Feeding tube

Feeding tube
Intervention
ICD-9-CM 96.35
MeSH D004750

A feeding tube is a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral feeding or tube feeding. Placement may be temporary for the treatment of acute conditions or lifelong in the case of chronic disabilities. A variety of feeding tubes are used in medical practice. They are usually made of polyurethane or silicone. The diameter of a feeding tube is measured in French units (each French unit equals 0.33 millimeters). They are classified by site of insertion and intended use.

Indications for using a feeding tube

There are dozens of conditions that may require tube feeding. The more common conditions that necessitate feeding tubes include prematurity, failure to thrive (or malnutrition), neurologic and neuromuscular disorders, inability to swallow, anatomical and post-surgical malformations of the mouth and esophagus, cancer, Sanfilippo syndrome, and digestive disorders.

Types

The most common types of tubes include those placed through the nose, including nasogastric, nasoduodenal, and nasojejunal tubes, and those placed directly into the abdomen, such as a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube.[1][2]

Nasogastric feeding tube

A nasogastric feeding tube or NG-tube is passed through the nares (nostril), down the esophagus and into the stomach. This type of feeding tube is generally used for short term feeding, usually less than a month, though some infants and children may use an NG-tube longterm. Individuals who need tube feeding for a longer period of time are typically transitioned to a more permanent gastric feeding tube. The primary advantage of the NG-tube is that it is temporary and relatively non-invasive to place, meaning it can be removed or replaced at any time without surgery. NG-tubes can have complications, particularly related to accidental removal of the tube and nasal irritation.

Pilot research explores the possibilities of guiding patients to self-intubate with NG-tubes.[3]

Nasojejunal feeding tube

A nasojejunal or NJ-tube is similar to an NG-tube except that it is threaded through the stomach and into the jejunum, the middle section of the small intestine. In some cases, a nasoduodenal or ND-tube may be placed into the duodenum, the first part of the small intestine. These types of tubes are used for individuals who are unable to tolerate feeding into the stomach, due to dysfunction of the stomach, impaired gastric motility, severe reflux or vomiting. These types of tubes must be placed in a hospital setting.

Gastrostomy or gastric feeding tube

A gastric feeding tube (G-tube or "button") is a tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition. One type is the percutaneous endoscopic gastrostomy (PEG) tube which is placed endoscopically. The position of the endoscope can be visualized on the outside of the patient's abdomen because it contains a powerful light source. A needle is inserted through the abdomen, visualized within the stomach by the endoscope, and a suture passed through the needle is grasped by the endoscope and pulled up through the esophagus. The suture is then tied to the end of the PEG tube that will be external, and pulled back down through the esophagus, stomach, and out through the abdominal wall. The insertion takes about 20 minutes. The tube is kept within the stomach either by a balloon on its tip (which can be deflated) or by a retention dome which is wider than the tract of the tube. G-tubes may also be placed surgically, using either an open or laparoscopic technique.

Some individuals continue to use a long, catheter-like tube, while others use a small "button" with a detachable extension set for feedings. Most G-tubes can be changed easily at home. Gastric feeding tubes are suitable for long-term use, though they sometimes need to be replaced if used long term. The G-tube can be useful where there is difficulty with swallowing because of neurologic or anatomic disorders (stroke, esophageal atresia, tracheoesophageal fistula), and to avoid the risk of aspiration pneumonia. However, in patients with advanced dementia or adult failure to thrive it does not decrease the risk of pneumonia. Dementia patients may attempt to remove the PEG, which causes complications.[4]

Gastric drainage tube

A G-tube may instead be used for gastric drainage as a longer term solution to the condition where blockage in the proximal small intestine causes bile and acid to accumulate in the stomach, typically leading to periodic vomiting. Where such conditions are only short term, as in a hospital setting, a nasal tube connected to suction is usually used. A blockage lower in the intestinal tract may be addressed with a surgical procedure known as a colostomy, and either type of blockage may be corrected with a bowel resection under appropriate circumstances. If such correction is not possible or practical, nutrition may be supplied by parenteral nutrition.

Gastrojejunal feeding tube

A gastrojejunostomy or GJ feeding tube is a combination device that includes access to both the stomach and the jejunum, or middle part of the small intestine. Typical tubes are placed in a G-tube site or stoma, with a narrower long tube continuing through the stomach and into the small intestine. The GJ-tube is used widely in individuals with severe gastric motility, high risk of aspiration, or an inability to feed into the stomach. It allows the stomach to be continually vented or drained while simultaneously feeding into the small intestine. GJ-tubes are typically placed by an Interventional Radiologist in a hospital setting. The primary complication of GJ-tube is migration of the long portion of the tube out of the intestine and back into the stomach.

