Tube Feeding In Patients Research Articles

Managing gastric residual volumes in the critically ill patient: an update

Gastric residual volumes (GRVs) remain a major deterrent to adequately feeding patients with gastric-delivered enteral nutrition. The purpose of this review was to define the most up-to-date consensus of the utility of the use of GRVs for monitoring tube-feeding intolerance in gastric-fed patients. The paper summarizes the pathophysiology of gastroparesis, the techniques for measuring GRVs, the significance of a large GRV, other factors to consider when measuring GRVs, the correlation between GRVs and aspiration pneumonia, national guideline statements on GRVs, the use of prokinetic agents in the treatment of high GRVs and the clinical impact of tolerating larger GRVs. The utility of GRVs for prevention of aspiration events with tube feeding has been brought into question. Large GRVs usually result from some impediment in gastrointestinal motility (e.g. gastroparesis). There are numerous methods for measuring GRVs, most of which have not been standardized. It appears that there is little correlation between large GRVs and the development of aspiration pneumonia when tube feeding patients. Prokinetic agents have an inconsistent effect on the GRV size. US guidelines state that GRVs of less than 500 ml should not result in termination of enteral feeding. Allowing larger GRVs will allow patients to receive more calories when gastric fed without a deleterious clinical impact. The use of GRVs as a marker of feeding tolerance is of questionable utility.

Outcomes of Gastrostomy Feeding Tubes in Patients Undergoing Primary Chemoradiation for Oral Cavity, Oropharynx, Hypopahrynx and Larynx Squamous Cell Carcinoma (SCC) at Nottingham University NHS Trust: a Retrospective Analysis 2004–2008

Outcomes of Gastrostomy Feeding Tubes in Patients Undergoing Primary Chemoradiation for Oral Cavity, Oropharynx, Hypopahrynx and Larynx Squamous Cell Carcinoma (SCC) at Nottingham University NHS Trust: a Retrospective Analysis 2004–2008

Perspectives of Community Members regarding Tube Feeding in Patients with End-Stage Dementia: Findings from African-American and Caucasian Focus Groups

Research has demonstrated that placement of permanent feeding tubes to provide artificial nutrition is more common among non-white populations, but there is a scarcity of research regarding why those differences may exist. The purpose of this study is to describe and understand community members' attitudes toward tube feeding and end-of-life decision-making. Four focus groups were convened in Greenville, NC. The 28 focus group participants were 11 African American and 17 Caucasian community members between ages 51 and 81. Two focus groups were held with Caucasian participants and two with African-American participants. Focus groups were recorded and transcribed, and qualitative analysis was performed using NVivo software. Seven themes resulted from the analysis of the transcripts. They included: "A feeding tube is," "Food is important," "They want to do the right thing," "To make a rational decision," "There are worse things than death," "There's a lot of good things," "It's out of my hands." There were more commonalities than differences in the views of African Americans and Caucasians on perspectives on tube feeding and elders with dementia. An unexpected emphasis was placed on the importance of food as a symbol of caring. Families tend to be oriented toward personal fidelity to the elder and the symbolic role of feeding in fulfilling that fidelity.

Tracheobronchial malposition of fine bore feeding tube in patients with mechanical ventilation

