Nasoenteric Feeding Tubes Research Articles

Is It Appropriate to Redo the Endoscopic Examination to Confirm the Position of an Endoscopically Placed Nasoenteral Feeding Tube?

Is It Appropriate to Redo the Endoscopic Examination to Confirm the Position of an Endoscopically Placed Nasoenteral Feeding Tube?

Comparative evaluation of nasoenteral feeding and jejunostomy feeding in acute corrosive injury: a retrospective analysis

Nutritional support in corrosive injury patients is traditionally achieved through total parenteral nutrition (TPN) or jejunostomy feeding (JF). There are no reports of nasoenteral tube feeding in patients with corrosive ingestion. We report our experience with nasoenteral tube feeding (NETF) and compare the outcome of these patients with those undergoing JF. Tertiary medical center in North India. The records of 53 and 43 patients with severe acute corrosive injury who underwent NETF and JF, respectively, were reviewed. All had received a 50-kcal/kg, 2-g/kg protein homogenized liquid diet for 8 weeks. A contrast study was performed at 8 weeks, and body weight and serum albumin levels were recorded at hospitalization and at 8 weeks. Change in weight and serum albumin at 8 weeks and stricture development rate. Strictures developed in 41 (80.39%) and 36 (83.72%) patients in the NETF and JF groups, respectively. Development of esophageal stricture (P = .71) and gastric stenosis (P = .89) was comparable in the 2 groups. No significant changes in serum albumin and weight were noted at 8 weeks in either group. The complication rate was lower in the NETF group compared with the JF group. Although all of the patients in the NETF group had a patent lumen, 5 in the JF group had total obstruction precluding endoscopic intervention. Retrospective study design. NETF is as effective as JF in maintaining nutrition in patients with severe corrosive injury. The stricture development rate is similar, but nasoenteral tube placement provides a lumen for dilatation should a tight stricture develop.

Approach to Enteral Feeding in the PICU

The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. Early institution of EN is recommended and the gastric route is preferred because of ease of administration and reduced costs compared with the transpyloric route. In patients with poor gastric emptying or in cases where a trial of gastric feeding has failed, transpyloric or postpyloric feeding may be used to decrease the risk of aspiration and to improve enteral feed tolerance. However, there is no evidence of benefit for routine use of small bowel feeding in all patients admitted to the PICU. The placement of blind nasoenteric feeding tubes can be technically challenging, is not without complications, and requires local expertise and experience for successful placement and maintenance. A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.

Endoscopic Position Control of Nasoenteral Feeding Tubes by Transnasal Re-endoscopy: A Prospective Study in Intensive Care Patients

In critically ill patients, correct placement of enteral feeding tubes is usually controlled by X-ray. A bedside method without radiation exposure would be preferable. This study aimed to demonstrate the feasibility and value of endoscopic position control for enteral feeding tubes by transnasal re-endoscopy. A total of 120 consecutive examinations in critically ill patients were analyzed. Immediately after transnasal endoscopic placement of a feeding tube, the correct position was determined by re-endoscopy. In cases of incorrect position, replacement was performed instantly until the correct position was achieved. Abdominal X-ray with contrast was performed thereafter and served as the gold standard. In 95 patients (79%), endoscopic control showed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (one attempt in 22 patients, two attempts in 3 patients). Radiological control showed correct position in 118 patients (98%). In two cases, the feeding tube was displaced in the meantime. The sensitivity and positive predictive value of endoscopic position control was 100% (95% confidence interval, CI; 97-100%) and 98% (95% CI; 94-99%), respectively. The cost savings per case ranged from $281 to $302, depending on different cost assumptions. Endoscopic position control of enteral feeding tubes by re-endoscopy is feasible, very accurate, leads to a high rate of successful feeding tube placements, and has the potential of substantial cost-savings.

