68.Tube Feeding: Indications, Types and their Characteristics, and Complications

1/15

Explanation

In this module, we discuss indications for tube feeding, different types of tube feeding and their characteristics, and complications arising from tube feeding. To learn about specific tube feeding methods, please see Module 67.

2/15

Explanation

Nutrition screening and nutrition assessment are performed to calculate the amounts of nutrition and hydration a patient requires. When patients have difficulty getting their required intake by normal means, nutrition support is necessary. Even with efforts to improve oral eating through, for example, dysphagia diets, energy drinks, energy gels, and isotonic gels, patients may still have difficulty getting sufficient intake of nutrition and hydration; this difficulty is an indication for artificial hydration and nutrition (AHN). Methods of AHN include enteral nutrition (tube feeding) and parenteral nutrition. In tube feeding, nutrition is digested and absorbed in the intestines as in normal eating; so, compared with parenteral nutrition, tube feeding is more physiological and involves fewer metabolic complications. For these reasons, tube feeding is the first-line method of ANH when the intestine can be used.

3/15

Explanation

Contraindications for tube feeding are diseases and pathologies in which the intestine must not be used. The diseases and pathologies in which the intestine absolutely must not be used (absolute contraindications) are complete bowel obstruction, gastrointestinal perforation, and generalized peritonitis.

In the next slide, we see the merits of using the intestine. To take advantage of the merits, tube feeding is now more frequently being applied proactively, making pathologies that are considered relative contraindications (shown in this slide) now less common.

4/15

Explanation

Although total parenteral nutrition offers the advantage of reliable administration of required hydration, energy, protein, minerals, vitamins, and trace elements, there are reasons why tube feeding is recommended as the first-line method of ANH when the intestine can be used. First, prolonged total parenteral nutrition leads to disuse atrophy of the intestine and also often causes problems such as catheter-related sepsis and metabolic complications. Second, some energy sources are not yet included in transfusions, so these transfusions are not at all perfect.

Tube feeding, on the other hand, involves continued use of the intestine, which is effective for maintaining the structure and function of the intestine, as well as immunocompetence and biological defense mechanisms. Also, tube feeding is far cheaper than total parenteral nutrition.

5/15

Explanation

Typical methods of tube feeding include nasogastric tube feeding (NG), percutaneous endoscopic gastrostomy (PEG), and intermittent oral catheterization (IOC). There are several other tube feeding methods, some of which are shown in this slide, which are sometimes chosen for specific pathologies.

6/15

Explanation

The table summarizes the characteristics of typical tube feeding methods.

NG has become so widespread that it can be performed at all medical centers in Japan, but it also poses many problems associated with indwelling a tube that's inserted into the nose and passes through the throat. Indwelling a particularly large tube in a manner that crosses the throat horizontally greatly hinders swallowing and poses a major obstacle in dysphagia training. Also, while NG is widespread, the technique needs more careful confirmation after tube insertion and before nutrition infusion, because administering nutrition with the tube misplaced into the trachea can cause fatal complications.

PEG, although it requires endoscopic surgery, was rapidly adopted because it allows for tube placement with a relatively simple surgery. Because PEG enables long-term stable nutrition management, it's often chosen when patients are suspected of needing tube feeding for prolonged periods of time. Disadvantages include problems associated with fistulas and replacing tubes. In particular, fistula care often comprises medical treatment or is close to medical treatment, which can easily cause caregivers to perceive a heavier burden.

With IOC, a tube is inserted into the mouth or nose only when nutrition is administered. So, the biggest advantage of IOC is that allows for dysphagia training to be conducted without a tube. Also, insertion (swallowing) of the tube in the mouth is itself a form of dysphagia training. IOC has several other advantages; for example, the low likelihood of gastrointestinal complications associated with nutrition administration (vomiting, diarrhea, etc) is low, and the rate of infusion can be increased. However, because IOC involves insertion of a tube every time nutrition is administered, it's difficult to do with patients who experience severe discomfort or the gag reflex is triggered when the tube is inserted. Another problem is that IOC is not yet widespread.

7/15

Explanation

While NG, PEG, and IOC are the most common methods of tube feeding, there are no clear criteria about which method should be used. Instead, indications are determined through comprehensive assessments on a case-by-case basis. The algorithm we see here was created based on guidelines by the American Society for Parenteral and Enteral Nutrition. If the gastrointestinal tract can be used, enteral nutrition is chosen. If enteral nutrition is likely to be prolonged, PEG is recommended; if enteral nutrition is likely to be short-term, NG is recommended. IOC, regardless of the expected duration, may be proactively selected if it can be performed at the center in question (ie, if a staff member there has been trained in IOC management) and its advantages can be utilized.

8/15

Explanation

If patients present with any of the diseases or pathologies shown here, consider switching to another method of tube feeding.

9/15

Explanation

Complications of tube feeding should be considered in the following separate categories: feeding tube-related complications, gastrostomy-related complications, gastrointestinal symptoms, metabolic problems, and infections. This slide summarizes feeding tube-related complications. In NG and IOC, there's a risk of misplacement into the trachea; in PEG, there's a risk of misplacement into the abdominal cavity. In all of these cases, administering nutrition with a misplaced tube leads to major accidents that could result in death.

Gastroesophageal reflux is likely to occur when formula is administered directly to the stomach with patients in a supine position.

Administering medications in a crushed form can easily cause a blockage in the tube, so the simple suspension method should be proactively used.

10/15

Explanation

This is a summary of gastrostoma-related complications, all of which require caution. As we can see, these complications include wound infections, skin issues peripheral to the gastrostoma, compression necrosis of the gastric mucosa, and buried bumper syndrome.

The risk of buried bumper syndrome can be reduced by gently pulling the catheter and lightly moving it up and down or by rotating the catheter smoothly.

11/15

Explanation

Here is a summary of other complications. As for gastrointestinal symptoms, diarrhea frequently poses a problem early in tube feeding. Diarrhea is often dealt with by reducing the rate of infusion, but prolonged infusion can easily lead to reduced ambulatory time, thereby hindering rehabilitation. IOC is unlikely to result in gastrointestinal symptoms even if the rate of infusion is increased.

12/15

References

  1. Soda M：Adaptive criterion and its methodology for tube feeding. The Japanese Journal of Nursing Arts 46：1268-1272, 2000
  2. Funahashi M et al： Intermittent use of oral catheter for feeding dysphagic children．Official Journal of the Japanese Society of Child Neurology 17：3-9，1985
  3. Kisa T et al：Application of Oral catheter for feeding for dysphagia．Sogo rehabilitation19：423-430, 1991
  4. Hida M：Merit and demerit of tube feeding. -Digestion and absorption from the nutritional physiological view. The Japanese Journal of Nursing Arts 46：1252-1257，2000
  5. Nozaki S：Intermittent oral catheterization for ALS．Neulorogy 60：543-548, 2004
  6. Okuma R et al：Alternative nutrition for dysphagia patients. Advantage and adaptation of Intermittent tube feeding. Medicina 38：692-698, 2001

Recommended readings

  1. Saitoh E, Ueda K, eds.: Dysphagia rehabilitation, 3rd Edition, Ishiyaku Publishers
  2. Higashiguchi T:NST Perfect Guide Basic and practice of Nutritional therapy, 2nd Edition, Shorinsha Publishers
13/15

 

14/15

 

15/15