Enteral tube feeding in the community: survey of adult patients discharged from a Dublin hospital

BACKGROUND AND AIMS: No previous study has examined the state of patients on enteral tube feeding in the community in the Republic of Ireland. METHODS: Fifty adult patients discharged from a Dublin hospital on enteral tube feeding were assessed retrospectively. RESULTS: Sixty-six per cent of the sample were over 65 years of age. Patients required enteral tube feeding as a consequence of swallowing difficulties caused by stroke (46%) or cancer of the head and neck (24%). Most patients were on full nutritional support and, in total, had spent over 49 years tube feeding in the community. Geriatric stroke patients were found to have poor functional ability and nutritional assessment proved difficult to carry out on many of these patients. Problems encountered with feeding included blocked tubes (30%), infected stoma sites (16%), and logistical problems regarding feed and equipment. Nutritional follow-up was not routine in patients with poor mobility, and 55% of patients on long-term tube feeding had not been reviewed by a dietitian in over 1 year. Patients had little faith in their general practitioner's knowledge of enteral feeding. CONCLUSIONS: While patients and families appear to cope remarkably well with tube feeding in the community, more support is necessary to ensure appropriate feeding and to monitor the nutritional status of these patients.     

The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post-ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during "downstream" jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual-purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.     

Formulation of enteral diets for use in jejunal enteral feeding

Nasogastric enteral feeding is not tolerated in patients with gastric atony and in many critically-ill patients in whom gastric emptying may be delayed and in whom gastro-oesophageal regurgitation may lead to pulmonary aspiration of enteral feed and the development of pneumonia. Initial attempts to overcome these problems led to the development of post pyloric enteral feeding techniques with the infusion port of the tubes positioned in the duodenum. In many centres this technique is still the most practised post-pyloric enteral feeding technique. Nasoduodenal feeding tubes often retroperistalse into the stomach. The technique of choice, therefore, in these difficult patients is to position the infusion port of the feeding tube well distal to the ligament of trietz (post ligament of trietz nasojejunal enteral tube feeding). While nasogastric and nasoduodenal enteral feeding techniques have been shown to elicit a stimulatory exocrine pancreatic response, distal jejunal enteral feeding does not. During this mode of feeding the ileal brake is activated and pancreatic exocrine pancreatic secretion inhibited by the action of the released peptide YY and glucagon-like peptide-1 hormones, in turn the inhibition of pancreatic secretion being the result of inhibition of trypsin secretion. In the light of the findings showing the absence of a stimulatory pancreatic exocrine response to nasojejunal enteral feeding these patients should receive a predigested rather than a polymeric enteral diet.     

Tube feeding patients with advanced dementia: an ethical dilemma.

Many patients with dementia lose the ability to feed themselves in the advanced stages of the disease. Tube feeding is sometimes initiated to overcome feeding difficulties. Recent studies have questioned the appropriateness of tube feeding in these patients. There is limited research to support the benefits of enteral nutrition in patients with advanced dementia. Deciding whether to tube feed or to withhold tube feeding from a patient with dementia poses a difficult challenge, and many carers may make decisions without adequate information and with an overly hopeful view of the future clinical course. Numerous studies have examined opinions about life-sustaining treatments; many individuals do not want to be tube fed if they were to develop dementia. Results from studies examining the opinions of physicians and other health professionals regarding the use of tube feeding in these patients are conflicting. A number of factors, such as race and cultural background may affect decisions. Healthcare professionals, relatives and patients must be aware of the realistic expectations of tube feeding in patients with dementia, as it can be difficult to withdraw once it has been initiated.     

A technique for positioning nasoenteral feeding tubes

The use of nasoenteral alimentation in many neurologically depressed patients is a common practice. These patients are also at increased risk of sustaining feeding tube malplacement. The morbidity and mortality involving feeding tube malposition in these debilitated patients is high. In this paper, we present four case reports of morbidity, with one resultant mortality, associated with small-bore nasoenteral tube malposition. We are also suggesting a nasoenteral intubation protocol which we feel will decrease the incidence of feeding tube malplacement.     

