69.Specific Methods: Nasogastric Tube Feeding, Oro-esophageal Tube Feeding, and Percutaneous Endoscopic Gastrostomy

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Explanation

The tube used in nasogastric tube feeding is chosen based on its material and size.

There are 3 main types of materials.

Polyvinyl chloride is relatively soft but hardens with prolonged placement because of degeneration caused by digestive juices. So, polyvinyl chloride tubes must be replaced weekly, making them unsuitable for prolonged placement. However, they are cheap and economical for short-term use.

Silicon and polyurethane tubes are frequently used for prolonged nasogastric feeding because they are soft, cause only minimal irritation of mucosa, and are resistant to degeneration by digestive juices.

To avoid clogging, we should use tubes that are at least 5 Fr for liquid elemental formulas and at least 8 Fr for polymeric (intact) formulas1. Tubes should not be larger than 12 Fr to minimize pain and discomfort, and we should select the smallest, softest tube possible to minimize pain and negative effects on swallowing movements.

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Explanation

The tube to be inserted must be long enough to reach the site where it will be indwelled. When the tube is to be indwelled in the stomach, the insertion length is approximately 55 cm (the length to the cardia plus 10 cm). A rough indicator of the length to the cardia is the length from the patient's nostril to their earlobe plus the length from their earlobe to their xiphoid process2. The length is decided based on the patient's physical structure.

In certain cases, such as in refractory gastroesophageal reflux, the tube may be indwelled in the upper small intestine. Tubes indwelled here are at least 120 cm long with an anchor attached to the tip (eg, an ArgyleTM ED Tube) and are passed through the pylorus using the peristaltic movement of the gastrointestinal tract. Confirm the position of the tube over time with X-rays. If the ED tube is not moving through the patient as smoothly as it should, consultation to a physician should be needed.

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Explanation

When inserting the tube, we must be careful not to hinder swallowing movements. The tube is inserted into the piriform sinus ipsilateral to the nasal cavity so that it is not in contact with the epiglottis. To perform this insertion, rotate the neck to the side opposite the nasal cavity into which the tube is inserted. Rotating the neck is known to open the pharynx on the opposite side to which the neck is rotated and the resting pressure of the opposite side upper esophageal sphincter effectively reduces, which makes the tube pass through easy3.

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Explanation

Let's look now at tube insertion with neck rotation4. 1) Put the patient in a reclining position with their head on a thick pillow to relax the neck muscles. 2) Rotate the neck to the side opposite the nasal cavity into which the tube is to be inserted. 3) Once a length of tube equal to the length from the nose to the ear (roughly 15 cm) has been inserted, ask the patient to swallow. 4) If the tube is pushed through quickly as the patient swallows, it will pass smoothly through the open upper esophageal sphincter. If the patient has a coughing fit or you feel some resistance, pull the tube out slightly, increase the neck rotation angle slightly, and reinsert the tube. 5) If you feel resistance in the lower esophagus (40-45 cm), stop moving forward and slowly insert the tube to the required length while asking the patient to dry swallow.

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Explanation

There are many medical accidents of mis-injection of nasogastric tube feeding. So, it's important to confirm that the tube is correctly inserted into the gastrointestinal tract before administering nutrition. The following recommendations for confirming the position of the tube were made in 2005 by the Japanese Nursing Association5: 1) aspirate the gastric contents, 2) listen for bubble sound, and 3) perform radiography. And the same year, a British Patient Safety Alert6made the following recommendations: 1) measure the pH of the aspirate (≤ 5.5); 2) use radiography to check the position of the tube, but not frequently; 3) do not use auscultation of air bubble sound through the feeding tube ('whoosh' test) because it is unreliable ; 4) do not interpret the absence of dyspnea as evidence that the tube has been placed correctly; and 5) be careful about the effect of antacids on pH measurements. The same recommendations were made in Japan in 2006 by the Office of Patient Safety Promotion of the Japan Council for Quality Health Care.

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Explanation

Let's look at the manual written by the Medical Safety Management Committee at Seirei Mikatahara General Hospital for confirming the position of a nasogastric feeding tube to prevent misplacement. First, confirm the sound of bubbles, aspirate gastric contents, and measure their acidity. If gastric contents cannot be aspirated or if their pH is ≥ 6, perform radiography to confirm the position of the tube. The tube must have a radiopaque line embedded in it.

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Explanation

Here we show how to place a tube for intermittent oro-esophageal tube feeding (hereafter "OE", sometimes abbreviated as "IOE"). In OE, swallowing the tube is itself a form of dysphagia training, so we should place the patient in a position conducive to swallowing and proceed as follows7. 1) Use a relative large diameter tube (16-28 Fr) to enable easy insertion. And if the tube enters the air way, a thick tube is very irritating, so we could avoid misplacement into the trachea. 2) Remove saliva and phlegm from the oral cavity and the pharynx. 3) Put the patient in a reclining position with their head on a thick pillow to relax the neck muscles. 4) Gently protrude the patient's jaw forward to open the pyriform sinus. 5) Insert the tube toward the contralateral pharyngeal wall.

