Pleural complications of nasoenteric feeding tubes

Pliable, small-bore, feeding tubes are inserted frequently in critically ill patients. The use of wire stylets to facilitate passage of these tubes has increased the chances of unrecognized tracheal intubations, particularly in obtunded patients. Five patients with depressed sensoria had inadvertent transbronchial insertions of feeding tubes into their pleural spaces over a 28-month period. The incidence of this complication among intensive care unit patients was 0.3%. Sequellae included pneumothoraces in four patients, pleural effusions in three patients, and pneumonia with a pulmonary abscess in one patient. The presence of cuffed endotracheal tubes did not prevent this complication in patients with depressed cough reflexes. Inexperience of feeding tube insertors may have contributed to pleural intubations in four of the patients. In patients with depressed sensoria, adequate confirmation of feeding tube location in the stomach or duodenum requires both chest and abdominal roentgenograms.     

Pneumothorax following attempted nasogastric intubation for nutritional support

Nasogastric intubation is a routine procedure, performed daily by both medical and nursing staff. It is a simple procedure, but not without complications which can be life threatening. We present an unusual, life threatening complication which occurred when nasogastric intubation using a no. 8 polyurethane tube with its metal stilet resulted in a pneumothorax after intubation of the endotracheal tree in the presence of a cuffed endotracheal tube. We emphasize that the presence of a cuffed endotracheal tube should not be considered a safeguard against pulmonary intubation during nasogastric placement of a feeding catheter.     

Nasopulmonary intubation with feeding tubes: case reports and review of the literature

Pulmonary aspiration of regurgitated feeding material is a recognized complication of enteral nutrition by feeding tube. Nasopulmonary intubation with feeding tubes has been reported infrequently. We present two patients with such complications. In one, nasopulmonary intubation resulted in a pneumothorax. In the other unrecognized misplacement resulted in pneumonia and hydrothorax. Similar cases in the literature are discussed. Common features of this complication are: (1) patients who are obtunded, debilitated, or without gag reflex; (2) previous successful insertion of a tube; (3) successful passage past endotracheal tubes and tracheostomies; and (4) positive auscultation of insufflated air over the left upper quadrant. Complete prevention of this complication probably is not possible, but health care personnel should be aware of this potential problem in the patient at risk.     

Improved design of nasogastric feeding tubes

Disappointed with the overall performance of weighted and unweighted nasogastric feeding tubes, a design programme was initiated which resulted in the development of two new nasogastric tubes, one weighted and one unweighted. The tubes were manufactured with polyurethane rather than polyvinylchloride (PVC) which permitted an increase in diameter of the internal lumen which in turn was coated with water activated lubricant to ease removal of the introducer wire. A specially modelled outflow port was incorporated into the tips of both tubes. The performance of the two new polyurethane nasogastric feeding tubes was assessed under controlled trial condition using as a reference a widely used PVC unweighted open ended tube. While intubation times were similar in patients without concurrent endotracheal intubation, it took a significantly shorter time to intubate patients with concurrent endotracheal intubation with the new weighted tube. Following tube intubation, it was possible to aspirate gastric contents significantly more often through the new polyurethane tubes (p < 0.001) than through the PVC tube, and the unweighted polyurethane tube stayed in situ longer (p < 0.05) than the PVC tube. The newly designed polyurethane nasogastric feeding tubes are the first tubes that have been shown to have advantages over the simpler type of open ended, unweighted PVC nasogastric feeding tubes.     

Clinical audit: optimal positioning of endotracheal tubes in neonates

BACKGROUND: The malposition of endotracheal tubes (ETTs) can be associated with endo-bronchial intubation or accidental extubation. A variety of methods have been reported for predicting insertional length (IL) including weight, nasal-tragus length (NTL) and sternal length (STL) measurements. In our unit no consistent predictor method was being used. AIM: To audit the proportion of endotracheal tubes that required a significant position change after oral intubation. Our standard set was that the endotracheal tube should be in a satisfactory position in > 80% of cases. If not met, practice would then be re-audited after a consistent predictor method had been implemented. METHODS: Data regarding changes in endotracheal tube position were collected. Significant position changes were defined as adjustments > 0.5 cm. RESULTS: Twenty two babies were included in the initial audit, and only 73% of endotracheal tubes had a satisfactory position. Thirty six babies were included in the re-audit and when the nasal-tragus length predictor was used, 94% of endotracheal tubes had a satisfactory position, meeting the standard. CONCLUSION: The nasal-tragus length predictor improved the accuracy of endotracheal tube positioning after oral intubation. It is a simple, fast, reproducible method and can be used in everyday practice to help avoid significant endotracheal tube malposition.     

