Findings of Videofluoroscopic Swallowing Studies AreAssociated with Tube Feeding Dependency at Discharge in StrokePatients with Dysphagia

The factors associated with tube feeding dependency in stroke patients with dysphagia have received little attention. This study aimed to identify factors independently associated with tube feeding dependency at discharge in stroke patients with dysphagia using videofluoroscopic swallowing studies (VSS) and clinical findings. One hundred eighty-one consecutive tube-fed inpatients with stroke-related dysphagia referred for VSS were enrolled in the study. Of them, 47 patients continued to require tube feeding at discharge. In the final logistic regression analysis model, advanced age, recurrent stroke, confinement to a wheelchair at discharge, long duration from stroke onset to VSS, and stasis in valleculae or pyriform sinuses and aspiration on VSS were independently associated with tube feeding dependency at discharge. This study confirms the association between findings of VSS and tube feeding dependency at discharge in stroke patients with dysphagia. Based on the final regression model, a preliminary equation was proposed to help clinicians better predict the tube feeding dependency at discharge in stroke patients with dysphagia. An erratum to this article is available at .     

Tube esophagogram: a better radiological technique for evaluation of esophageal diseases

Forty-six patients with suspected esophageal disease were studied by tube esophagography. This was performed by positioning a rubber tube in the proximal esophagus, followed by swallowing of high density barium suspension and insufflation of air through the tube. Comparison in 20 cases showed superiority of tube study over conventional double contrast barium, with alteration in diagnosis in six cases and additional information in 14 cases. Tube esophagogram is a safe, simple and valuable adjunctive technique leading to accurate and definitive radiological diagnosis of esophageal disease.     

Percutaneous endoscopic gastro-duodenostomy: modified technique

OBJECTIVES: Percutaneous endoscopic gastro-jejunostomy is appropriate for patients with severe neurologic deficit to avoid repeated tube feeding-related aspiration. We describe a modified technique of endoscopic gastro-duodenostomy. PATIENTS AND METHODS: This technique was performed in 9 patients with severe neurologic deficit. No fluoroscopy was necessary. The gastrostomy button was pushed across the pylorus into the bulb; a nasogastric tube was then placed in the duodenum under endoscopic control and the button was drawn to the gastric wall. When the gastroduodenal tube migrated or was occluded, the button was placed in the bulb through the pylorus and maintained in this position for alimentation. RESULTS: Placement of the gastro-duodenostomy tube was successful without any complication in 100% of patients. The mean duration of the procedure was 15 min. The tube had to be removed for migration (N = 4) and occlusion (N = 5) after a mean period of 5.8 weeks (range: 2-10). During the follow-up period, no tube feeding-related aspiration was observed. CONCLUSION: This modified low-cost technique of endoscopic gastro-duodenostomy is simple and efficient.     

Plastic endobronchial tubes in the management of life-threatening hemoptysis

Plastic double-lumen endobronchial tube was used to maintain the airway in a patient with massive hemoptysis and nonresectable lung cancer. This tube is superior to the previously used Carlens tube, as it can be inserted in emergency situations and does not require surgical setting. In addition, the larger internal diameter of these tubes allows better airway clearance and passage of a flexible bronchoscope. The double-lumen tube may be considered as an alternative to selective main-stem intubation.     

Treatment of acute nontoxic megacolon during colonoscopy: tube placement versus simple decompression

The study compares the efficacy of colonoscopic decompression versus decompression and tube placement in the treatment of Ogilvie's syndrome. Nine patients were treated with a single colonoscopic decompression which resulted in four recurrences. In contrast, there were no recurrences observed in 11 patients who underwent decompression and subsequent tube placement (p less than 0.05). There was no morbidity observed from either decompression or tube placement. Tube placement added less than 10 min of additional procedure time to the colonoscopy. The tube utilized in this study was an enteroclysis tube with sideholes cut in the distal 20 cm. The tube was easily inserted over a Teflon-coated flexible guide wire inserted through the colonoscope into the cecum following decompression. This study demonstrates that colonoscopic decompression followed by tube placement is the preferred treatment modality for acute nontoxic megacolon.     