Transnasal Route: New Approach to Endoscopy

Transnasal esophagogastroduodenoscopy (TN-EGD) has recently become one of the frequently used methods of upper gastrointestinal endoscopy in some countries. Changes in blood pressure, heart rate, and oxygen saturation are smaller for TN-EGD than for conventional transoral esophagogastroduodenoscopy, making it a safer procedure. Lower pain and gag reflex enable TN-EGD to be performed without conscious sedation. TN-EGD is applied in various gastrointestinal (GI) procedures such as percutaneous endoscopic gastrostomy, nasoenteric feeding tube placement, endoscopic retrograde cholangiopancreaticography with nasobiliary drainage and lithotripsy, long intestinal tube placement in small-bowel obstruction, esophageal manometry, foreign body removal, botulinum toxin injection for achalasia, esophageal varix evaluation with the aid of endoscopic ultrasonography, and the double-scope technique for endoscopic submucosal dissection. The establishment of standard training programs and nationwide guidelines, the dissemination of educational information, the improvement in endoscopy devices and accessories, and the availability of insurance coverage for the procedure will obviously further widen the adoption of TN-EGD.

The Routine Bridling of Nasojejunal Tubes Is a Safe and Effective Method of Reducing Dislodgement in the Intensive Care Unit

To determine if the routine bridling of nasoenteric feeding tubes in the intensive care unit is a low-morbidity, cost-effective method of decreasing tube dislodgement. Data were prospectively collected from 62 consecutive bridled patients and compared with that from 172 consecutive unbridled patients for differences in tube dislodgement, nasal ulceration, and estimated cost. Bridled patients demonstrated significantly less tube dislodgement (6.5% vs 32.6%, P < .0001). Bridling resulted in 4 cases of nasal ulceration per 800 tube feeding days, all of which were associated with red rubber catheter bridles. Conversion to 1/8-in umbilical tape bridles eliminated ulceration and further reduced dislodgement from 10% to 4.8%. Implementation of bridling saved an estimated $4038 over 3 months. Nasal bridling is a simple, cost-effective practice that may reduce the rate of nasoenteric tube dislodgement. The use of 1/8-in umbilical tape may be more effective and safer than 8-Fr red rubber catheters for this purpose.

Use of a Colorimetric Carbon Dioxide Sensor for Nasoenteric Feeding Tube Placement in Critical Care Patients Compared With Clinical Methods and Radiography

Misplacement of nasoenteric feeding tubes (NFTs) into the airway instead of the esophagus leads to complications. Healthcare providers have relied on clinical methods, devices such as carbon dioxide (CO(2)) sensors, and radiography (the gold standard) to evaluate NFT placements. Most institutions include radiographs in their protocols for NFT insertions, making it expensive and cumbersome. A new commercial CO(2) sensor was developed to assist in these procedures, and the authors evaluated its use. Nurses performing NFT placement completed questionnaires following each procedure. The nurses recorded the clinical methods used to determine proper insertion and, based on them, where the NFT was located. Nurses then evaluated NFT insertion with the CO(2) sensor; from the readings, they recorded where the tube was located. Confirmation of tube placement was performed radiographically. The authors evaluated 424 NFT insertions. Of these, 15 (3.5%) were incorrectly placed into the airway, and 409 were correctly placed into the esophagus. The CO(2) sensor correctly assessed NFT placement in 421 (99%) of the 424 cases. The authors found the device to have a sensitivity of 86.7% and a specificity of 99.8%. The CO(2) sensor is a helpful bedside tool to use in conjunction with clinical methods during NFT insertions. However, there is insufficient evidence to abandon the use of radiographs to confirm tube placement.

Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes: Outcomes and Limitations in Non–Critically Ill Patients

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non-critically ill patients. The authors collected data on consecutive patients from a non-critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non-critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy.

Transnasal endoscopy for the placement of nasoenteral feeding tubes: does the working length of the endoscope matter?

Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. Randomized controlled study. University Hospital of Zurich, Switzerland. Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Success rates of endoscopic placement of enteral feeding tubes. A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001). In rare cases, the randomization list could not be followed correctly. This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Gastrotracheal and Gastrobronchial Fistulas: Management with Covered Expandable Metallic Stents