Clinical evaluation of a newly designed nasogastric enteral feeding tube

Concerned with reports in the literature of a rising incidence of enteral feeding tube clogging, we initiated a design programme in an attempt to improve the clinical efficacy of nasogastric and nasoenteric enteral feeding tubes. Tube design has been based on a remodelling of the outflow part of a polyurethane feeding tube previously developed in our unit. The tip of the newly designed 8F enteral feeding tube is shorter in length with a rounded end to minimize discomfort during intubation. The port itself incorporates a tapered outflow design with the side walls now extending below the mid-point of the internal flow lumen resulting in a 28% increase in port area compared to the equivalent and originally designed tube. The performance of the newly designed polyurethane feeding tube was assessed under controlled trial conditions using as references two widely used 8F polyurethane nasogastric feeding tubes whose design has been based on different principles (Flexiflo, weighted tip, open-ended with two side ports; Freka, occluded tip, two simple large side ports). Eighty-eight of 90 patients entered into the study were successfully intubated with no significant differences being noted in intubation times in the three groups. Significantly less discomfort occurred during intubation of patients with the Radius tube as compared to the Freka tube (P < 0.05). Although there were no clear differences between the Flexiflo and Freka tubes either in regard to the number of attempts required for intubation or aspiration or discomfort during intubation or ease of aspiration, fewer attempts at insertion and aspiration were needed and intubation and aspiration were easier for patients randomised to the Radius group than those to the Flexiflo and Freka groups (P < 0.05). We conclude that the clinical performance of the newly designed Radius enteral feeding tube compares favourably with that of the reference tubes. Only one of the new tubes (3.3%) blocked during the course of the study. High rates of non-elective extubation were observed in the three study groups (Radius 80.0%, Flexiflo 73.3%, Freka 73.3%). Design modifications are unlikely to influence non-elective nasogastric feeding tube extubation rates which remain a major clinical problem.     

Bedside placement of small bowel feeding tubes in hospitalized patients: a new role for the dietitian

OBJECTIVE: The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes. METHODS: The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement. RESULTS: Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements. CONCLUSIONS: Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.     

Procedures for home enteral nutrition.

As emphasis on early hospital discharge increases, home tube feeding is becoming a popular method of efficiently delivering nutritional support. This paper describes the team approach to home enteral feeding practices at the Foothills Hospital in Calgary, Alberta. Three groups of patients are referred to the program: those who require tube feedings permanently as the sole means of nutrition; those who require supplementation from tube feedings; and those who temporarily require tube feeding. The dietitian selects an enteral formula suitble for the patient. Although continuous enteral feedings are generally better tolerated by patients, intermittent feedings may be more psychologically acceptable. Continuous feedings are initiated at 50 ml per hour and increased to approximately 150 ml per hour, depending upon patient tolerance and nutritional goals. Complications can result from mechanical problems (e.g. equipment failure) and metabolic/physiologic problems (e.g. constipation). A total of 35 patients have been taught the technique of home tube feeding. The program has been well accepted by patients and physicians.     

胰十二指肠切除术中经胃造口管放置空肠营养管的临床研究

目的:观察胰十二指肠切除术中经胃造口管放置空肠营养管的临床疗效和病人的生存质量。方法:将25例胰十二指肠切除术病人随机分为术中经胃造口管放置空肠营养管(观察组)和传统放置胃管EN治疗(对照组),对比两组病人的手术操作时间、术后并发症、住院费用、住院时间,术后第7和第14天抑郁自评量表和焦虑自评量表评分、免疫和营养状况等指标的差异和生活质量评分(QLQ-C30)的差异。结果:观察组病人均在术中成功经胃造口管放置空肠营养管,无发生导管相关并发症,未增加手术时间、住院费用和住院时间。两组病人抑郁与焦虑评分均有显著性差异(P<0.05),术后QLQ-C30评分差异亦有显著性意义。两组病人营养状况和免疫功能指标无显著性差异。结论:胰十二指肠切除病人术中经胃造口管放置空肠营养管是安全有效的肠内营养途径,有助于提高病人的生活质量。     

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW: Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements. RECENT FINDINGS: Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method. SUMMARY: The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.     

Devices and techniques for bedside enteral feeding tube placement.

Enteral feedings are an integral part of care for many hospitalized patients. Accessing the gastrointestinal (GI) tract safely and in a timely manner can be challenging. Various techniques and devices to enhance the safety of bedside feeding tube placement are available for clinicians. Three specific devices are highlighted, including the colorimetric CO(2) detector (CCD), a magnetically guided feeding tube (MGFT), and the electromagnetic tube placement device (ETPD). The CO(2) detector is applied to detect the presence or absence of CO(2), thus assisting in correct placement of the feeding tube tip into the GI tract vs the lung. The MGFT uses a magnetic device to manipulate the feeding tube through the GI tract into the small intestine. The ETPD provides real-time visualization of the feeding tube as it progresses into the small intestine. Training and repetition are essential for safe and successful feeding tube placement, and the highlighted devices can contribute to both of these goals.     

Clinical experience with modified enteral formulas for patients with diabetes

Standard tube-feeding formulas may not meet the specific nutritional needs of many patients with impaired glucose tolerance. In particular, standard enteral formulas often cause potentially dangerous increases in blood glucose levels. Clinical experience and studies to date have shown advantages of using disease-specific enteral formulas for these patients. Specialized formulas with increased fiber may improve glycemic control, although the concomitant increases in viscosity of these formulas may limit their usefulness for tube feeding. Glucerna, a specialized formula with low-carbohydrate, high-monounsaturated-fat content that has been enriched with a fiber source that permits tube feeding, has been shown to improve glycemic control and decrease the potential for complications. Appropriate tube feeding for patients with impaired glucose tolerance, however, extends beyond formula composition. Patients also require ongoing blood glucose monitoring, evaluation of gastric motility, and assessment of overall health and nutritional status.     