Effects of the Removal of the Tracheotomy Tube on Swallowing During the Fiberoptic Endoscopic Exam of the Swallow (FEES)

This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient’s swallowing function will improve once the tracheotomy tube has been removed. Work for this project was completed at Marianjoy Rehabilitation Hospital, Wheaton, Illinois.     

Small bowel obstruction from a dislodged feeding tube

Elderly nursing home patients may suffer from inadequate oral nutritional intake for a variety of reasons. In some of them, nutritional status cannot be maintained without the use of enteral feeding. Nasogastric tube feeding is associated with significant patient discomfort, and may lead to significant complications. Thus, in those who require long-term enteral tube feeding, a gastrostomy tube may be necessary. Although surgical insertion may occasionally be required, percutaneous insertion with upper endoscopy assistance is usually safe and feasible. This case represents an unusual complication of such a gastrostomy tube, which draws attention to the need for appropriate care of these tubes.     

Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?

Replacement of gastrostomy tube in patients under-going percutaneous endoscopic gastrostomy (PEG) is generally considered as a safe and simple procedure. However, it could be associated with serious complications, such as gastrocutaneous tract disruption and intraperitoneal tube placement, which may lead to chemical peritonitis and even death. When PEG tube needs a replacement (e.g., occlusion or breakage of the tube), clinicians must realize that the gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation between gastric wall and abdominal wall in PEG. In general, the tract of PEG begins to mature in 1-2 wk after placement and it is well formed in 4-6 wk. However, this process could take a longer period of time in some patients. Accordingly, this article describes three major principles of a safe PEG tube replacement: (1) good control of the replacement tube along the well-formed gastrocutaneous tract; (2) minimal insertion force during the replacement, and, most importantly; and (3) reliable methods for the confirmation of intragastric tube insertion. In addition, the management of patients with suspected intraperitoneal tube placement (e.g., patients having abdominal pain or signs of peritonitis immediately after PEG tube replacement or shortly after tube feeding was resumed) is discussed. If prompt investigation confirms the intraperitoneal tube placement, surgical intervention is usually required. This article also highlights the fact that each institute should have an optimal protocol for PEG tube replacement to prevent, or to minimize, such serious complications. Meanwhile, clinicians should be aware of these potential complications, particularly if there are any difficulties during the gastrostomy tube replacement.     

The provision of a percutaneously placed enteral tube feeding service

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.     

Fabrication of Aluminum Foam-Filled Thin-Wall Steel Tube by Friction Welding and Its Compression Properties

Aluminum foam has received considerable attention in various fields and is expected to be used as an engineering material owing to its high energy absorption properties and light weight. To improve the mechanical properties of aluminum foam, combining it with dense tubes, such as aluminum foam-filled tubes, was considered necessary. In this study, an aluminum foam-filled steel tube, which consisted of ADC12 aluminum foam and a thin-wall steel tube, was successfully fabricated by friction welding. It was shown that a diffusion bonding layer with a thickness of approximately 10 μm was formed, indicating that strong bonding between the aluminum foam and the steel tube was realized. By the X-ray computed tomography observation of pore structures, the fabrication of an aluminum foam-filled tube with almost uniform pore structures over the entire specimen was confirmed. In addition, it was confirmed that the aluminum foam-filled steel tube exhibited mechanical properties superior to those of the ADC12 aluminum foam and steel tube. This is considered to be attributed to the combination of the aluminum foam and steel tube, which particularly prevents the brittle fracture and collapse of the ADC12 foam by the steel tube, along with the strong metal bonding between the aluminum foam and the steel tube.     

Discard first tube for coagulation testing

Tissue thromboplastin may contaminate the first tube sample due to the trauma of the venipuncture, and therefore, affect the accuracy of coagulation testing. This practice was stopped by Clinical and Laboratory Standards Institute after several studies. However, most of the studies have verified these conclusions and refuted the need for a discard tube when drawing samples for coagulation tests in healthy groups. The purpose of our study was to evaluate the clinical importance of discarding a tube for prothrombin time (PT) determinations on large samples with international normalized ratio (INR) values between and over targeted therapeutic range. Patients receiving oral anticoagulation therapy (OAT) managed by our cardiology service were selected for this study. Tube 1 was always treated as the discard tube. Tube 2 was allocated to be analyzed along with the tube 1 for coagulation tests. Individual values were grouped into four cohorts according to the INR range. The ranges were as follows: less than 2.0, 2.1-3.0, 3.1-4.5 and more. Three hundred and seventy-six samples were drawn for PT/INR and activated partial thromboplastin time testing. We found statistically significant differences between tube 1 and tube 2 (P < 0.05), and satisfactory correlation coefficients were obtained by linear regression analysis (0.86 or greater in all cases). This study consisted of a high number of samples. Our data suggest that drawing a discard tube is still necessary for coagulation testing. Consideration should be given to revising the international guidelines related to the necessity of a discard tube for repeated evaluation of coagulation tests especially receiving long-term OAT.     

