Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Improving the safety of nasogastric tube insertion by the “SORT maneuver” during the novel coronavirus pandemic (COVID-19)

The "SORT maneuver" (sniffing position, NGT orientation, contralateral rotation, and twisting movement) was introduced in 2016 to ease nasogastric intubation for unconscious patients in operating theatre and critical care setting [1]. This technique is aimed at a safe practice without using equipment. Safety has never been more important than the current outbreak of SARS-CoV-2 infection. SORT maneuver can be of benefit for both the healthcare workers and the patients who are struggling with coronavirus during this pandemic.

From the practitioner’s point of view, any procedure which is done in close contact with an infected patient’s airway carries a higher risk of respiratory infection transmission which may not get totally eliminated after tracheal intubation [2, 3]. With regards to NGT intubation, this is supported by updated guidelines that consider placement of any enteral access device as an aerosol-generating procedure [4]. Moreover, NGT insertion may expose healthcare workers to infectious saliva of patients with coronavirus [5]. Feasibility of NGT insertion and the number of attempts for intubation matter as well, when it comes to a safe bedside practice. The first clinical trial reporting successful employment of SORT maneuver for NGT insertion in unconscious patients admitted to intensive care unit was just recently published with promising results [6]. This study showed that ease of insertion was considerably greater and success rate was much higher for SORT maneuver than the other conventional technique of neck flexion and lateral pressure. The observation that SORT was “easy to learn by unskilled providers” is an asset in a crisis like COVID-19 outbreak [7]. Also, compared to this technique which is based on anatomical approach, NGT insertion using laryngoscope and/or Magill forceps can even increase the risk substantially as it is more invasive and requires closer proximity to the airway [8]. Although trachea is intubated, security of airway is not guaranteed at least in circumstances such as ventilation at high inspiratory pressure, sputum induction, and manual ventilation especially with undersized or uncuffed tracheal and tracheostomy tubes [9].

On the other hand, the management of the patients’ coexisting problems such as cardiovascular disease and hemodynamic instability is a challenge during NGT intubation. Pharyngeal manipulation during NGT insertion is a potential treat for cardiac patients by increasing demand especially in hypertensive patients with uncontrolled blood pressure. These patients are the most vulnerable group to higher incidence of severe illness and worse outcome in COVID-19 as well [10, 11]. Smooth process of NGT insertion without equipment using SORT maneuver, is capable of preventing from brisk hemodynamic response and its adverse effects [12]. If this is also of benefit for infected patients with coronavirus, is a question to be addressed. Using paralyzing drugs whenever is indicated, mitigates patient’s reactions and probably can reduce the risk [3]. However, unlike the operating theatre, we seldom use these agents in intensive care unit.

NGT tube insertion in intubated patient is a quite common procedure in operation theatre and intensive care settings. In patients with COVID-19 infection, SORT maneuver may protect both practitioners and patients from further avoidable hazards. I would encourage my colleagues to verify these proposals in their daily practice and by further investigations through clinical trials.

Availability of data and materials

Data sharing does not apply to this article as no datasets were generated or analyzed during the current study.



Coronavirus disease 2019


Nasogastric tube


  1. Najafi M, Golzari S. SORT maneuver for nasogastric tube insertion. Anaesthesia. 2016;71:351–1.

    Article  CAS  Google Scholar 

  2. Public Health England. COVID-19: infection prevention and control guidance. 2020. Accessed December 7, 2020.

  3. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID‐19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020;75:785–99.

    Article  CAS  Google Scholar 

  4. Martindale R, Patel JJ, Taylor B, Warner M, McClave SA. Nutrition therapy in the patient with COVID-19 disease requiring ICU care. American Society for Parenteral and Enteral Nutrition, Society of Critical Care Medicine. Available at: Accessed December 1, 2020.

  5. Sturrock BR, Fanning SJ, Khan M, Sajid MS. Should nasogastric tube insertion during the COVID-19 pandemic be considered as an aerosol-generating procedure? Br J Hosp Med. 2020;81:6.

    Article  Google Scholar 

  6. Sanaie S, Mirzalou N, Shadvar K, Golzari SE, Soleimanpour H, Shamekh A, Bettampadi D, Safiri S, Mahmoodpoor A. A comparison of nasogastric tube insertion by SORT maneuver (sniffing position, NGT orientation, contralateral rotation, and twisting movement) versus neck flexion lateral pressure in critically ill patients admitted to ICU: a prospective randomized clinical trial. Ann Intensive Care. 2020;10:79.

    Article  Google Scholar 

  7. Najafi M. SORT maneuver: ease and safety for the practitioner and the patient. Ann Intensive Care. 2020;10:160.

    Article  Google Scholar 

  8. Sanaie S, Mahmoodpoor A, Najafi M. Nasogastric tube insertion in anaesthetized patients: a comprehensive review. Anaesth Intensive Ther. 2017;49:57–65.

    Article  Google Scholar 

  9. Weissman DN, de Perio MA, Radonovich LJ. COVID-19 and Risks Posed to Personnel During Endotracheal Intubation. JAMA. 2020;323(20):2027–8. doi:

    Article  CAS  PubMed  Google Scholar 

  10. Schiffrin EL, Flack JM, Ito S, Muntner P, Webb RC. Hypertension and COVID-19. Am J Hypertens. 2020;33:373–4. doi:

    Article  CAS  PubMed  Google Scholar 

  11. Cummings MJ, Baldwin MR, Abrams D, Jacobson SD, Meyer BJ, Balough EM, Aaron JG, Claassen J, Rabbani LE, Hastie J, Hochman BR. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. The Lancet. 2020;395:1763–70.

    Article  CAS  Google Scholar 

  12. Najafi M. Nasogastric tube insertion easily done: the SORT maneuver. Indian J Crit Care Med. 2016;20:492–3.

    Article  Google Scholar 

Download references


Not applicable.


No funding.

Author information

Authors and Affiliations



M.N. designed and wrote this article. The author read and approved the final manuscript.

Authors’ information

Dr. Najafi is trained in anesthesiology, intensive care and cardiac anesthesia. He is associate professor of anesthesiology at Tehran Heart Center, affiliated to Tehran University of Medical Sciences and adjunct professor at Schulich School of Medicine, Western University.

Corresponding author

Correspondence to Mahdi Najafi.

Ethics declarations

Ethics approval and consent to participate

Institutional review board is not required for this type of articles.

Consent for publication

Not applicable.

Competing interests

The author declares that he has no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Najafi, M. Improving the safety of nasogastric tube insertion by the “SORT maneuver” during the novel coronavirus pandemic (COVID-19). Patient Saf Surg 15, 4 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: