Effect of nasogastric tubes on incidence of aspiration

Leder SB, Suiter DM. Effect of nasogastric tubes on incidence of aspiration.

Objective

To determine what effect, if any, a nasogastric (NG) tube has on occurrence of anterograde aspiration during objective evaluation of swallowing using both liquid and puree bolus consistencies.

Design

Prospective, consecutive.

Setting

Large, urban, tertiary care, teaching hospital.

Participants

Referred sample of 1260 consecutively enrolled inpatients. Group 1 (n=630; 346 male, 284 female) had an NG tube and group 2 (n=630; 360 male, 270 female) did not have an NG tube at time of referral for dysphagia evaluation.

Intervention

Fiberoptic endoscopic evaluation of swallowing (FEES).

Main Outcome Measure

Aspiration status.

Results

A Pearson chi-square indicated no significant differences (P>.05) for aspiration of either liquid or puree food consistencies dependent on presence of an NG tube. Separate binary logistic regression analyses were used to determine if the presence of an NG tube interacted with participants’ age to affect the dependent variables of liquid and puree aspiration. There were no significant effects for liquid aspiration (odds ratio [OR]=1.004, P>.05; 95% confidence interval [CI], 0.987−1.021) or puree aspiration (OR=0.992, P>.05; 95% CI, 0.971−1.014). In addition, no significant interactions (P>.05) were found between NG tube status and sex, age, or diagnostic category, and presence of an NG tube did not significantly increase the odds of either liquid aspiration (OR=1.092, P>.05; 95% CI, 0.842−1.418) or puree aspiration (OR=0.975, P>.05; 95% CI, 0.713−1.333). Last, subjects between 60 and 90 years of age, regardless of NG tube status, aspirated more frequently than younger subjects.

Conclusions

No statistically significant differences were found regarding aspiration status for liquid or puree food consistencies between 2 separate but comparable groups, that is, one with and one without an NG tube, regardless of sex, age, or diagnostic category. Because objective swallowing evaluation, for example, FEES, can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate dysphagia. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation.     

Bronchopleural complications of nasogastric feeding tubes

Enteral alimentation via small soft feeding tubes is becoming more common as the importance of nutrition is recognized in the debilitated patient. The monofilament wire stylets that stiffen these tubes during their insertion may cause potentially lethal bronchopleural complications unless correct insertion techniques are used and the tube's position is carefully checked before starting enteral nutrition.     

Guidelines for testing the placing of nasogastric tubes

The National Patient Safety Agency has produced guidance on the safe testing of nasogastric tubes. This article outlines the recommendations and discusses their rationale and background.     

Safe placement of nasogastric tubes in children

Insertion of nasogastric tubes is a common nursing procedure but practice rituals and unfounded assumptions can compromise safety. Current methods for checking the position of nasogastric tubes are not always suitable in children but there is limited guidance on how to proceed when gastric placement cannot be determined. As a result of a local adverse incident, a working party challenged the assumptions and rituals of practice using an evidence-based framework. A nasogastric tube algorithm was developed using a risk assessment approach to improve the safety of children in hospital and community settings.     

Cancers of the maxillary sinus

Maxillary sinus cancers are rare as compared with cancers of other sites. Because the onset is insidious, they are at an advanced stage at diagnosis and therefore present a therapeutic challenge for local control. Traditionally, treatment has been surgery or irradiation, or a combination of the two. Local control and survival, however, remains poor. Numerous chemotherapeutic agents have shown activity against squamous cell cancers of the head and neck. In several studies the use of either neoadjuvant or concurrent chemotherapy has improved local control and survival when compared with historical controls. Randomized studies are needed to confirm the benefit of chemotherapy over the standard forms of surgical and radiation therapy.     

Mucocoeles of the maxillary sinus

Mucocoeles of the paranasal sinuses most commonly occur in the frontal or anterior ethmoidal sinuses. We report two rare cases of mucocoele of the maxillary sinus and describe the presentation, investigations and treatment. A review of the literature on this rare clinical entity is included, with specific reference to diagnostic imaging to distinguish mucocoeles from neoplastic sinus disease.     

