Сокцитрусовых стимулируют желудочные соки и ускоряют проверку зондов у пациентов после инсульта

Applying citrus juice to the tongue and gums may stimulate gastric secretions and reduce delays in starting nasogastric use Abstract Dysphagia is common following stroke, and many patients require a nasogastric tube to support hydration, nutrition and medication administration. Before every use, it is essential to check the nasogastric tube is in the correct position, which is done by aspirating gastric fluid and checking the pH level. However, gastric fluid aspiration is often unsuccessful, requiring a chest X-ray for confirmation, which can delay feeding and medication administration for several hours. This article outlines a local review exploring whether applying orange or lemon juice to the gums and tongue could stimulate gastric fluid production and improve aspiration success in adult patients. In all patients reviewed locally, gastric aspirate was successfully obtained following the intervention, avoiding the need for chest X-ray confirmation. Citation: Maguire H et al (2026) Orange and lemon juice used to improve nasogastric tube aspiration success. Nursing Times; 122: 7. Authors: Holly Maguire is advanced nurse practitioner for stroke; Grace Casquejo is stroke nurse; Surabhi Saxena is research nurse, all at University Hospitals of North Midlands NHS Trust; Debbie Wyatt is assistant librarian, Health Library for North Staffordshire Library and Knowledge Service. - This article has been double-blind peer reviewed - Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser) Introduction Stroke is the second leading cause of death and the third leading cause of disability worldwide. The incidence of stroke rose by 70% between 1991 and 2021, and the estimated global cost of stroke is predicted to double by 2050 (Feigin et al, 2025). Dysphagia (difficulty swallowing) following stroke is common, affecting up to 60% of patients, with around half of this group requiring a nasogastric (NG) tube in the days and weeks that follow (Banda et al, 2022). NG tubes are thin, plastic tubes introduced via the nose, through the oesophagus and into the stomach and can be used for hydration, nutrition and medication administration. They are passed ‘blind’ at the bedside; that is, without visualisation of the tube inside the body and its path into the stomach. The procedure is performed with, ideally, the patient in an upright position, with the head bent forward, and the patient swallowing during insertion; the anatomy usually guides the NG tube to the gastric tract. However, the NG tube can be misplaced into the respiratory tract. Feeding through an NG tube in the respiratory tract causes severe, and often fatal, aspiration pneumonia and is classed as a ‘never event’ by NHS England (2021). Inserting and checking the correct position of NG tubes is guided by strict protocols and safety checks (Nasogastric Tube Special Interest Group, 2020). In current practice across the UK, after placing an NG tube and before any use, it is essential to confirm the correct position by testing the pH of gastric fluid aspirated through the NG tube using pH strips or pH paper, which change colour in response to acidic or alkaline substances. This helps determine whether the aspirate originates from the stomach rather than the respiratory tract (NHS Improvement, 2016). For aspiration testing, an acid pH level of <5.5 indicates that the NG tube tip is within the stomach and safe to use (Fig 1). Frequently, an aspirate is unobtainable – in up to 46% of patients (Rowat et al 2018) – or a pH level falls outside of the expected limit, often caused by medications but potentially due to NG tube misplacement (Fan et al, 2019). In these situations, the ‘gold standard’ investigational method of checking the correct NG tube position is a chest X-ray (Taylor and Manara, 2021). Upon review of a chest X-ray, the clinician must follow the four-stage verification process identified by NHS Improvement (2016) before an NG tube is deemed safe to use (Fig 2). In the NHS alone, more than 790,000 NG tubes are placed each year, and each tube must be checked daily, or more often, to ensure safe placement before commencement of each use (NHS Improvement, 2016). The process of obtaining a chest X-ray for a stroke patient is lengthy. First, a clinician must request the investigation, then a porter is needed to transport the often immobile patient to the radiology department and back, frequently accompanied by a nurse or carer or other health professional. After the image is completed, a clinician with competency-based training is required to review the images to ensure correct positioning prior to use, following the verification process. During this radiological process, it is also possible for the position of the NG tube to change. Brazier et al (2017) reported that this process often takes up to eight hours, leaving patients without hydration, nutrition and medications for excessive periods of time. This process may occur daily for some stroke patients throughout their hospital stay, leading to multiple chest X-rays resulting in radiation exposure, alongside extended periods without hydration, nutrition or medications, which may influence recovery and certainly affect wellbeing. Taylor and Manara (2021) reported that some patients in their trial required more than 20 chest X-rays to verify NG tube position during their hospital admission. And, at an estimated cost of £158.64 per chest X-ray, this also significantly contributes to spending on stroke care (McFarland, 2016). “Within current practice, many patients were often left without nutrition for many hours while awaiting chest X-ray confirmation” Method Stroke nurses on the local unit at the University Hospitals of North Midlands NHS Trust in Stoke-on-Trent were frustrated, as were patients and their families, after waiting excessive periods of time for chest X-rays to confirm an NG tube position. A local audit, which included 60 acute stroke patients, demonstrated that patients waited an average of 5.5 hours from chest X-ray request to confirmation that the NG tube was safe to use, and underwent an average of nine chest X-rays during admission. These delays in NG tube feeding not only affect comfort and wellbeing but also interrupt