Jejunal feeding tube

A jejunostomy feeding tube (J-tube) is a tube surgically or endoscopically inserted through the abdomen and into the jejunum (the second part of the small intestine). Please note that alternatively a jejunostomy commonly refers to a surgical fistula created connecting the jejunum or the abdominal wall. There are several techniques for placement, including a direct surgical or endoscopic technique, or a more complicated Roux-en-Y procedure. The J-tube may use a long, catheter-like tube or a button. Depending on the placement type, the tube may be changed at home, or may need to be changed at a hospital. A J-tube is helpful for individuals with poor gastric motility, chronic vomiting, or at high risk for aspiration and in those in whom gastrostomy tubes are contraindicated.

Effectiveness

The effectiveness of feeding tubes varies greatly depending on what condition they are used to treat.

Children

Feeding tubes are used widely in children with excellent success for a wide variety of conditions. Some children use them temporarily until they are able to eat on their own, while other children require them longterm. Some children only use feeding tubes to supplement their oral diet, while others rely on them exclusively. [5]

Advanced Dementia

Patients with advanced dementia who are unable to feed themselves should have another person feed them in preference to the medical intervention of having a feeding tube.[6] In such patients, feeding tubes do not increase life expectancy or protect the patient from aspiration pneumonia.[6] Feeding tubes can also increase the risk of pressure ulcers, require pharmological or physical restraints, and lead to patient distress.[6] There is evidence which shows that patients who get feeding assistance rather than tubes have better outcomes.[6] In the final stages of dementia, assisted feeding may still be preferred over a feeding tube to bring benefits of palliative care and human interaction even when nutritional goals are not being met.[6][7]

Eating disorders

Patients with the eating disorder anorexia nervosa may be tube fed if they are significantly malnourished. This can be voluntary or in some cases where the patient is resistant to feeding under the force of legislation about mental health. Patients may tamper with their feeds, which can interfere with the effectiveness of feeding.

ICU

Nasogastric tubes are often used in the intensive care unit (ICU) to provide nutrition to critically ill patients while their medical conditions are addressed. There is moderate evidence for use of feeding tubes in the ICU, especially if requiring mechanical ventilation for more than three days.

Mechanical obstruction and dysmotility

There is at least moderate evidence for feeding tubes improving outcomes for chronic malnutrition in patients with cancers of the head and neck that obstruct the esophagus and would limit oral intake, acute stroke while the patient undergoes rehab, and ALS.

Complications

The nasogastric (NG) tube is meant to convey liquid food to the stomach. Thus, its tip must rest in the stomach. When inserted incorrectly, the tip may rest in the respiratory system instead of the stomach; in this case, the liquid food will enter the lungs, resulting in pneumonia and can, in rare cases, lead to death. The incorrect insertion of fine nasogastric tubes which are stiffened with wires has been associated with the puncture of the lungs and pneumothorax; however this is a rarer complication.[8]

The gastrostomy tube is associated with its own set of complications. Leakage of gastric contents (containing hydrochloric acid) around the tube into the abdominal (peritoneal) cavity results in peritonitis, a serious complication which will cause death if it is not properly treated. Septic shock is another possible complication.[9][10] Minor leakage may cause irritation of the skin around the gastrostomy site or stoma. Barrier creams, to protect the skin from the corrosive acid, are generally recommended.

All feeding tubes will eventually need to be changed because of wear and tear, or a clogged lumen. The change of a gastrostomy tube is not without risks. The loop-gastrostomy tube is a recent innovation which minimizes the risks of tube change.[11]

Side Effects

Some side effects may occur with tube feeding. Several complications only become evident when enteral nutritional support (ENS) is applied on a long-term basis.[12] Medically fragile patients remain malnourished during the first year of life despite receiving ENS. Study shows that a majority of children receiving long-term enteral nutritional support are not provided with an adequate amount of energy for their age and showed a lack of appetite.[13][14][15][16]

Failure to gain weight is mainly caused by an imbalance of beneficial variables and undesired adverse effect. The main reasons for this mismatch were limited tolerance, nausea, recurrent vomiting, gagging, and retching.[17] This may even result in growth retardation.[18][19]

As a result, the patient might not thrive age-appropriately, despite receiving sufficient amounts of carefully selected nutrients. This condition may lead to tube dependency.

