Postpyloric Versus Gastric Tube Feeding for Preventing Pneumonia and Improving Nutritional Outcomes in Critically Ill Adults.

Abstract

What is the effectiveness and safety of postpyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding?Adequate nutrition is a key component to providing holistic care to critically ill patients. Assessing the need for nutritional support and providing early intervention can have many beneficial outcomes for patients, including improved disease progression and recovery time, improved immune response, and decreased overall complications.1 Early feeding for critically ill patients may be provided via enteral or parenteral routes. According to international guidelines,1–3 enteral feeding is the preferred method for patients who have a functioning gastrointestinal (GI) tract but who cannot maintain adequate oral intake. The advantages of enteral nutrition include prevention of GI atrophy and the systemic spread of GI bacteria.As with any intervention, potential challenges and side effects need to be taken into consideration. One main issue with feeding via the enteral route is the reduction in gastric motility including decreased gastric emptying and weakening of the gastric sphincters. This reduction in gastric motility can in turn can lead to gastroesophageal reflux (GER) and the risk of aspiration pneumonia. In addition, overall caloric intake can be an issue related to gastric intolerance, large residual volumes, and interruptions to continual feeding. Postpyloric feeding, in which the feeding tube is placed directly into the duodenum or the jejunum, could solve these issues by decreasing GER and residual volumes.Although gastric and postpyloric feeding in critical care patients have been compared in several meta-analyses,4 investigators reached different conclusions regarding the benefits and complications of using a postpyloric feeding tube. These discrepancies affect both standard guidelines and clinical practice. The purpose of this systematic review was to evaluate the potential benefits and adverse effects of using early postpyloric feeding in the adult critical care setting.This summary is based on a Cochrane systematic review that included individual patient data from 14 randomized controlled trials, with a total of 1109 participants.4 The systematic review examined both primary and secondary outcomes.The authors independently assessed the risk of bias for each study, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and publication bias. The authors resolved any disagreements by reviewing and discussing the data.Risk ratio (RR) or mean differences (MD) were used as the measure of treatment effect between different comparisons and outcomes. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to provide a level of the quality of evidence for each outcome (very low, low, moderate, or high).5This systematic review and meta-analysis found moderate-quality evidence suggesting that postpyloric feeding decreases incidences of pneumonia by 30% and low-quality evidence suggesting that postpyloric feeding may lead to an increase in the amount of total nutrition delivered compared with gastric tube feeding. This review also found low-quality evidence suggesting that insertion of a postpyloric feeding tube is a safe intervention and is not associated with any more complications such as epistaxis and GI bleeding than gastric tube insertion. Therefore, using a postpyloric feeding tube may be preferred for ICU patients when feasible.Placement of a postpyloric feeding tube, however, can be challenging, often requiring expertise and a variety of radiological devices. Because the findings of this review do not recommend a best method for placing the postpyloric feeding tube, nurses should use their clinical judgment as to which method is best for their clinical scenario. If nurses lack skill in postpyloric feeding tube placement, consider additional training so that placing a postpyloric feeding tube is among the options they can choose from.As nurses caring for critically ill patients, we should advocate for the best evidence-based treatment for our patients. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine if we should implement it in our unit.