The increasing prevalence of the use of enteral feeding tubes during critical illness leads to the increased potential for malposition of the tube [1], which may result in severe complications. We report tracheobronchial malposition of feeding tubes in six mechanically ventilated patients. From January 2008 to August 2011, six multiple trauma patients with mechanical ventilation in the emergency ICU were included in this study. They were male, aged 20 to 84 years, with an injury severity score (ISS) of 29 to 41. Five patients were intubated and one underwent tracheotomy. Insertion of a fine bore feeding tube (CH10 CM145 Bengmark naso-intestimal tube, Nutricia Medical Devices BV, Switzerland) was tried 1 to 3 days after ICU admission. The first patient had intermittent cough accompanied by slight irritability and tachycardia during insertion. Immediate bronchoscopy confirmed malposition of the feeding tube in the trachea. The feeding tube was inserted without obvious difficulty in the following four patients. However, auscultation detected inconclusive bubbling sounds from the epigastrium after insufflation of air. Later, bronchoscopy for treatment of pneumonia in one patient and chest radiography in three patients revealed trachebronchial malposition of the tube before initiation of enteral nutrition. The sixth patient had no cough during insertion but auscultation detected slight bubbling sounds from the epigastrium after insufflation of air. However, chest computed tomography (CT) confirmed tracheobronchial malposition of the feeding tube (Figure ​(Figure1).1). The patient died of septic shock due to blood stream infection 12 days later. Figure 1 Chest radiological images in the sixth patient with tracheobronchial malposition of the feeding tube. (a,b) Chest computed tomography (CT) on the first day showed the enteral feeding tube (white arrows) was misplaced into the left tracheobronchial tree ... Endotracheal intubation and tracheotomy have been thought to be potential risk factors for trachebronchial malposition of the feeding tube [2]. Mechanically ventilated patients have poor response due to sedation. The metal stylet and weighted tip contribute to the rigidity of the feeding tube, which may be easy to pass through the space between the tracheal wall and inflated cuff. It has been advised to monitor the pressure of the endotracheal tube's cuff during insertion [3]. Neither auscultation of bubbling sounds from the epigastrium after insufflation of air nor aspiration of 'gastric content' is thought to be reliable. Measuring the level of carbon dioxide in the feeding tube is a simple way to confirm trachebronchial malposition [4]. The UK National Patient Safety Agency has requested pH testing of gastric aspirate be used as the first line method for testing trachebronchial malposition, with pH between 1 and 5.5 as the safe range [5]. X-rays are used as a second line test when all the above methods have failed to confirm the position. Caution should be taken when interpreting chest X-rays with regard to four signs that indicate correct positioning of the tube (Figure ​(Figure11).

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. Median survival from disease onset was 842 days [interquartile range (IQR) 573-1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443-1032), RIG 633 days (IQR 496-1039) and NGT 427 days (IQR 77-781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106-546) days, RIG 216 (IQR 83-383) days and NGT 28 (IQR 14-107) days. Survival between gastrostomy and NGT treated patients was significant (P < or = 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.

Gastrostomy and dementia.

Tube feeding in patients with dementia is controversial. Weight loss is not an inherent part of the disease but can occur early in the process. This may be because of dysphagia (swallowing difficulty). Patients are at risk of malnutrition and also pneumonia. The problem with gastrostomies may be that they are inserted too late in the disease process.

Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer

For patients with a diagnosis of head and neck cancer, oral nutrition may not provide adequate nutrition during radical radiotherapy or chemoradiation treatment, resulting in enteral feeding initiation. Enteral feeding may be delivered via a nasogastric tube or by a gastrostomy tube. The present study aimed to determine how different treatment modalities impact on requirement for enteral feeding and which method of enteral feeding provided the most benefit to the patient, as demonstrated by weight loss and the number of unscheduled radiotherapy treatment interruptions. Patients who were treated with radical radiotherapy or chemoradiation between January 2004 and June 2007 were reviewed retrospectively (n = 196, male = 149, female = 47). Data were collected on demographics, diagnosis, T and N classification, nutritional status, unscheduled radiotherapy treatment interruptions, and type and duration of enteral feeding. Subjects were divided into three subgroups depending on the treatment received. Comparisons were then made between methods of enteral feeding. Combined modality treatment (Induction Chemotherapy and Chemoradiation) results in a higher proportion of patients requiring enteral feeding (66-71% compared to 12% for radiotherapy). Patients fed via a prophylactic percutaneous endoscopic gastrostomy lost the least amount of weight during treatment (-4.6% to +1.4%), although the method of enteral feeding did not statistically influence weight difference at the end of treatment. The enteral feeding method did not influence unscheduled radiotherapy treatment interruptions. Combined modality treatment results in a greater requirement for enteral feeding, with these patient groups having the greatest weight loss. The findings obtained in the present study indicate that the method of enteral feeding did not statistically influence weight loss at the end of treatment or unscheduled radiotherapy treatment interruptions.

