How to Check Gag Reflex in an Intubated Patient

Assessing for a gag reflex is a basic skill that can become important in a variety of medical settings. It is also a way to measure brain death. Medical experts, however, now caution against using the gag reflex as a primary determinant of whether to intubate, or as a measure of airway health. So first responders must balance competing information and studies to make informed decisions in each individual case. Here’s what you need to know about checking for a gag reflex in an intubated patient. 


Why Check for the Gag Reflex? 

The gag reflex can reveal much about a patient’s neurological and respiratory health. However, it’s important to bear in mind that both neurologically normal people and people who are accustomed to an endotracheal tube may not have a gag reflex. So use supplemental tests depending on your reason for assessing the gag reflex. 


The gag reflex may be stronger in people whose noses are obstructed, children under 4, heavy smokers, those with unusual soft palates, and people with gastrointestinal conditions. 


The elderly and people with sleep apnea may have a weak or even nonexistent gag reflex. Traditionally, the presence of a gag reflex has been used to guide intubation decisions. A weak gag reflex is an important risk factor for aspiration pneumonia, so its absence may trigger intubation in at-risk patients. 


The absence of a gag reflex may also suggest brain death in comatose patients. However, the use of the Glasgow Coma Scale is typically more reliable, and the absence of a gag reflex is a common finding in medical settings, particularly when a patient is intubated. 


How to Check the Gag Reflex

Different textbooks and healthcare guides recommend different procedures for testing the gag reflex. Although some suggest testing the posterior tongue, one study found that just 18 percent of providers were able to induce a gag this way. The more effective strategy is to touch the back of the pharynx with a laryngoscope or tongue depressor. In an intubated patient, checking the gag reflex can prove even more challenging. Some common techniques include

  • Wiggling the endotracheal tube back and forth 
  • Inserting either a catheter or tongue depressor into the throat 


Is Checking the Gag Reflex Really Necessary?

An emerging body of evidence suggests that the gag reflex is unpredictable, even in healthy people. One study found poor inter-observer agreement about gag reflexes, suggesting that a test of the gag reflex is subjective at best. 


Moreover, the risks of an absent gag reflex may not be as clear as they seem. One study found no statistically significant relationship among strong patients between gag reflex absence and aspiration risk. Indeed, in some cases, the gag reflex may offer false reassurance, while its absence may trigger unnecessary medical interventions. And of course, checking the gag reflex can be a painful and frightening procedure, especially for children and elders. 


This is why agencies must establish clear policies for when this test is necessary, and how to proceed in response to its results. The gag reflex is not a reliable sole determinant of whether to intubate a patient, nor whether it’s time to remove the endotracheal tube. Instead, look for other signs.


Why You Need the Right Equipment 

No matter how your agency handles the gag reflex in intubated patients, one fact is certain: Having the right equipment ensures prompt intervention that can save lives.  For help finding the right respiratory equipment and suction machine for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.