The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients

Abstract

Introduction: In the management of dysphagic stroke patients, percutaneous endoscopic gastrostomies (PEGs) are frequently sited early due to the failure of nasogastric tube (NGT) feeding, with NGTs becoming displaced in over 58% of cases. PEG insertion is a procedure with significant mortality and morbidity. We adapted a novel technique of securing NGTs (a nasal loop) which is non-invasive, allows successful NG feeding and may avoid the need for PEG placement. Aims: To show that nasal loops result in improved delivery of enteral nutrition. To compare the outcome and complication rate of nasal loop fed patients with those undergoing PEG feeding. Methods: A 6 month prospective audit of dysphagic stroke patients who were referred for PEG. All patients who were referred with failed NG feeding within 28 days of presentation were offered a nasal loop. Patients who were 28 days post-stroke had a PEG placed if appropriate. The daily feed intake was monitored before and after nasal loop placement. Complication rates and patient outcomes were documented at 2 week and 3 month follow-up. Results: Nasal loop group: 14 patients had a nasal loop for a median of 15 days. The median daily feed provided was 0% before nasal loop and 100% after. Four patients went on to recover normal swallowing, 4 patients died and 6 later proceeded to PEG. PEG group: Seven patients proceeded direct to PEG, 1 died and 6 were alive and PEG fed at 3 months. There were 6 complications from PEG insertion. No patients recovered normal swallowing. Conclusions: 1. Nasal loops are safe, well tolerated, and effective at delivering full enteral nutrition. 2. Nasal loops allow time for patients who may recover normal swallowing to do so, and thus avoid a PEG. 3. Nasal loops avoid unnecessary PEG insertion in those with a poor prognosis who will not ultimately survive their initial stroke.