A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg?

A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg?

Use of Feeding Tubes in Patients with Advanced Dementia: Are We Doing Harm?

The decision to place a feeding tube in a patient with advanced dementia is difficult for both family members and health care professionals. There is increasing evidence that the use of feeding tubes in these patients does not improve survival, prevent aspiration pneumonia, prevent or heal decubitus ulcers, or improve other clinical outcomes. Yet, despite this evidence, more than one third of nursing home residents with advanced dementia have feeding tubes, and many of these individuals have feeding tubes inserted on hospital admission for an acute care problem. Health care professionals need to examine the evidence carefully to identify practices that provide patients and families with information to make informed choices and respect their rights and dignity at end of life.

Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis

Enteral nutrition (EN) reduces infectious complications and mortality compared with parenteral nutrition (PN) in patients with predicted severe acute pancreatitis. However, to date the complications attributable to the administration of EN and PN in this patient group have not been comprehensively studied. The aim of the study was to systematically review the complications related to the use of nutrition in patients with predicted severe acute pancreatitis receiving EN v. PN. The Cochrane Library, MEDLINE and Scopus were searched. Randomised controlled trials (RCT) of EN v. PN in predicted severe acute pancreatitis were selected. Pooled estimates of complications were expressed as OR with corresponding 95 % CI. Data from five RCT were meta-analysed. Diarrhoea occurred in six of ninety-two (7 %) patients receiving PN and twenty-four of eighty-two (29 %) patients receiving EN (OR 0.20; 95 % CI 0.09, 0.43; P < 0.001). Hyperglycaemia developed in twenty-one of ninety-two (23 %) patients receiving PN and nine of eighty-two (11 %) receiving EN (OR 2.59; 95 % CI 1.13, 5.94; P = 0.03). Given a significant reduction in infectious complications and mortality associated with the use of EN over PN that has been consistently demonstrated in previous studies, the former should be the treatment of choice in acute pancreatitis. Further clinical studies should investigate the strategies to mitigate the complications of enteral tube feeding in patients with acute pancreatitis.

介護老人福祉施設における経管栄養利用者の受け入れ状況（全国調査）

This study describes the acceptance of patients with feeding tubes in nursing homes for the elderly. We sent questionnaires to 1,438 nursing homes in 2006-7 asking how many patients with feeding tubes the nursing homes had and how many new patients with feeding tubes they would accept in the future. The response rate was 63.6%. We analyzed the data of 735 nursing homes. The median range (25-75%) of the number of patients, patients accepted, and total number of patients currently resident was determined. The percentage of tube feedings to total beds in those categories was 8.0% (range 4.0-13.3), 5.0% (0-10.0), and 13.3% (8.0-23.8), respectively. Whereas 6% of the nursing homes had no limits on acceptance of patients with feeding tubes, 27.2% of the nursing homes replied that they would no longer accept such patients. Factors associated with restricted acceptance included nurse responses (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.30-0.95), a facility with over 100 beds (OR 2.14, 95% CI 1.10-4.17), and no current patients with feeding tubes (OR 4.19, 95% CI 2.36-7.43). One quarter of nursing homes for the elderly in Japan replied that they would no longer accept patients with feeding tubes. More nurses than other professionals replied that they would accept patients with feeding tubes. Larger nursing homes were less likely to accept tube-feeing patients. Furthermore, nursing homes with no tube-feeding patients were unwilling to accept such patients.