The present study evaluated the clinical results of covered tracheobronchial metallic stent placement in the management of gastrotracheal fistulas (GTFs) and gastrobronchial fistulas (GBFs). Sixteen patients with GTFs or GBFs after esophagogastrectomy were treated with one of two types of covered tracheobronchial metallic stents: a hinged stent or a straight stent. These included 12 GTFs and four GBFs. Thirteen hinged stents and three straight stents were placed during the initial procedure. Data regarding the technical success of stent placement, initial clinical success and failure, fistula reopening, and complications were obtained. Stent placement was technically successful in all patients. The stent completely sealed off the fistula in 12 of 16 patients (75% initial clinical success rate), whereas the remaining four patients (25%) had persistent aspiration symptoms as a result of incomplete GTF or GBF closure (ie, initial clinical failure). During follow-up, the fistula reopened in three of the 12 patients in whom initial clinical success was achieved (25%). Two reopened fistulas were sealed off with stent placement, and one was treated with a nasoenteric feeding tube and a nasogastric decompression tube. All patients died during the 1-year follow-up period; mean survival time was 17 +/- 3.02 weeks (range, 1-42 weeks) after stent placement. Mean survival in patients in whom initial clinical success was achieved was significantly longer than in patients with initial clinical failure (P = .003; log-rank test). Use of covered metallic stents appears to be a safe and moderately effective procedure to occlude GTFs and GBFs.

Endoscopic placement of enteral feeding catheters

Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present. Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement. Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.

Enteral access for nutrition in the intensive care unit

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. 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. 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.

Management of established percutaneous gastrostomy tubes in adults-A systematic review

Objective The purpose of this review is to critically appraise and summarise the best available evidence relating to the management of percutaneous gastrostomy (PEG) tubes in adults. Question What are the best methods of preventing and managing complications associated with PEG tubes? These complications include occlusion, site infection, excoriation at the stoma site and accidental removal Inclusion Criteria Types of participants This review will include adult patients (> 18 years of age) with PEG tubes in the acute, aged or community setting. Studies relating to neonates or children will be excluded. Types of interventions This review will include studies that assess the effectiveness of interventions for preventing complications associated with PEG tubes. These may include, but are not limited to, frequency and volume of flushing, use on antibiotics, site dressing regimes, manipulation of the tube to prevent excoriation and techniques to prevent and manage accidental tube removal. Studies examining the appropriateness of techniques of PEG tube insertion and/or the timing of initial feeding post insertion will not be included. Studies involving nasogastric, nasoenteric or jejunal feeding tubes will also be excluded from this review. Types of outcome measures The primary outcomes of interest are objective or subjective measures of the following: 1. Occlusion 2. Site infection ( such as erythema, purulent drainage, positive swabs) 3. Excoriation at stoma site 4. Accidental removal

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement. This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1-mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time. Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00). The endoscopic procedure duration (12.8 +/- 6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 +/- 12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 +/- 6.2 minutes to 8.0 minutes +/- 4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures. NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.

Nasoenteral feeding tube placement: indications and nurse skills

Nutrition therapy (NT) is a powerful tool to assist the patients' nutritional needs mainly in the ICU, where the patients usually have high energy expenditures. The route mostly used for NT is the nasoenteral feeding tube (NFT), being easier and with lower costs. It can be accomplished by the nursing staff under direct vision by the nasal route (after training) or through endoscopy. The nasoenteral insertion is not free from complications, and these can be classified as: mechanics (obstruction of the probe, accidental exit, migration of the tube), infectious and psychological (anxiety, depression). The NFT is suitable for small and medium periods of NT (about 6 weeks).

Transnasal, ultrathin endoscopy for the placement of nasoenteral feeding tubes in critically ill patients: Does the working length of the endoscope matter?

Transnasal, ultrathin endoscopy for the placement of nasoenteral feeding tubes in critically ill patients: Does the working length of the endoscope matter?