Endoscopic placement of fine bore nasogastric and nasoenteric feeding tubes

In a small proportion of patients requiring enteral nutrition it may not be possible to site nasogastric or nasoenteric feeding tubes using standard intubation techniques. We describe an endoscopic method of tube placement applicable not only for positioning nasogastric feeding tubes in patients with coexisting oesophageal pathology, but also for placement of nasoenteric feeding tubes when disordered gastric emptying is present.     

Determination of a practical pH cutoff level for reliable confirmation of nasogastric tube placement

Background: Enteral feeding is a common method of nutrition support when oral intake is inadequate. Confirmation of correct nasogastric (NG) tube placement is essential. Risks of morbidity/mortality associated with misplacement in the lung are well documented. Studies indicate that pH ≤4 confirms gastric aspirate, but in pediatrics, a pH of gastric aspirate is often >4. The goal of this study was to determine a reliable and practical pH value to confirm NG tube placement, without increasing the risk of not identifying a misplaced NG tube. Methods: Pediatric inpatients older than 4 weeks receiving enteral nutrition (nasogastric or gastrostomy) were recruited over 9 months. Aspirate samples were pH tested at NG tube placement and before feedings. If pH >4, NG tube position was confirmed by chest radiograph or further investigations. In addition, intensive care unit (ICU) patients who required endotracheal suctioning were recruited, and endotracheal aspirate samples were pH tested. Results: A total of 4,330 gastric aspirate samples (96% nasogastric) were collected from 645 patients with a median (interquartile range [IQR]) age of 1.0 years (0.3–5.2 years). The mean (standard deviation [SD]) pH of these gastric samples was 3.6 (1.4) (range, 0–9). pH was >4 in 1,339 (30.9%) gastric aspirate samples, and of these, 244 were radiographed, which identified 10 misplaced tubes (1 with pH 5.5). A total of 65 endotracheal aspirate samples were collected from 19 ICU patients with a median (IQR) age of 0.6 years (0.4–5.2 years). The mean (SD) pH of these samples was 8.4 (0.8) (range, 6–9.5). Conclusion: Given that the lowest pH value of endotracheal aspirate sample was 6, and a misplaced NG tube was identified with pH 5.5, it is proposed that a gastric aspirate pH ≤5 is a safer, reliable, and practical cutoff in this population.     

Endotracheal intubation skills of medical students.

The ability and confidence of clinical medical students to insert endotracheal tubes correctly and quickly and to recognize oesophageal misplacement was evaluated. Ten (33%) of the medical students intubated the trachea correctly at their first attempt but 14 (47%) incorrectly identified the position of the endotracheal tube. However, recognition improved by their second and third attempts (70% and 80% respectively). Ninety-three percent of students intubated correctly on their third attempt. Although medical students can obtain better results at correct tube placement with repeated attempts under optimum conditions--a practice effect--and do better at recognizing correct tube placement there is still a persistent failure to recognize endotracheal tube misplacement, ie oesophageal intubation. It is the ability to recognize oesophageal intubation promptly that is a life-saving skill. This essential skill should be taught during the introductory anaesthesia programme through the use of clinical patients.     

7 g weighted versus unweighted polyurethane nasoenteral tubes--spontaneous transpyloric passage and clinical performance: a controlled randomised trial

A proportion of patients requiring enteral nutrition is at increased risk of regurgitation or pulmonary aspiration of enteral diet as a result of gastric atony or paresis. The positioning of the distal end of an enteral feeding tube beyond the pylorus into duodenum or jejunum may reduce this risk. It has been postulated that by suitable lengthening of feeding tubes and by altering the distal end tip profile or by the addition of a weight, spontaneous passage of a tube through the pylorus after pernasal insertion may be achieved. In a recent controlled trial we were unable to demonstrate any advantage to a) modifying the tip profile or b) the addition of a 2.4 g weight. This prospective controlled clinical study examined the difference between an unweighted polyurethane tube which had performed optimally in the previous study and a new 7 g weighted tube similar in all other respects. In both cases less than 50% of tubes had passed spontaneously through the pylorus when assessed at 24 h, with no significant difference in performance (p = 0.38). When comparing overall length of time that each tube remained in situ, there was similarly no significant difference between the 7 g weighted and unweighted tubes (p = 0.277). We conclude that the addition of a 7 g weight to a suitably lengthened enteral feeding tube confers no advantage on either incidence of spontaneous transpyloric passage or in prolonging tube usage. If post-pyloric feeding is indicated for a patient, positioning by either fluoroscopic or endoscopic techniques should be undertaken.     