According to the World Health Organization, “stunting is a result of long-term nutritional deprivation and often results in delayed mental development, poor school performance and reduced intellectual capacity” whereas “wasting in children is a symptom of acute under-nutrition usually as a consequence of insufficient food intake or a high incidence of infections, especially diarrhea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity and susceptibility” to diseases and increased risk of death”.[20] So, the high prevalence of malnutrition in medically fragile children is keeping them at continuous risk of developing secondary diseases, which can compromise their quality of life and may lead to detrimental outcomes.

Nowadays, medicine provides methods of getting rid of tubes and proceeding to natural oral intake. Tube-weaning programs have been initiated during the last decades using different approaches: inpatient versus outpatient, slow versus swift volume reduction.,[21] use of medication,[22] behavioral interventions,[23][24][25] hunger provocation, sensory stimulation or an interdisciplinary child-led method, based on psychodynamic principles[26][27][28][29][30][31][32][33]

The tube weaning method is based on teaching children how to interact with food, reduce food aversions and other complications.

See also

References

  1. ↑ Guenter, Peggi (2001). "Enteral Feeding Access Devices". In Guenter, Peggi; Silkroski, Marcia. Tube Feeding: Practical Guidelines and Nursing Protocols. Gaithersburg: Aspen Publishers. pp. 51–67. ISBN 978-0-8342-1939-7.
  2. ↑ "Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition". National Institute for Health and Care Excellence. February 2006.
  3. ↑ Quilliot, D.; Zallot, C.; Malgras, A.; Germain, A.; Bresler, L.; Ayav, A.; Bigard, M. -A.; Peyrin-Biroulet, L.; Ziegler, O. (2013). "Self-Insertion of a Nasogastric Tube for Home Enteral Nutrition: A Pilot Study". Journal of Parenteral and Enteral Nutrition 38: 895–900. doi:10.1177/0148607113502544. PMID 24142673.
  4. ↑ Siamak Milanchi and Matthew T Wilson (January–March 2008). "Malposition of percutaneous endoscopic-guided gastrostomy: Guideline and management". J Minim Access Surg. 4 (1): 1–4. doi:10.4103/0972-9941.40989. PMC 2699054. PMID 19547728.
  5. ↑ "Pediatric Feeding Tube". Feeding Clinic of Santa Monica. Retrieved 8 July 2013.
  6. 1 2 3 4 5 American Academy of Hospice and Palliative Medicine, "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Academy of Hospice and Palliative Medicine), retrieved August 1, 2013, which cites
  7. ↑ AMDA – The Society for Post-Acute and Long-Term Care Medicine (February 2014), "Ten Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (AMDA – The Society for Post-Acute and Long-Term Care Medicine), retrieved 20 April 2015.
  8. ↑ "Stomach Tubes". http://www.thoracic.org. American Thoracic Society. Retrieved March 30, 2012. External link in |work= (help)
  9. ↑ Melis M1, Fichera A, Ferguson MK. (July 2006). "Bowel necrosis associated with early jejunal tube feeding: A complication of postoperative enteral nutrition". Arch Surg 141 (7): 701–4. doi:10.1001/archsurg.141.7.701. PMID 16847244.
  10. ↑ Jun-Gyo Gwon, Young-Ju Lee,1 Kyu-Hyouck Kyoung,2 Young-Hwan Kim,1 and Suk-Kyung (September 2012). "Enteral nutrition associated non-occlusive bowel ischemia". J Korean Surg Soc. 83 (3): 171–174. doi:10.4174/jkss.2012.83.3.171. PMC 3433554. PMID 22977764.
  11. ↑ Pang, AS (2011). "Risk-free gastrostomy tube exchange". Annals of the Royal College of Surgeons of England 93 (5): 419–20. doi:10.1308/003588411X582717h. PMC 3365472. PMID 21943476.
  12. ↑ Segal D, Michaud L, Guimber D, et al. Late-onset complications of percutaneous endoscopic gastrostomy in children. J Pediatr Gastroenterol Nutr 2001;33:495–500
  13. ↑ Pearce CB, Duncan HD (2002). "Enteral feeding. Nasogastric, nasojejunal, percutaneous, endoscopic gastrostomy, or jejunostomy: its indications and limitations". Postgrad Med J 78: 198–204. doi:10.1136/pmj.78.918.198. PMC 1742333. PMID 11930022.
