nasal Bridle in situ will be reviewed weekly by the CNNS.
CNNS will ensure adequate supply of Nasal Bridle sets.
7. PROCESS
Equipment:Gloves/Apron
Nasal Bridle
8fg Nasoenteric Feeding Tube (if not already in situ)
Mouthcare swabs
Tissues
Scissors
Clinical Practice Guideline
Lubricating Jelly
pH indicator strips
enteral syringe
1. Following a referral the CNNS will assess the patient for appropriateness for nasal bridle
insertion.(Appendix 2)
2. If the patient has capacity the procedure should be explained to gain consent. If the patient is
deemed to lack capacity then a best interests decision should be made and documented in the
medical notes.
3. The patient should be positioned appropriately according to assessment, to enable ease of
placement.
4. Wash hands and apply gloves and apron in preparation for procedure.
Open and prepare equipment (as above).
5. Check nose for any signs of obstruction and that both the nose/mouth are clean as this may
impede insertion.
6. Lubricate rigid blue probe and insert into the nostril following the anatomy of the nose. If NGT in
situ insert rigid blue probe into the NGT nostril. Advance up to the 2nd groove on the probe and
maintain probe position.
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
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If blue probe will not advance try the other nostril (as patient may have deviated nasal septum or
obstruction in that nostril)
See Appendix 1 – Picture 1.
7. When rigid blue probe is in situ-insert the flexible white probe (with tape) into the opposite nostril
and withdraw the guidewire 1-2 cms.
This allows flexibility of the white probe and easier connection with the magnet of the rigid blue
probe. Some manipulation of the flexible white probe may be required until the magnets from both
the rigid blue probe and the flexible white probe unite within the nasopharynx.
OR
Fully insert the flexible white probe and completely remove the guidewire, very gently withdraw the
rigid blue probe until taped white probe and magnets unite.
If the magnets have joined then the flexible white probe will be able to be pulled through by the
rigid blue probe. (May also hear a click or feel the magnets joining)
(See Appendix 1 - Picture 3)
8. When confirmed that the magnets are joined- remove guidewire from flexible white probe (if still
in situ) prior to pulling through nostril.
9. Slowly withdraw the rigid blue probe from one nostril- pulling the flexible white probe with
attached tape up from the other nostril and over the nasal septum. Pull all the way out until only
the tape is visible protruding from both nostrils.
See Appendix 1 - Picture 4.
10. Using scissors cut the flexible white probe from the tape leaving only the tape in the nose. Tie
the tapes securely under the nose ensuring that the tape is not too tight as this will cause pressure
damage.
11. If inserting a naso-gastric feeding tube(NGT) at time of nasal bridle placement - check NGT
position as per Trust Policy prior to securing the clip of the nasal bridle onto the feeding tube.
11. Once feeding tube confirmed to be in correct position, or if tube already in-situ, place tube into
the groove in the clip, close to the patient’s nostril.
13. Put one of the tapes in the clip with the naso-enteric tube, close the clip and press firmly to
secure the tube in the clip.
14. After the clip has been closed – verify that it will not slip or re-open. Tie the tapes together
under the clip and trim excess tape. See Appendix 1 – Picture 6. Tape the tube to the side of the
patient’s face ensuring that the clip is not resting against the nares, as this will cause pressure
damage.
15. Document procedure with outcome in medical notes and provide nursing staff with a Nasal
Bridle care plan. (Appendix 3)
8. TRAINING REQUIREMENTS
The CNNS are responsible for training new in post nurses within the Clinical Nutrition Nurse
Specialist team.
The CNNS team are responsible for educating ward staff re care of a patient with a Nasal
Bridle in-situ
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9. REFERENCES AND ASSOCIATED DOCUMENTATION
Anderson M.R., O’Connor M. Mayer, P. et al (2004). The nasal loop provides an alternative to
percutaneous gastrostomy in high risk dysphagic stroke. Clinical Nutrition. 23(4)
Eisenberg P, Spies M, Metheny N., (1987). Characteristics of patients who remove their
nasal feeding tubes. Clinical Nurse Specialist.1(3):94-98.
Great Britain National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the
harm caused by misplaced nasogastric tubes. NPSA, London.
Gunn, S.R., Early, B.J., Zenati, M.S. and Ochoa, J.B. (2009). Use of a Nasal Bridle Prevents
Accidental Nasoenteral Feeding Tube Removal. Journal of Parenteral and Enteral Nutrition.
33(1) p50-54.
McGinnis, C. (2011). The Feeding Tube Bridle: One Inexpensive, Safe, and Effective Method
to Prevent Inadvertent Feeding Tube Dislodgement. Nutrition in Clinical Practice. 26(1) p7077.
Meer, J.A. (1989). A new nasal bridle for securing naso enteral feeding tubes. Journal of
Parenteral and Enteral Nutrition. 13(3) p331-34.