Nutritional support of the dysphagic patient: methods, risks, and complications of therapy

The indications, methods, and complications of nutritional support of 90 patients admitted with a primary complaint of dysphagia were reviewed. Patients were divided into two groups based on etiology of dysphagia (central neurologic vs local mechanical dysfunction). All patients on admission exhibited marked malnutrition with an average weight loss of 12 +/- 9.8% body weight, serum transferrin 165 +/- 60.1 mg/dl, and albumin 3.2 +/- 0.85 mg/dl. All patients were placed on either enteral (63%) or parenteral (37%) nutrition. Twenty-seven percent of all patients suffered a complication of nutritional therapy. Patients with nasoenteric tubes had a 10% complication incidence (aspiration or endotracheal placement of tube) resulting in a 30% mortality rate; significantly higher (p less than 0.05) than seen with other modalities. Any form of upper enteric feeding (nasoenteric or gastrostomy) was associated with significantly increased (p less than 0.01) risk of aspiration pneumonia. It is concluded that patients admitted to hospital with dysphagia as the major complaint suffer from severe malnutrition, and that upper gastrointestinal intubation should not be employed for feeding until the dysphagia has resolved.     

经内镜十二指肠营养管置放术在重度昏迷气管切开气管插管患者的应用价值

目的探讨经内镜十二指肠营养管置放术在重度昏迷气管切开气管插管患者的应用价值．方法对28例已行气管切开气管插管的重度昏迷患者进行经内镜十二指肠营养管置放术。结果本组28例患者经内镜十二指肠营养管置放术均获成功，术中未发生任何经内镜十二指肠营养管置放术相关性并发症。所有患者在术后立即恢复了胃肠营养=十二指肠营养管置放术最长用时为31min，最短仅8min，平均16min。患者平均带管时间为73(7～218)d。所有患者仅1例发生营养菅堵塞、脱管等现象。无一例出现通过十二指肠营养管注入的营养物或药物的反流。结论对于重度昏迷已行气管切开气管插管的患者，经内镜十二指肠营养管置放术是一种有效、简便、安全的建立胃肠营养的方法。     

Nasoenteric feeding tubes in critically ill patients (fluoroscopy versus blind)

Numerous complications have been encountered with small-bore nasoenteric feeding tubes, some potentially life threatening. Patients particularly at risk are those with anatomic abnormalities, debilitation, or neurologic impairment. Fluoroscopy has been reported to be a safe, efficacious modality for the placement of these tubes. Thirty critically ill patients were studied to assess caloric delivery, costs, and complications associated with both fluoroscopically and blindly placed feeding tubes. All patients had either a tracheostomy or an endotracheal tube. They were randomized to group A (fluoroscopy) or group B (blind). Caloric delivery was greater in group A patients on days 1 through 5, with statistically significant differences on days 1 through 4. The mean daily calories per patient over the study period was 1135 +/- 96 and 662 +/- 110 (mean +/- SEM) in groups A and B, respectively (P < 0.01). Costs were similar in both groups. The most frequent problems encountered were difficult insertion, tubes requiring replacement, and failure to intubate the duodenum. We conclude that critically ill patients intubated either endotracheally or with tracheostomy should have nasoenteric feeding tubes placed with the guidance of fluoroscopy.     

机械通气患者气管内导管生物被膜的观察

目的研究机械通气患者气管内导管生物被膜的形成情况以及生物被膜的形态和病原学分布特征及耐药性. 方法前瞻性研究了27例施行人工气道(气管插管和气管切开)并机械通气的患者拔除的气管内导管,分别进行扫描电镜观察生物被膜的形成,并进行细菌培养及耐药性检测. 结果 27例气管导管中培养阳性25例,占92.6%,以粪肠球菌、金黄色葡萄球菌及铜绿假单胞菌最常见,均呈高度耐药,但与痰培养结果差异无明显性;扫描电镜观察26例均可见膜状物,并可见细菌团状聚集,其间可见纤维样物质交联,膜状物中可见网状裂纹,其上附着大量细菌. 结论机械通气时气管内导管表面易黏附细菌,形成生物被膜,生物被膜的形成可能与VAP的发生有关,并常常导致难治性感染.     