therapy sessions. It is well understood that early and consistent NG tube feeding for dysphagic stroke patients substantially reduces the risk of death and improves early functional recovery (Kolanu et al, 2024). However, within current practice, many patients were often left without nutrition for many hours while awaiting chest X-ray confirmation. A novel practice was observed on the local acute stroke unit that warranted further investigation. After a nurse was unable to obtain a gastric aspirate, gauze soaked in orange or lemon juice was wiped along the patient’s gums and tongue. Within 10 minutes of this procedure, a second attempt to aspirate gastric fluid was made successfully. Gastric aspirate was obtained, checked and found to be within the pH range to indicate safe NG tube placement (<5.5), allowing feeding to commence within minutes of the process taking place. With the help of a local librarian, a full literature search followed, aiming to identify evidence to support this practice. The terminology for the evidence search was: “For patients with a nasogastric tube that requires a position check, if the first attempt is unsuccessful, does applying orange or lemon juice to the gums and tongue increase gastric secretions, improving the success of a second aspiration?” NHS Knowledge and Library Hub, CINAHL, Emcare, HMIC, Embase, MEDLINE, and TRIP Pro databases were accessed, followed by a web-based search. Although it is understood that citrus juice stimulates gastric fluid production (Wu et al, 2021), no evidence or clinical guidelines were identified to support the specific practice of applying orange or lemon juice to the gums and tongue to stimulate gastric secretions or improve NG tube aspiration success. This highlighted a significant gap in the research and local data collection followed. Results Data was collected from the local hyperacute stroke unit for 25 consecutive stroke patients requiring NG tube position checks after an unsuccessful attempt at gastric fluid aspiration via the NG tube. Gauze soaked in orange or lemon juice was applied to the gums and tongue to stimulate gastric fluid production. Ten minutes after this procedure, a second attempt to aspirate gastric fluid was made and was successful in every patient. Although the amount of gastric fluid aspirate differed between patients, enough was obtained to test pH levels in 100% of cases. Chest X-rays were not required and patients were able to start fluids, nutrition and medications sooner in every case, also meaning that all patients were able to continue their therapy without delays. “Chest X-rays were not required and patients were able to start fluids, nutrition and medications sooner in every case” Limitations Patients were included in this project when NG tube position verification was required and a gastric aspirate to check pH level was unobtainable. Only 25 patients from a single centre were included in this review and, due to the lack of a comparator group, caution must be applied when interpreting these results and considering repeatability. It is vital that oral hygiene is maintained, as coated mouths may prevent success, and any patients suffering from oral thrush were excluded. Conclusion For stroke patients with a nasogastric tube who are unable to provide a gastric aspirate, applying orange or lemon juice to the gums and tongue appears to stimulate gastric fluid production and warrants further investigation. This simple intervention has the potential to reduce the need for chest X-rays for nasogastric tube position verification and may influence recovery outcomes and improve patient wellbeing by minimising the time patients are left without nutrition, hydration and medications. Although these findings are encouraging, they are based on a small sample from a single centre and should be approached with caution when considering reproducibility. Further research involving larger patient groups and comparator data is needed. Key points - Up to 60% of stroke patients experience dysphagia, and up to 30% require a nasogastric tube - It is vital to ensure the nasogastric tube is in the correct position before each use - Nasogastric tube position confirmation by gastric fluid aspiration can fail, requiring a chest X-ray to confirm - Citrus juice applied to the gums and tongue could increase gastric fluid production, reducing the need for X-ray to confirm nasogastric tube position Banda KJ et al (2022) Prevalence of dysphagia and risk of pneumonia and mortality in acute stroke patients: a meta-analysis. BMC Geriatrics; 22: 1, 420. Brazier S et al (2017) Stroke: ineffective tube securement reduces nutrition and drug treatment. British Journal of Nursing; 26: 12, 656-663. Fan EMP et al (2017) Nasogastric tube placement confirmation: where we are and where we should be heading. Proceedings of Singapore Healthcare: 26,3: 189-195. Feigin VL et al (2025) World Stroke Organization: Global Stroke Fact Sheet 2025. International Journal of Stroke; 20: 2, 132-144. Kolanu ND et al (2024) Influence of nutritional interventions on functional outcomes in stroke rehabilitation: a systematic review. Cureus, 16: 2, e53711. McFarland A (2016) A cost utility analysis of the clinical algorithm for nasogastric tube placement confirmation in adult hospital patients. Journal of Advanced Nursing; 73: 1, 201. Nasogastric Tube Special Interest Group (2020) A Position Paper on Nasogastric Tube Safety. ‘TIme to Put Safety First’. BAPEN. NHS England (2021) Never Events list 2018. NHS England. NHS Improvement (2016) Resource Set: Initial Placement Checks for Nasogastric and Orogastric Tubes. NHS Improvement. Rowat AM et al (2018) Study to determine the likely accuracy of pH testing to confirm nasogastric tube placement. BMJ Open Gastroenterology; 5: 1, e000211. Taylor S, Manara AR (2021) X-ray checks of NG tube position: a case for guided tube placement. The British Journal of Radiology; 94: 1124, 20210432. Wu C et al (2021) Thirst relief effect of 0.75% citric acid spray during the anesthesia recovery period: a randomized controlled trial. Journal of PeriAnesthesia Nursing; 36: 6, 642-646. Help Nursing Times improve Help us better understand how you use our clinical articles, what you think about them and how you would improve them. Please complete our short survey.