Single-Stroke Attachment of Sheets to Tube Ends Made from Dissimilar Materials

This paper presents a new joining method by a forming process for attaching sheets to tube ends. The process consists of two different forming stages carried out sequentially in a single stroke. Firstly, the free tube end is flared by compression with a contoured die, then is squeezed (indented) against the sheet surface to create a mechanical interlocking. The new process is carried out at an ambient temperature and, in contrast to existing joining by forming operations based on tube expansion, it avoids seal welds, tube protrusions above the sheet surfaces, and machining of grooves on the sheet holes to obtain the form-fit joints. The paper starts by analyzing the process deformation mechanics and its main operating variables and finishes by presenting examples that demonstrate its effectiveness for attaching sheets to tube ends made from polyvinylchloride and aluminum. Experimental and numerical simulation work provides support to the presentation.     

Cecostomy

PURPOSE: The role and effectiveness of catheter tube cecostomy as a means of colonic decompression are not clearly defined. Our aim was to clarify the clinical indications, functional performance, and concomitant morbidity associated with tube cecostomy. METHOD: This was a retrospective chart review of patients receiving catheter tube cecostomy at the Mayo Clinic over an 11-year period. RESULTS: Sixty-seven patients (median age, 69 years) had catheter tube cecostomy placement. Clinical indications for tube cecostomy were colonic pseudo-obstruction, distal colonic obstruction, cecal perforation, cecal volvulus, preanastomotic decompression, and miscellaneous usage. Operation was emergent in 43 (64 percent) patients and elective in 24 (36 percent) patients. Tube cecostomy was the primary procedure in 47 (70 percent) patients and complimentary in 20 (30 percent) patients. Minor complications were seen in 30 patients (45 percent), including pericatheter leak, superficial wound infection, tube occlusion, skin excoriation, premature tube dislodgment, colocutaneous fistula, and ventral hernia. No patient required reoperation for tube-related morbidity. CONCLUSIONS: Catheter tube cecostomy is of therapeutic value in select clinical situations including refractory colonic pseudo-obstruction, cecal volvulus, cecal perforation, or distal colonic obstruction. Proper patient selection, careful tube placement, and vigilant postoperative tube care should provide adequate function with minimal morbidity.     

The effect of a gas leak around the endotracheal tube on the mean tracheal pressure during mechanical ventilation

Infants requiring mechanical ventilation are usually intubated with uncuffed endotracheal tubes, which permit gas to leak between the tube and the trachea. This gas leak may alter the mean pressure transmitted to the trachea by changing the pattern of airway flow and modifying the resistive behavior of the endotracheal tube. To test this hypothesis, we measured mean tracheal pressure, gas flow through the endotracheal tube, and resistance of the tube in rabbits ventilated with and without a leak. We also studied the effect of the tube size and the pattern of ventilation on these measurements. We found that a leak reduced the mean tracheal pressure by 15 to 21% with respect to the mean proximal airway pressure. This reduction was caused by an increased difference between inspiratory and expiratory flow through the endotracheal tube, and by the mean expiratory resistance of the tube being lower than its mean inspiratory resistance. The rabbits with smaller tubes had lower mean tracheal pressures. A ventilatory pattern of short inspiratory times and high peak pressures was associated with a proportionally greater decrease in mean tracheal pressure caused by the leak. These findings suggest that the mean proximal airway pressure, measured at the ventilator, may overestimate the mean tracheal pressure in the presence of a gas leak around the tube. Furthermore, the decrease in mean tracheal pressure caused by the leak may decrease oxygenation despite a constant mean proximal airway pressure.     