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Explanation

In the OE method, liquid food is injected into the esophagus and is transferred into the stomach by esophageal peristalsis, so OE is considered to be physiological. This is how infusion works. 1) The tube is inserted from the mouth to the stomach; entry of the tube into the stomach is confirmed by the sound of bubbles and aspiration of gastric contents. 2) The hole at the top of the tube (the infusion site) is then pulled up to the esophagus of under the second constriction and secured in place to prevent reflux, (30-40 cm in adults; the position of the hole should be confirmed by videofluoroscopy). 3) Infusion begins at a slow rate and, if there are no problems, increases to approximately 50 ml/min (500 ml is injected in 10-15 min). 4) If there is increased secretion of saliva during infusion, we ask the patient to swallow the secretion to generate esophageal peristalsis. After infusion is completed, the tube is removed8.

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Explanation

Here you can see OE actually be performed. The tube is swallowed from the mouth into the stomach; after the tube is confirmed to have entered the stomach, it's is pulled up to the required length and fixed in place. The procedure for this is as follows. 1) The oral cavity is moistened with an ice massage to make the tube easier to swallow. 2) The tube is inserted diagonally from the angle of the mouth. 3) When the tube enters the pyriform sinus, the patient is prompted to swallow. 4) The tube is inserted into the stomach, after which the sound of bubbles and the reflux of gastric contents are confirmed. 5) The tube is pulled up approximately 10 cm to under the second constriction of the esophagus and is fixed to the patient's cheek.

Be aware that the tube may be pulled out during infusion if the patient's cognition is poor or if the patient constantly moves their mouth (due to orofacial dyskinesia, etc).

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Explanation

Let's move on to early management following gastrostomy placement (which is now widely performed via percutaneous endoscopic gastrostomy (PEG)). Early management following gastrostomy placement must be tailored to the type of gastrostomy tube to be inserted. Observe whether there is any bleeding, redness, swelling, or ulceration from the gastrostomy. As a result of gastrostomy placement, the gastric wall and the abdominal wall are drawn together to the point that they adhere to each other; to release this adhesion, at 24 h after gastrostomy placement, gauze is inserted between the skin and the external bumper to create a 5 mm opening. The skin around the gastrostomy is washed and prophylactically debrided to keep it cleaner. The external bumper is rotated regularly to prevent adhesion to and/or burial in the mucosa9).

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Explanation

The most important aspects of gastrostomy management are fixation and cleanliness of the skin. Confirm daily that the gastrostomy tube is secure and that there is 1-2 cm of space between the stopper and the skin. To prevent adhesion, rotate the external bumper 90° on a regular basis (once daily). With a balloon tube, make sure to regularly check the amount of distilled water in the balloon.

Fistula formation is considered to take approximately 3 weeks to 1 month10. According to the gastrostomy tube placement method and the type of tube used, when and how often the tube should be changed.

The skin around the gastrostoma must be kept clean. With the physician's permission, patients may take showers as early as 2 weeks after gastrostomy and may take baths beginning at 3 weeks. If they can't bathe, they are washed with weakly acidic soap and lukewarm water.

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Explanation

A gastrostomy can be protected directly being covered with an abdominal bandage or belly band, by tailored clothing. Make sure that the gastrostomy tube does not injure or compress the surrounding skin and be careful to avoid accidentally the tube being pulled out.

Fistulas close in 2-3 hours, so if the gastrostomy tube is accidentally removed, treatment is needed to prevent the fistula from closing up. Consult with a physician in advance about what to do if the gastrostomy tube is accidentally removed.

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Explanation

This summarizes points to note that are common to all routes of tube feeding.

To prevent gastroesophageal reflux, raise the upper body to an angle of at least 60° without lying down for at least 30 min during and after infusion and for at least 2 h in the event of gastroesophageal reflux. In some cases, rest is not always necessary, but it might be better for patients to walk lightly.

The amount of infusion should be considered taking into account of oral intake and patient's condition. Keep in mind that tube feeding is force feeding. Tube feeding may prevent patients from feeling hungry or an appetite.

It's also important to prevent contamination of tube feeding formulas, which are high in calories and nutrition and so can easily breed bacteria.

Tube feeding formulas must be used 6-8 h after they are prepared (or opened). Leftover formula must be sealed tightly, stored in a refrigerator, and used within 24 h.

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Explanation

Infusion of oral medicine may cause clogging in the tube. To prevent blockage due to clogging, dissolve soluble medicines with a simple suspension method11. With the simple suspension method, we can dissolve certain types of medicine by soaking them in hot water at 55°C for 10 min, so there is no need to crush tablets.