Transnasal, Ultrathin Endoscopy for the Placement of Nasoenteral Feeding Tubes in Critically Ill Patients: Does the Working Length of the Endoscope Matter? First Results

Transnasal, Ultrathin Endoscopy for the Placement of Nasoenteral Feeding Tubes in Critically Ill Patients: Does the Working Length of the Endoscope Matter? First Results Stephan Wildi, Christoph Gubler, Stephan Vavricka, Dieter Menne, Michael Fried, Peter Bauerfeind Background: Early enteral feeding may improve outcomes in critically ill patients. Transnasal endoscopy with an ultrathin endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in these patients. Success rates were limited by the short working length of the ultrathin endoscopes. Aim: To compare the success rate of a 133 cm-long, ultrathin video-endoscope with a standard 92.5 cm-long, ultrathin, fiberoptic endoscope for the transnasal placement of nasoenteral feeding tubes. Methods: Critically ill patients were randomly assigned to transnasal feeding tube placement with the standard 92.5 cm-long, ultrathin, fiberoptic endoscope (Olympus GIF-N30) or a new 133 cmlong, ultrathin, prototype video-endoscope (Olympus XGIF-N140Y). Patients characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Results: To date, 89 patients (29 women; mean age 51.8, range 20-81) were analyzed. The two groups were similar with regard to patients characteristics, body length, technical difficulty and patient tolerance. So far, the 133 cm-long instrument tended to be superior with respect to successful placement of the nasoenteral feeding tube (90% vs. 76%). Procedure time tended to be longer with the 133 cm-long instrument (557sec vs. 462sec). Conclusions: This ongoing study demonstrates that placement of a nasoenteral feeding tube with a 133 cm-long, ultrathin video-endoscope is safe and tends to be more successful than with 92.5 cm-long, ultrathin, standard instrument. Abstracts

Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill.

Inadvertent passage of a nasoenteric feeding tube into the tracheobronchial tree can result in pneumothorax. Measures requiring feeding tube passage to 35 cm only followed by a radiograph to verify intraesophageal placement and creation of a specialized placement team were implemented to decrease the incidence of procedure-related pneumothorax. This study evaluates the effectiveness of our safety measures. Radiology reports from January 2000 through July 2003 were searched by computer with an algorithm designed to detect feeding tube placements possibly associated with the complication of intrabronchial placement or pneumothorax. Results were manually examined to eliminate false positives and verify causality. Feeding tubes were placed in 4,190 unique patients during the study period; 87 patients had an intrabronchial malposition, and 9 experienced a pneumothorax caused by their feeding tube. The safety measures resulted in a significant decrease in procedure-related pneumothorax (0.09% versus 0.38%, p < 0.05), and a decrease in pneumothorax among patients with an intrabronchial placement (3% versus 27%, p < 0.05). More than two-thirds of patients with a misplaced tube had an endotracheal tube or tracheostomy, illustrating that such patients are not protected. Repeated malposition in the same patient was surprisingly common; 32% of patients with one intrabronchial misplacement ultimately had multiple misplacements. The risk of pneumothorax increased with misplacement at night (p < 0.05) and increased exponentially with each additional misplacement (p < 0.05). Creating a specialized placement team, and initiating the safety measure of limiting feeding tube placement to 35 cm and obtaining a radiograph before full advancement reduced the incidence of procedure-related pneumothorax.

Placement of nasoenteral feeding tubes using external magnetic guidance

Enteral feeding is preferred over parenteral methods, and feeding into the duodenum is preferred over gastric feeding in certain groups of critically ill patients. However, with current techniques, feeding tubes often coil in the stomach, exposing patients to the risk of aspiration. This study investigated whether a nasoenteral feeding tube can be guided beyond the pyloric sphincter, using external magnetic guidance. This is a case series of 288 critically ill patients who needed placement of an enteral feeding tube, carried out in the intensive care units and wards of a university-affiliated community hospital. A 12-French polyurethane nasoduodenal feeding tube was modified by placing a small magnet in the distal tip. After inserting the tube through the nares into the esophagus, an external magnet was used to draw the tube tip beyond the pyloric sphincter and further into the duodenum or jejunum. Placement was verified by plain abdominal x-ray, and the depth of insertion (stomach, proximal duodenum, distal duodenum, or jejunum) was recorded. Three hundred twenty-nine intubations were performed in 288 patients (mean procedure time 15 minutes). In 293 cases (89.1%), the tube was placed beyond the pyloric sphincter. In 139 insertions (42.2%), the tube tip was in the distal portion of the duodenum or the jejunum. There were no significant complications. This case series demonstrates that external magnetic guidance achieves transpyloric placement of an enteral feeding tube in 89.1% of cases. This reliable bedside technique is superior to other methods described in the literature.