Knot formation in a long tube used in the treatment of a post-operative adhesive small bowel obstruction

The complications specific to the management of the nasointestinal long tubes for small bowel obstruction are not generally appreciated. We report here of a case of knot formation of the long tube which was inserted for a 60 year-old male. Because it was difficult to place the tube in the distal stomach despite frequent changes in patient position, two coiled loops were noted at the fornix as the tip of the tube reached the antrum. The tube was gently removed without injury to the esophagus or stomach under fluoroscopic control. This case illustrates that when a long tube is used, the formation of multiple coils in the stomach should be avoided during placement to prevent knotting. Furthermore, a knotted tube can be gently removed non-operatively without esophageal injury. A short tube may be superior to a long tube because most of the complications can be avoided.     

Gastric outlet obstruction caused by gastrostomy tube balloon in 3 cases

We report 3 cases with unusual complications of gastric outlet obstruction caused by a gastrostomy tube balloon. All cases developed vomiting, and 2 cases were accompanied by hematemesis. Gastric ulcer was observed in 1 case, aspiration pneumonia was observed in 2 cases, and pancreatitis was observed in 1 case. This condition improved rapidly by correction of the position of the balloon in all cases. In patient vomiting during management for gastrostomy we need to consider migration of the gastrostomy tube balloon. Careful management of the gastrostomy tube balloon is important.     

Abdominal placement of tube thoracostomy due to lack of recognition of paralysis of hemidiaphragm.

Tube thoracostomy is an invasive procedure that carries a risk of complications. We report a patient with liver cirrhosis, ascites and large left-sided pleural effusion, in whom a trocar type chest tube was inserted at the seventh left intercostal space in the midaxillary line. Chest roentgenogram revealed that the drainage tube was placed into the abdominal cavity because of a misrecognized elevation of the left hemidiaphragm. This case demonstrates that the placement of a tube thoracostomy requires caution in the identification of possible abnormalities which can lead to dangerous complications.     

Intracolonic bypass by an intraluminal tube

The most important cause of morbidity and mortality in colonic resection remains anastomotic leakage and, to this end, temporary stomas, with their own incidence of mortality or morbidity, are often created. Problems associated with both anastomosis and stoma can be prevented with the use of an internal bypass tube. This tube is implanted in the proximal colon above the proposed anastomotic site, then passed distally to the rectal ampulla, following which, the proximal and distal colonic segments are anastomosed. The fecal stream and gastrointestinal secretions are thereby prevented from coming in contact with the anastomotic site. The tube is expelled spontaneously after a varying time. The anastomoses in the experimental animals were subjected to maximal stress. Additionally, large dehiscences and induced fecal peritonitis were purposefully created in some animals. Results demonstrated that the intracolonic bypass tube prevents leakage even from gross dehiscences and that these dehiscences progress to complete healing. The experimental study leading to its clinical adaptation is presented.     

Evaluation of two methods used to stabilize oral endotracheal tubes

This study examined the effects of using an oral endotracheal tube holder versus conventional taping for stabilization of oral endotracheal tubes. Twenty-five patients were studied for 4 days, while 5 remained in the study 3 days. Each of the 30 patients had each of the two methods of stabilization in place for at least 1 day. The oral endotracheal tube holder significantly (p less than 0.0001) decreased both internal and external movement of the tube. Although self-extubation did occur in two instances, it was evaluated as less likely to occur when the tube holder was used to secure the endotracheal tube. Skin breakdown was also observed less frequently with the tube holder. Overall, nursing staff had a higher level of acceptance of the tube holder as the method of choice for stabilization of an oral endotracheal tube. Patient perceptions of the system were not evaluated because of the degree of illness of the patients.     

Iatrogenic pleuropulmonary charcoal instillation in a teenager

Activated charcoal given through a nasogastric tube is a standard intervention for many types of toxic ingestions in the emergency department. This case study describes a teenage girl whose multidrug overdose was complicated by accidental charcoal instillation into her left lung and pleural space through a misplaced nasogastric tube. The ensuing empyema did not respond to antibiotic therapy alone, probably due to the inherent properties of charcoal, and required a chest tube placement with continuous irrigation. Unlike previously reported cases, this patient did well clinically, without long-term morbidity.