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Which tube placement is best for a patient requiring enteral nutrition?
Comparative advantages of EN tubes
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.
Comparative advantages of EN tubes
Comparative advantages of EN tubes
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.
Case
A 68-year-old diabetic nonverbal female presents to the ED because of “seizure” 1 hour ago. On exam, her blood glucose is 200. She is unable to speak and has dysphagia because of a stroke she sustained last month. The patient’s husband adds that she hasn’t been eating and drinking sufficiently in the past couple of days. Imaging was negative for any acute intracranial bleeds or lesions. Labs showed a serum sodium level of 150 milliequivalents/L. D5W is started, and the following day, the patient has a sodium level of 154 milliequivalents/L.
Brief overview
Many hospitalized patients are unable to maintain hydration and/or nutritional status by mouth and will need enteral nutrition. Variables such as past medical history, swallowing ability, history of aspiration, prognosis, and functional capacity of each gastrointestinal segment will determine the best option for enteral nutrition for each patient. Each type of enteral tube feeding has advantages, disadvantages, and complications.
Overview of the data
Enteral nutrition should be started within 24-48 hours in a critically ill patient who is unable to maintain intake according to the American Society of Parenteral and Enteral Nutrition.1 This can be provided through a nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG) tube, PEG tube with jejunal extension (PEG-J), or a percutaneous endoscopic jejunal (PEJ) tube.1
NG tubes are often the first method deployed because of their low cost and convenience. They are also suitable for the patient who requires this type of feeding for less than 4 weeks. However, NG tubes do require some patient cooperation (to place and maintain)and are contraindicated in some patients with orofacial trauma, upper GI tumors, inadequate lower esophageal sphincter tone, and gastroparesis.2
Another option is a PEG tube, which is a good alternative for patients who are sedated; ventilated; or have neurodegenerative processes, stroke with dysphagia, or head and neck cancers. These are typically recommended when enteral nutrition will be needed for more than 4 weeks. Disadvantages of PEG tubes include tube obstruction or displacement, gastroesophageal reflux, and leakage of gastric content around the percutaneous site or into the peritoneum.
PEG-J tubes, PEJ tubes, or jejunostomy tubes are best suited for patients with GI dysmotility, patients who have unsuccessfully undergone the aforementioned methods, patients with histories of partial gastrectomies, or patients with gastric or pancreatic cancers/multiple traumas. The PEG-J tube extends into the distal duodenum; because it is longer and more narrow, it is more likely to coil and occlude the flow of nutrients during feedings.2,3 Jejunal feeding methods incorporate a continuous pump controlled infusion; if set too rapidly, this could cause dumping syndrome. A benefit of jejunal nutrition is a lower risk of aspiration, compared with other enteral tubes.4
It is best to appraise the selected method for its efficacy and patient preference. The American College of Gastroenterology recommends starting with orogastric or nasogastric feeds, and switching to postpyloric or jejunal feeds for those intolerant to or at high risk for aspiration.5 The most important aspect is early enteral nutrition in hospitalized patients unable to maintain oral nutrition.
Application of the data to the original case
This is a severely hypernatremic diabetic patient unable to swallow. On day 2 of her hospitalization, the clinical team provided the patient with an NG tube for increased free-water intake to gradually decrease her serum sodium. By hospital day 4, the patient’s sodium had normalized. Considering the patient’s long-term prognosis and dysphagia, discussions were held with the patient and husband for PEG tube placement. The patient received a PEG tube and was subsequently discharged 2 days later.
Bottom line
Enteral nutrition is a common need among hospitalized patients. Modality of enteral nutrition will depend on the patient’s past medical history, anticipated duration, and preferences.
Dr. Basnet is the hospitalist program director for Apogee Physicians Group at Eastern New Mexico Medical Center in Roswell. Ms. Tayes is a third-year medical student at Burrell College of Osteopathic Medicine in Las Cruces, N.M., with interests in surgery, internal medicine, and emergency medicine. Ms. Gallivan is a third-year medical student at Burrell College of Osteopathic Medicine, with interests in cardiothoracic surgery, general surgery, and internal medicine.
References
1. Boullata JI et al. ASPEN Safe Practices for Enteral Nutrition Therapy. J Parenter Enteral Nutr. 2016;1-89.
2. Kirby DF et al. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108:1282.
3. Lazarus BA et al. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46.
4. Alkhawaja S et al. Postpyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015 Aug 4;(8):CD008875.
5. McCalve SA et al. ACG Clinical Guideline: Nutrition therapy in the hospitalized patient. Am J Gastroenterol. 2016;111:315-34. doi: 10.1038/ajg.2016.28.
Additional reading
Bellini LM. Nutrition Support in Advanced Lung Disease. UptoDate. https://www-uptodate-com.ezproxy.ad.bcomnm.org/contents/nutritional-support-in-advanced-lung-disease?. Published April 20, 2018.
Commercial Formulas for the Feeding Tube. The Oral Cancer Foundation. https://oralcancerfoundation.org/nutrition/commercial-formulas-feeding-tube/. Published June 5, 2018.
Marik Z. Immunonutrition in critically ill patients: A systematic review and analysis of the literature. Intensive Care Med. 2008;34(11). doi: 10.1007/s00134-008-1213-6.
Wischmeyer PE. Enteral nutrition can be given to patients on vasopressors. Crit Care Med. 2020;48(1):122-5. doi: 10.1097/CCM.0000000000003965.