  14. ↑ Ishizaki A, Hironaka S, Tatsuno M, et al. Characteristics of and weaning strategies in tube-dependent children. Pediatr Int 2013;55;208-213
  15. ↑ Khan Z, Marinschek S, Pahsini K, Scheer P, Morris N, Urlesberger B, Dunitz-Scheer M. Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support. J Pediatr Gastroenterol Nutr. 2015 Jul 31. [Epub ahead of print]
  16. ↑ Stratton RJ, Elia M (1999). "The effects of enteral tube feeding and parenteral nutrition on appetite sensations and food intake in health and disease". Clin Nutr 18: 63–70. doi:10.1016/s0261-5614(99)80053-3.
  17. ↑ Pahsini K, Marinschek S, Khan Z, Dunitz-Scheer M, Scheer PJ. Unintended Side-Effects of Enteral Nutrition Support: the Parental Perspective: A Quantitative Analysis. J Pediatr Gastroenterol Nutr. 2015 Jul 20. [Epub ahead of print]
  18. ↑ Dunitz-Scheer M, Levine A, Roth Y, et al. Prevention and treatment of tube dependency in infancy and early childhood. Infant Child Adolesc Nutr 2009;1;73-82
  19. ↑ Ishizaki A, Hironaka S, Tatsuno M; et al. (2013). "Characteristics of and weaning strategies in tube-dependent children". Pediatr Int 55: 208–13. doi:10.1111/ped.12030.
  20. ↑ "WHO. NLIS. Country Profile Indicators Interpretation Guide" (PDF). http://www.who.int/en/. External link in |work= (help)
  21. ↑ Wright CM, Smith KH, Morrison J (2011). "Withdrawing feeds from children on long term enteral feeding: factors associated with success and failure". Arch. Dis. Child 96: 433–9. doi:10.1136/adc.2009.179861.
  22. ↑ McGrath Davis AM, Bruce AS, Mangiaracina C, Schulz T, Hyman P (2009). "Moving from tube to oral feeding in medically fragile nonverbal toddlers". J. Pediatr. Gastroenterol. Nutr. 49: 233–6. doi:10.1097/mpg.0b013e31819b5db9.
  23. ↑ Clawson EP, Kuchinski KS, Bach R (2007). "Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy". NeuroRehabilitation 22: 397–406.
  24. ↑ Byars KC, Burklow KA, Ferguson K, O'Flaherty T, Santoro K, Kaul A (2003). "A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings". J. Pediatr. Gastroenterol. Nutr. 37: 473–80. doi:10.1097/00005176-200310000-00014.
  25. ↑ Benoit D, Wang EE, Zlotkin SH (2000). "Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial". J. Pediatr 137: 498–503. doi:10.1067/mpd.2000.108397.
  26. ↑ Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M (2006). "Tube weaning according to the Graz Model in two children with Alagille syndrome". Pediatr. Transplant 10: 934–7. doi:10.1111/j.1399-3046.2006.00587.x.
  27. ↑ Dunitz-Scheer M, Wilken M, Walch G, Schein A, Scheer P (2000). "How do we get rid of the tube?". Kinderkrankenschwester 19: 448–56.
  28. ↑ Dunitz-Scheer M, Wilken M, Lamm B. "Sondenentwöhnung in der frühen Kindheit. Monatsschr. Kinderheilkd 2001; 149: 1348–59, (German)
  29. ↑ Dunitz-Scheer M, Scheer P, Tappauf M (2007). "From each side of the tube. The early autonomy training (EAT). Program for tube-dependent infants and parents". The Signal 15: 1–9.
  30. ↑ Dunitz-Scheer M, Huber-Zeyringer A, Kaimbacher P, Beckenbach H, Kratky E, Hauer A. "Schwerpunkt: Sondenentwöhnung. Pädiatrie und Pädologie 2010; 4&5: 7–13, (German)
  31. ↑ Trabi T, Dunitz-Scheer M, Kratky E, Beckenbach H, Scheer PJ (2010). "Inpatient tube weaning in children with long-term feeding tube dependency: a retrospective analysis". Infant Ment. Health J. 31: 664–81. doi:10.1002/imhj.20277.
  32. ↑ Marinschek S, Dunitz-Scheer M, Pahsini K, Geher B, Scheer P (Nov 2014). "Weaning children off enteral nutrition by netcoaching versus onsite treatment: a comparative study". J Paediatr Child Health 50 (11): 902–7. doi:10.1111/jpc.12662.
  33. ↑ Dunitz-Scheer M, Marinschek S, Beckenbach H, Kratky E, Hauer A, Scheer P (2011). "Tube dependency: A reactive eating behavior disorder. ICAN". Infant, Child, & Adolescent Nutrition 3 (4): 209–216. doi:10.1177/1941406411416359.

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