Caring for Tube‐Fed Children

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral‐motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech‐language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent‐child interaction is an important part of the assessment and treatment of the tube‐fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube‐fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.     

Total parenteral nutrition and tube feeding for elderly patients: findings of an OTA study

A 1987 report by the US Office of Technology Assessment (OTA), Life-Sustaining Technologies and the Elderly discusses current utilization of tube feeding and total parenteral nutrition (TPN) for elderly people and the related issues of patient access to treatment, decision making practices, and quality of care. Factors that limit access for some elderly patients include negative attitudes of some health professionals about whether elderly people can benefit from tube feeding and TPN, lack of adequate nutritional standards for the elderly and lack of staff in some treatment settings who are trained and have enough time to assess nutritional status in elderly patients, and payment problems. Public controversy about life-sustaining technologies for elderly people now focuses on decisions about withholding or withdrawal of tube feeding, but debate about the legal and ethical issues involved in these decisions tends to obscure the relevant clinical considerations. Research issues and clinical practice concerns related to decision making and quality of care for elderly patients on tube feeding and TPN are discussed.     

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。     

Adverse effects from inappropriate medication administration via a jejunostomy feeding tube.

Numerous complications can arise when administering medications to patients receiving continuous enteral feeding. We report a case of a patient who could not be fed by mouth and was receiving continuous jejunal enteral feeding who had an adverse event associated with inappropriate administration of a medication via his jejunostomy tube. He had taken an extended-release niacin product before hospitalization for type IIb hyperlipidemia. The patient was inappropriately given a single dose of 750 mg of niacin as the short-acting tablets that were crushed and administered via the jejunostomy tube. He experienced severe cutaneous flushing, a feeling of warmth, itching, nausea, and emesis. He was noted to have "prickly heat" to the forehead, according to the nursing notes. A discussion of problems and guidelines for medication administration in adult patients receiving continuous tube feeding is provided.     

What you think is not what they get: significant discrepancies between prescribed and administered doses of tube feeding

Enteral tube feeding remains an indispensible strategy to treat disease-related malnutrition. In the present study we evaluated in clinical practice whether prescribed feeding volumes correspond with administered quantities and we highlight possible causes for discrepancies. During a 4-month observation period data from all patients fully depending on tube feeding (1.5-2.5 litres/d) were collected in a Dutch 900-bed academic hospital. The range for administered feeds to be adequate was set at 100 +/- 10% of the prescribed dose. Fifty-five patients (mean age 57 (SD 30) years) were included. Tube feeding was given continuously via pump (n 37) or drip (n 3), in portions (n 14) or by combined modes (n 1). Administered tube feeding amounts were significantly lower than prescribed in 40% of all patients (P < or = 0.001). The mean ratio of administered v. prescribed energy was 87 (SD 21) % (all modes), 85 (SD 24) % (pump), 94 (SD 12) % (portions) and 88.3 (SD 18.1) % (drip), respectively. The mean energy deficit amounted to 1089 kJ/d (range -7955 to +795). Only on intensive care unit wards did feeding administration meet the set goal. Feeding interruptions because of diagnostic or therapeutic procedures were the main reason for decreased intakes. Our findings show that many patients relying on tube feeding do not meet their nutritional goals during hospital stay. This problem can be addressed by adapting feeding schedules and the use of formulations with a higher energy density.     

脑卒中病人鼻饲管直径与肺部感染的相关性研究

目的:研究鼻饲管直径大小与脑卒中吞咽困难病人肺部感染发生率的相关性.方法:将90例脑卒中吞咽困难病人随机分为大口径鼻饲管组、小口径鼻饲管组和静脉营养组,每组30例.观察各组肺部感染发生率,并进行比较.结果:大、小口径鼻饲管组及静脉营养组肺部感染发生率分别为40%,13.33%和36.67%.总鼻饲组肺部感染发生率与静脉营养组相似(P＞0.05).小口径鼻饲管组肺部感染发生率显著低于大口径鼻饲管组及静脉营养组(P＜0.05).结论:鼻饲不会增加脑卒中病人肺部感染发生率,应用小口径鼻饲管可降低脑卒中病人肺部感染的发生率.     

Bacterial contamination of reconstituted and commercially prepared enteral feeds

Bacterial contamination of two forms of a commercially available nasogastric tube feed has been assessed in 28 patients receiving fine-bore nasogastric tube feeding. A commercially prepared liquid form of the feed was compared with a powdered form which required reconstitution prior to administration. The effect of differing concentrations of feed on bacterial growth was also assessed.No significant differences in bacterial counts were found, irrespective of the form or concentration of feed used. The bacterial counts of all feeds were significantly greater 6–12 h after commencing the feed than at the start of feeding. Contamination from the feed reservoirs and giving sets may be as important as contamination of the feed itself, therefore careful technique is required in the filling of reservoirs and delivery of the feed as well as in the preparation of the feed.