Nursing care of patients with nasogastric feeding tubes

Nasogastric tubes are commonly used for patients as a short-term method of providing continuous, pre-packed liquid feed. In order to explore how evidence-based practice is being incorporated into care, we conducted a survey investigating the views and practices of nutrition specialist nurses in acute trusts across the UK. A postal questionnaire comprising 35 questions considered the role of the nutrition specialist nurse, care of patients with nasogastric tubes, and training and education of nurses in the care of these patients. Results of this small study indicate differences in the education and practice of nursing care for patients with nasogastric tubes. Therefore, it is vital that evidence and good practice is disseminated both locally and nationally by benchmarking practice and by sharing knowledge and experiences in both journals and conferences. Nurses also need support in practising their skills to ensure they feel confident in caring for patients with nasogastric tubes.     

Accidental removal of endotracheal and nasogastric tubes and intravascular catheters

OBJECTIVES: To characterize the rates of accidental removal of endotracheal tubes, nasogastric tubes, central venous catheters, and arterial catheters. To assess the efficacy of corrective measures aimed at reducing the accidental removal of these devices. DESIGN: Prospective, observational, and interventional study. SETTING: Eighteen-bed medical-surgical intensive care unit of a 650-bed tertiary care hospital. PATIENTS: Patients admitted to the intensive care unit who had any of the following devices in place for more than 24 hrs: endotracheal tube, nasogastric tube, central venous catheter, arterial catheter. MEASUREMENTS AND INTERVENTIONS: Data were collected on the date of placement of tubes and catheters, position of vascular catheters, date of removal, and reason for removal. The study involved three consecutive 6-month periods. At the end of the first and the second periods, information about rates of accidental removal was provided to the physicians and nurses. In addition, the personnel were instructed to be more vigilant and specific measures aimed at reducing the accidental removal were introduced. MAIN RESULTS: In the first period, 289 endotracheal tubes were placed and 13.1% (24.7 per 1000 days) were removed accidentally. In the second and third periods, 17.1% (25.5 per 1000 days) and 11.4% (15.1 per 1000 days) were removed accidentally, respectively. In the first period, 368 nasogastric tubes were placed and 41% (73.9 per 1000 days) were removed accidentally. In both the second and the third period, a significant reduction in the rate of accidental removal was observed (32.4% or 41.2 per 1000 days and 25.8% or 29.8 per 1000 days, respectively). A significant decrease was observed in the rates of accidental removal of central venous catheters from 7.5% (12.4 per 1000 days) in the first period to 3.6% (5.4 per 1000 days) in the second period. The rate of arterial catheters accidentally removed expressed according to the time at risk significantly decreased from 46.5 per 1000 days in the first period to 19.1 per 1000 days in the second period and 25.3 per 1000 days in the third period. CONCLUSIONS: The information provided by the rates of accidental removal expressed by patient-days is helpful to compare results obtained in populations with different times of follow-up. Education of medical personnel and limiting upper-extremity access to within 20 cm from any catheter or tube resulted in a significant reduction of patient-related removal of tubes and catheters.     

不同上颌窦底形态冲顶对冲顶器、窦底骨质及黏膜应力和位移影响的三维有限元分析

背景:上颌窦内提升术往往在盲视下操作,很难判断上颌窦黏膜的完整性,也不清楚上颌窦底形态是否会影响上颌窦内提升窦底冲顶过程.目的:通过建立不同上颌窦底形态的上颌窦区域及冲顶器的三维有限元模型,了解窦底形态对上颌窦内提升术窦底提升安全性与效率的影响.对象:男性志愿者1名,45岁,全口牙列完整,牙周组织健康,上颌窦底形态为浅凹形.采用16排螺旋CT获取数据重建三维有限元模型.设计、时间及地点:重复观察测量,于2007-05/10在上海大学快速制造中心完成.方法:利用逆向工程建立了浅凹形、深凹形和凸形窦底形态的上颌窦区域三维有限元模型.模拟上颌窦内提升手术,在窦底部位施加动态冲击载荷进行窦底提升.主要观察指标:分析窦底冲顶时冲顶器、窦底骨质及黏膜的应力和位移情况.结果:深凹形的上颌窦底进行提升时效率最高、风险较小,面凸形上颌窦底形态应力分散的作用较强,提升效率最低,而且黏膜上张力增加,不利于上颌窦底的提升.结论:三种不同的上颌窦底形态中,凹形上颌窦底提升时黏膜上张力增加对内提升术有着不利的影响,凸形上颌窦底提升效率最低.     