Head and neck cancer patients included at home enteral nutrition by tube

To know characteristics and the patients' evolution with head and neck cancer who received radiotherapy treatment and they were included at a home enteral nutrition (HEN) by feeding tube programme. To analyse the weight evolution according to the start of HEN before or after radiotherapy. Observational study of tube feeding patients with head and neck cancer who were included in HEN programme in our hospital for two years. Variables analysed: gender, age, Body Mass Index (BMI), Karnofsky Index (KI), reason for nutritional support, type of feeding tube, formula used and prescribed caloric contribution, necessity to change access device and HEN days. 62 patients were studied (77.4% men; 22.6% women). Age 64 +/- 10.1 years (rang: 39-90). The dysphagia was the main cause to begin enteral nutrition by feeding tube in these patients. Naso-gastric tube was prevalence (67.7%). The most used formula was polymeric hypercaloric diet with a mean of caloric contribution of 1,629 +/- 267.09 kcal/day. Overall, there was a weight loss in all patients during the study period time. However, patients who began the HEN by feeding tube before the radiotherapy treatment, the BMI did not decrease. All patients who began feeding tube before oncological treatment didn't lose weight for the period of study.

G.P.17.02 Efficacy and complications of gastrostomy tube feeding in patients with muscular dystrophies

To evaluate the efficacy and complications of gastrostomy tube feeding for patients with muscular dystrophies, we reviewed clinical records of 36 patients with muscular dystrophies who underwent gastrostomy between 2004 and 2008 consecutively; 27 patients with Duchenne muscular dystrophy (DMD), one with Becker muscular dystrophy (BMD), 2 with facioscapulohumeral muscular dystrophy (FSHD), 5 with myotonic dystrophy (MD), and one with plectinopathy. Mean age of the patients at the time of procedure was 35.6 years (range 19–66 years).

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.

Utilidad de la enteroscopia de simple y de doble balón

Single- and double-balloon enteroscopes have similar efficacy. The entire small bowel can be examined through the oral route in 60–90 minutes in 25–40% of patients. Using the oral and rectal routes, complete examinations can be performed in 75% of patients The diagnostic indications are mid-gastrointestinal bleeding tumors, Crohn's disease, intestinal obstruction and atypical malabsorption. Therapeutic indications include access to enterostomy, hemostasis, foreign body withdrawal, dilatation and polypectomy in the small bowel. This procedure is also useful to place enteral feeding tubes in patients with an excluded stomach. Hemostatic efficacy is high in patients with elevated transfusional requirements. For polypectomy, this technique has not been demonstrated to have the same efficacy/risk as colonoscopy. Complications include pancreatitis (0.34%) and perforation (0.34–6.4%). The level of evidence for almost all indications is low, since few prospective and homogeneous studies have been performed.

A study of reasons for failure to administer prescribed volume of nasogastric enteral feeds in a district general hospital

Background: A number of studies have demonstrated that the amount of enteral feed delivered is often significantly less than that prescribed (Park, 1992; Reid, 2006), which can impair nutritional status (National Institute for Health and Clinical Excellence, 2006). The aim of this survey was to establish the amount of feed administered versus that prescribed and identify the reasons for patients failing to receive the volume of feed prescribed.Methods: Data were collected prospectively on 20 consecutive patients on medical or surgical wards, who were commenced on nasogastric feeding (NGF). Feed requirements were determined by a clinical dietitian. The volume of feed administered versus that prescribed was calculated from the daily fluid balance charts. Medications and reasons for failure to administer prescribed feed were ascertained from medical, nursing and dietetic records and questioning staff. This was recorded on a data collection form.Results: Data were evaluated for 13 male and seven female patients, mean age 66 years (range 35–91 years) on gastroenterology, oncology and surgical wards. In total, 235 days of NGF were prescribed. Under‐delivery of feed occurred on 70 out of 235 (30%) days. Mean (SD) NGF delivered was 77% (39%) of feed prescribed. No feed was administered on 39 out of 235 days (17%). Fifty‐five percent of patients were on proton pump inhibitors (PPIs). Reasons for not administering feed or administering less than that prescribed are detailed in Fig. 1.Discussion: Inadvertent removal and inability to confirm correct positioning of nasogastric tubes (NGTs) accounted for significant interruptions to feeding resulting in under‐delivery of feed and lost feeding days (27%). Fifty‐five percent of patients were on PPIs because these are known to increase gut pH; this warrants further investigation of the possible cause of obtaining an unsuitable pH. The mean NGF delivered is similar to other studies mentioned. The limitations of this study include the small sample size and the possible inaccuracies of the fluid balance charts. image [ Reasons for failure to administer prescribed feed expressed as a percentage (n = 70). ]Conclusions: As a consequence, the nutrition support team is working on improving methods of securing NGTs, investigating aspiration practice, encouraging a review of PPIs and optimising radiography procedures. The study highlights the opportunities for improving practice to ensure that patients receive the feed prescribed.References National Institute of Health and Clinical Excellence (2006) Nutrition support in adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE, Available at http://www.nice.org.uk/guidance/CG32 (accessed on 3 December 2008).Park, R.H.R., Allioson, M.C., Lang J., Spence E., Morris A.J., Danesh B.J.Z., Russell, R.I. &amp; Mills P.R. (1992) Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ304, 1406–1409.Reid, C. (2006) Frequency of under and overfeeding in mechanically ventilated ICU patients: causes and possible consequences. J. Hum. Nutr. Diet.19, 13–22.