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Explanation

Diarrhea is a complication of tube feeding. The most common causes of diarrhea in tube feeding are believed to be osmotic pressure and the rate of infusion. Diarrhea is treated by reducing the rate of infusion to minimize the effect of osmotic pressure. If the intestine has not been used for a long time due to fasting, we must first infuse warm water slowly and carefully and then increase the infusion rate gradually until the required volume is reached.

The rate of infusion must be adjusted appropriately in accordance with the type of formula and the site of infusion. In post-pyloric (enterostomy/nasojejunal tube feeding, etc) infusion of semi-solid feeds, dumping syndrome often occur without sufficient digestion and when hypertonic feeds are infused rapidly into the small intestine12. In that case the general rule is to perform continuous administration with a continuous infusion pump.

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Explanation

Semi-solid diet tube feeding method is considered effective for preventing gastroesophageal reflux and diarrhea. It is indicated for patients with normal gastrointestinal motility in the stomach and normal digestion and absorption, but it is not indicated for patients with advanced hiatal hernias or patients with an enterostomy (eg, patients who have undergone gastrectomy). It must be performed while taking into account the viscosity, volume, and infusion time considered to be effective.

Semi-solid diet tube feeding was defined by the Japanese Ministry of Health, Labour and Welfare for supporting the calculation of the home-care guidance management fee.

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References

  1. Sato A: Enteral feeding with nasogastric tube. Types of nasal feeding tubes, Higashiguchi T ed, The Complete Guide to NSTーFundamentals and Practices of Nutritional Therapy. Shorinsha, Tokyo, 2005, 58-60.
  2. Mikako T:Tube feeding, Supervised by Kawashima M, Basic Nursing Skills Guide. Shorinsha, Tokyo, 2007, 139-146.
  3. Takehara I: The kinesiology of head rotation in swallow. Sogo Rehabilitation 36, 1999, 737.
  4. Fujimori M: A New Insertion Technique for the Nasogastric Tube Using Neck Rotation. Japanese Journal of Nursing Art and Science 4(2), 2005, 14-21.
  5. Journal nursing association:Preventing Accidents Involving Incorrectly Inserted or Incorrectly Infused Nasal Feeding Tubes, Appendix to Association News Medical and nursing safety management information No 8, 422, 2002, 11.
  6. National Patient Safety Agency. (2005)"Reducing the harm caused by misplaced nasogastric feeding tubes," Patient safety alert 05(http://www.npsa.nhs.uk)
  7. Patient safety promotion:Proposals Ensuring the safety of nasal feeding tube insertion. Journal of patient safety promotion 13, 2006, 3941.
  8. Fujishima I:Rehabilitation for swallowing disorders associated with stroke 3rd ed. Ishiyaku publisher Tokyo, 1998, pp122-124.
  9. Sasaki M:Artificial Concentrated Liquid Diet, Sasaki M ed, Practical techniques for enteral nutrition for Nutrition Support Team. Shorinsha, Tokyo, 2007, 131-137.
  10. Sowa T:Enteral nutrition of Percutaneous Endoscopic Gastrostomy. To ensure proper nutrition management, Osaka, Fuji-Medical 2nd ed, 2005, 34-35.
  11. Kurata N・Fujishima I ,ed:Simple suspension method. Handbook on tube administration-List of drugs that can be administered 2nd ed, Jiho, 2006.
  12. Tanaka Y:How to choose a nasogastric tube and enteral tube feeding. Basic knowledge of tubing and catheters, Sasaki M, ed, Practical techniques for enteral nutrition for Nutrition Support Team, Shorinsha, Tokyo, 2007, 78-81.
  13. Goda F: Guidebook for Semi-Solid Short-Term Feeding through Gastrostomy. Improving the Quality of Life of Patients with PEG. Ishiyaku publisher, Tokyo, 2006, 9-45.

Recommended readings

  1. Sasaki M: Artificial Concentrated Liquid Diet. Sasaki M ed Practical techniques for enteral nutrition for Nutrition Support Team. Tokyo, Shorinsha, 2007.
  2. Fujishima I: Rehabilitation for swallowing disorders associated with stroke. 2nd ed, Ishiyaku publisher, Tokyo, 1998.
  3. Kurata N, Fujishima I eds: Simple suspension method. Handbook on tube administration-List of drugs that can be administered 2 nd ed. Jiho, 2006.
  4. Sowa T: Enteral nutrition of Percutaneous Endoscopic Gastrostomy. To ensure proper nutrition management 2nd ed, Fuji-Medical, 2005.
  5. Japanese society for clinical nutrition and metabolism ed: Guidelines for intravenous and enteral nutrition for paramedical practitioners. Nankodo, Tokyo, 2000.
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