自制鼻咽通气导管

目的：研制一种新型鼻咽通气导管，解决患者在麻醉过程中舌后坠导致上呼吸道不通畅问题。方法：利用套囊已破损的各型号乳胶弹簧气管导管，剥掉套囊，根据患者需要长度不同，剪去导管尾端多余部分，然后装上导管接头。结果：观察50例麻醉过程中发生舌后坠患者，置入该通气导管后，鼾声消失，呼吸道通畅。结论：新型鼻咽通气导管改制容易，符合临床需要。     

Transnasal endoscopic placement of feeding tubes in the intensive care unit

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double-lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty-one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8-mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x-ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.     

Esophageal perforation by nasoenteral feeding tube—A case report

The use of nasoenteral feeding tubes has increased in recent years. However, the rigid wire used to stiffen the tube during insertion can produce complications. To prevent the perforation of the enteral or respiratory tract, the wire introducer should not be advanced beyond the nasopharynx, and the placement of the tube should be systematically verified with X-rays.     

Perforation of the small bowel after insertion of feeding jejunostomy: a case report

Feeding jejunostomy has become a useful method of feeding many patients with upper digestive tract dysfunction from a variety of causes. Although problems infrequently do occur with the tube itself, such as dislodgement or obstruction, most patients tolerate the procedure well. We report here a case of perforation of the jejunum that was caused by the tube itself and required reoperation. As with many problems in surgery, careful attention to technical details should help prevent this and other problems after feeding tube insertion.     

High frequency-low morbidity mechanical complications of tube feeding: a prospective study

Because of preferential use of the enteral route for nutritional support, a prospective study of mechanical complications was done in 109 consecutive patients. One hundred seventy-two nasogastric tubes were placed in 60 patients, 42 esophagostomies in 28 patients, 32 gastrostomies in 22 patients and 9 jejunostomies in 8 patients. Data show that the use of enteral feeding tubes is not without complications. The complications fell into two major categories. There were 15 low frequency mechanical complications, of which four (2 carotid artery blowouts, 1 gastrointestinal perforation, and 1 aspiration) were of high morbidity and 11 of low morbidity. There were 132 high frequency-low morbidity complications with the use of 255 tubes. These consisted mainly of unplanned and untimely removal of feeding tubes with interruption of feedings and necessitating tube replacement. Data indicate that the main problems related to the use of enteral nutrition are not the dramatic complications which create notoriety but those related to the ordinary mechanical complications occurring daily and which command little attention because of their low mortality. These can assume importance because of their high frequency and as such are characterized as high frequency-low morbidity complications.     

上消化道穿孔超过24小时后手术并放置空肠营养管27例的临床观察

目的评价上消化道穿孔超过24小时后手术并放置空肠营养管的临床疗效。方法术中行穿孔修补,尽可能地彻底清除腹腔脓液、脓苔,温生理盐水清洗腹腔直至清洁,空肠上段留置空肠营养管。结果 27例患者均未发生修补口瘘、腹腔脓肿、切口感染及短期肠梗阻,平均住院天数13d,一期愈合出院。结论上消化道穿孔超过24小时、腹腔严重污染的患者,术后采用空肠营养管行早期肠内营养,对患者术后恢复有指导性作用     

Enteral access for nutrition in the intensive care unit

PURPOSE OF REVIEW: Enteral nutrition is the preferred route for nutrition support in the intensive care unit setting. This is usually delivered through nasoenteric feeding tubes in patients with an otherwise functional gastrointestinal tract. Placement of nasoenteric feeding tubes, however, may be difficult in this setting. Nasoenteric feeding tubes may be placed by multiple methods, each with their particular advantages and disadvantages. This review summarizes the recent literature on different methods of nasoenteric feeding tube placement with emphasis on critically ill patients. RECENT FINDINGS: Bedside assisted methods using electromyogram, electrocardiogram, and magnetic fields to provide immediate positional feedback to help guide tube advancement appear promising. Bedside methods using specific protocols, modified feeding tubes, prokinetics or magnetic assistance were also successfully reported. None of these methods has been prospectively compared with more commonly practiced methods in large studies. Endoscopic nasoenteric tube placement methods including transnasal approaches using ultra-thin endoscopes have been recently described and appear to be equivalent to fluoroscopic placement. All these recently reported techniques, however, may require more specialized equipment or training than is currently widely available. SUMMARY: Feeding tubes can be placed using bedside, fluoroscopic, and endoscopic means. Novel bedside methods have been recently described using immediate positional feedback or new assistive methods. Endoscopic techniques have similar success rates to fluoroscopic techniques and provide data on upper gastrointestinal abnormalities. There is no clear universal standard method. When feeding tube placement is required the technique used depends on local institutional resources and expertise.