Endoscopic sinus surgery in cases of cholesterol granuloma of the maxillary sinus

Cholesterol granuloma is usually associated with middle ear disease and is very rare in the paranasal sinuses. We report a case of cholesterol granuloma originating in the maxillary sinus of a 52-year-old female. Endoscopic sinus surgery was performed on the left maxillary sinus, and the cholesterol granuloma was successfully removed by the middle meatal antrostomy. Light microscopic examination showed granulomatous tissue with typical cholesterol clefts, multinucleated foreign body giant cells, small areas of hemorrhage, hemosiderin-laden macrophages and plasma cells. We also describe the details of the endoscopic surgical techniques employed in the treatment of this disorder.     

Large complex odontoma of the left maxillary sinus

Odontomas as a group are the most common odontogenic neoplasms. They are mixed lesions containing fully formatted dental tissues, both epithelial and mesenchymal, and are usually found during a routine radiographic examination or as a factor in noneruption. Odontomas can be divided into two types: the complex and the compound odontoma. Both types are composed of enamel, dentin, cementum and pulp tissues, but in complex odontomas the tissues are arranged in a haphazard fashion with no discernible dental structures, whereas in compound odontomas the dental tissues exist in a more regular pattern so that the lesion consists of tooth-like structures. We report a case of a 23-year-old man with a large complex odontoma involving the left maxilla and maxillary sinus with clinical, radiographic and histological findings. Because of the size of the mass and its clinical course, benign neoplasms were considered in the differential diagnosis. Surgery was the treatment of choice, and recurrence of the lesion is not expected.     

Insertion of difficult nasogastric tubes through a nasoesophageally placed endotracheal tube

A technique is described to facilitate the insertion of NG tubes with the aid of nasoesophageal insertion of an endotracheal tube. This technique is particularly useful in comatose and anesthetized patients. The equipment utilized is easily assembled and readily available. We have found this method to be easier and more successful than those previously described.     

两种上颌窦内提升术对上颌窦内垂直骨量不足患者的疗效

目的探讨两种上颌窦内提升术治疗上颌窦内垂直骨量不足患者的近远期疗效。方法选取2017年3月至2019年3月收治的58例上颌窦内垂直骨量不足患者为研究对象,根据治疗方法的不同将其分为水压法组(n=30)和冲顶法组(n=28)。水压法组采用水压法治疗,冲顶法组采用冲顶法治疗。比较两组手术时间、视觉模拟评分(VAS)、上颌窦底提升高度、骨吸收高度、种植体存留率及不良反应情况。结果两组手术时间和上颌窦底提升高度比较差异无统计学意义(P> 0. 05)。水压法组VAS评分明显低于冲顶法组(P <0. 01)。术后6、12、24个月,两组骨吸收高度逐渐增高(P <0. 01);术后6、12、24个月,水压法组骨吸收高度明显低于冲顶法组(P <0. 01)。两组种植体存留率比较差异无统计学意义(P> 0. 05)。两组患者术中及随访期间均未发生上颌窦黏膜穿孔、出血等并发症。结论水压法和冲顶法治疗上颌窦内垂直骨量不足患者均能够有效提升上颌窦底高度,种植体留存率较高,且具有较高的安全性;而水压法较冲顶法近远期吸收少,患者术后疼痛感低。     

Measures to test placement of nasogastric and nasointestinal feeding tubes: a review

A literature review regarding commonly recommended bedside measures to test nasogastric and nasointestinal feeding tube placement is presented in this article. Among the methods discussed are: aspiration of recognizable gastrointestinal contents, auscultation of insufflated air, measurement of pH of gastrointestinal secretions, and observing for coughing and choking, inability to speak, and the appearance of bubbles from the end of the tube when it is held under water. Fallibilities in these methods as well as discrepancies in recommendations for their implementation and interpretation are discussed along with implications for current practice and needed areas for research.