Churning: The Association between Health Care Transitions and Feeding Tube Insertion for Nursing Home Residents with Advanced Cognitive Impairment

There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment. A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment. Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9-3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile. Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.

Single Port Access (SPA™) gastrostomy tube in patients unable to receive percutaneous endoscopic gastrostomy placement

Access procedures for alimentation have been performed both endoscopically and surgically. In those patients in whom endoscopic tubes cannot be placed, the minimally invasive approach is a viable alternative. To minimize incisions and their sequelae, we have developed a single port access (SPA) technique in which minimal access surgery can be done through one portal of entry, often the umbilicus. We have used the SPA technique to place gastric feeding tubes in patients who are not candidates for PEG tubes due to supraglottic stenosis. We reviewed our experience in the first five procedures we performed. In all five patients a gastrostomy tube was placed laparoscopically via an umbilical incision and a left-upper-quadrant tube insertion point. Mean operative time was 44 min. All patients began tube feeds on postoperative day 1. We present the first series of five SPA gastric tube placements, offering a viable alternative to PEG or open placement.

Percutaneous feeding tubes in patients with head and neck cancer: rethinking prophylactic placement for patients undergoing chemoradiation

Objectives Although intensified therapy has contributed to improved outcomes for patients with head and neck cancer, acute toxicity has increased as well. To lessen the severity of nutritional compromise in these patients, our institutional protocol has been to routinely place feeding tubes before the initiation of therapy. This investigation details the toxicities associated with feeding tube placement and predictors for duration of tube dependence. Materials and methods The records of the Radiation Oncology Department at Emory Clinic were reviewed for patients receiving definitive radiotherapy between 6/1/2003 and 6/1/2006. The records of the subset of patients with feeding tube placement before the initiation of therapy were then reviewed for toxicities as well as length of time of tube dependence. Results There were 102 eligible patients. Radiotherapy was delivered with concomitant chemotherapy in all. Median time with feeding tube in place for all patients was 4.4 months (range, 0.2–28.9 months). For 82 patients with eventual tube removal, the median time of tube dependence was 3.8 months (range, 1.4–28.9 months). Risk factors for prolonged tube dependence are analyzed; on multivariate analysis, patient age, T stage, and nodal status remained significant. The most common complication was tube replacement, with 11.8% of all tubes requiring replacement. Infection and pain occurred in 8.8% and 5.9% of patients, respectively. Conclusion Feeding tubes are required for more than 2 months after combined modality treatment of head and neck cancer. They are generally well tolerated, but toxicities are not trivial: more than 10% require replacement and more than 8% of patients develop infection at the insertion site. We are assessing their routine placement in light of these data.

A randomised clinical trial of transnasal endoscopy versus fluoroscopy for the placement of nasojejunal feeding tubes in patients with severe acute pancreatitis

Objectives:To compare transnasal endoscopy with fluoroscopy for the placement of nasojejunal feeding tubes (NJTs) in patients with severe acute pancreatitis.Methods:100 patients were randomised to receive NJTs by transnasal endoscopy or...