Norton B. et al. (1996). A randomised prospective comparison of percutaneous endoscopic
gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical
Journal.; 312:13-16.
Pancorbo-Hidalgo, P.L., Fernandez, F.P., Rimirez-Perez, C. et al (2001). Complications
associated with enteral nutrition by nasogastric tube in an internal medicine unit. Journal of
Clinical Nursing. 104 p482-90.
Popovich, M.J. Lockrem, J.D., Zivot, J.B. (1996). Nasal bridle revisited: an improvement in
the technique to prevent unintentional removal of small bore nasoenteraic feeding tubes.
Critical Care Medicine. 24(3) p429-31.
Royal College of Nursing (2004). Restraint Revisited – rights, risks and responsibility RCN
London.
Seder, S.W., Stockdale, W., Hale, L. and Janczyk, R.J. (2010). Nasal bridling decreases
feeding tube dislodgement and may increase caloric intake in the surgical intensive care unit:
A randomized, controlled trial. Critical Care Medicine. 38(3) p797-801.
The FOOD Trial Collaboration (2005). Effect of timing and method of Enteral tube feeding for
dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet.
365:764-72.
Williams J. (2005) Using an alternative fixing device for naso-gastric tubes. Nursing Times.
101(34):26-27.
Acknowledgements
Derby Hospitals NHS Foundation Trust (2005). Proposal for the change in practice relating to
the securing of naso-gastric tubes utilising nasal bridles within a specified group of adult
patients.
Winchester and Eastleigh Healthcare NHS Trust (2006). Nasal Tube Retaining System (nasal
loop): guidelines for use
The AMT Bridle. Nasal tube retaining system. Product information leaflet.
Guideline for Insertion of a Nasal Bridle retaining loop
.
(Review date June 2015 )
03/07/13
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10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
Patients requiring assessment for Nasal Bridle are referred to the CNNS team.
Appropriate consent is obtained prior to Nasal Bridle insertion.
Weekly review of all patients with Nasal Bridle by CNNS team
Nasal Bridle guideline is issued by CNNS team to any patient with a bridle
CNNS team are responsible for monitoring compliance with this guideline.
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
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Appendix 1: Indications/ contraindications for Nasal Bridle Insertion
INDICATIONS:
Persistent removal of a naso-enteric feeding tube.
Naso-enteric feeding tube that has required radiologic or endoscopic insertion and/or would
be difficult to replace.
CONTRAINDICATIONS:
Abnormal clotting e.g raised INR, low platelets.
Excessive agitation
# base of skull +/- facial trauma
Grossly deviated nasal septum
Mechanical obstruction-i.e nasopharyngeal airway in situ
Patient’s with mental capacity to consent to treatment who refuse a naso-enteric feeding
tube and/or nasal bridle
Persistent vomiting – a nasal bridle will not prevent displacement
CONSIDERATIONS;
Nasal polyps/deformity/anatomically challenging.
History of epistaxis
Ethical/cultural issues
Mental capacity act
Use of Mittens with or without Nasal Bridle in patient’s who lack mental capacity,but have
good manual dexterity, as a feeding tube can be pulled out with the bridle still in-situ.
Nasal Bridle and naso-enteric tube placement in endoscopy with sedation, in patients who
are intolerant of bedside placement
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
03/07/13
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Appendix 2: Pictures to demonstrate nasal bridle insertion
Picture 2
Picture 5
Picture 3
Picture 4
Picture 6
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
03/07/13
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Appendix 3:
Nasal Bridle Care Plan
Patient Name:
Hospital Number:
Date of Insertion:
DAILY:






Check that the bridle tape and clip are secure
Ensure the tapes are not over-tight.
Check that the clip is not resting against the nares as this will cause pressure
damage.
Inspect the skin around the nostrils for any signs of soreness/pressure necrosis.
Clean around nostrils to prevent build-up of any crusting and reduce the risk of
skin becoming sore.
Apply skin barrier as required.
Refer to the Nutrition Nurses for advice if you have any concerns. The Nutrition
Nurses will review patient on a weekly basis otherwise.
How to Remove the Nasal Bridle:
If the patient becomes very agitated and is pulling aggressively at the feeding tube you may
have to remove the Nasal Bridle to prevent damage to the nasal septum. Please contact the
Nutrition Nurses for assessment during normal working hours.
Out of hours ward staff can remove the Nasal Bridle if it becomes absolutely necessary,
but please consider:


Other methods of maintaining the Nasal Bridle (e.g. mittens or 1:1 care)
How will the patient receive nutrition if the Nasal Bridle and feeding tube are
removed?
To remove the
Nasal Bridle
Using scissors cut the
white tape here. Pull the
feeding tube (with clip and
tape attached) from the
opposite nostril until the
whole tube is removed.
Guideline for Insertion of a Nasal Bridle retaining loop
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(Review date June 2015 )
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