Nasoenteric Feeding Tube Insertion

Published on 22/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/04/2025

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W17 Nasoenteric Feeding Tube Insertion

Deepika Mohan

image Before Procedure

Indications

• Inability to maintain volitional intake in the setting of a functional gastrointestinal tract and:

• Critical illness expected to require more than 2 days’ intensive care unit (ICU) stay
• Poor nutritional status
• Multiple comorbid conditions
• Weight loss and nutrient depletion
• Failure to eat for more than 7 days

Contraindications

• Inability to tolerate enteral nutrition:

• Mechanical bowel obstruction
• Peritonitis
• Hemodynamic compromise (e.g., starting or escalating dose of vasopressors in previously stable patient)
• Short gut (relative)

• Severe cranial or facial fractures
• Esophageal obstruction or recent surgery
• Esophageal or gastric varices
• Coagulopathy (relative)

Equipment

• Tube:

• Nasogastric sump tube (14F-18F)
• Nasoenteric feeding tube with stylet and/or metal weighted tip

• Lubricant
• Gloves
• Gown with long sleeves
• Eye protection
• Emesis basin
• Syringe

• 60-mL Toomey syringe if inserting sump tube
• 10-mL Luer-Lok syringe if inserting nasoenteric feeding tube

• Stethoscope
• Adhesive device

• Tape
• Bridle

• Optional:

• Lidocaine jelly
• Pro-motility agent (e.g. metoclopramide, erythromycin)
• End-tidal CO2 detector

image Anatomy

Successful placement of the feeding tube requires that it pass through the nasal cavity, pharynx, esophagus, and into the stomach. The nasal cavity consists of the nares, septum, lateral nasal wall, and roof. The pharynx consists of a space that extends from the nares down to the inferior border of the cricoid cartilage. At this level, it divides into the esophagus and larynx. The esophagus continues until it terminates in a smooth-muscle sphincter that separates the lower esophagus from the stomach. Typically the lower esophageal sphincter lies 40 cm from the incisors. The pylorus lies approximately 60 to 65 cm from the incisors.

image Procedure

• Position patient:

• If awake, place in sitting position.
• If intubated or unable to comply with instructions, place supine, and elevate head of bed to 45 degrees.

• Coat tube with lubricant.

• Consider applying lidocaine jelly to back of nares.

• Insert tube into nares.
• As tube enters the hypopharynx, ask patient to tilt head forward and swallow.
• Once inserted to 35 cm, tape tube in place and confirm intraesophageal position:

• Obtain chest x-ray (CXR) or
• Attach end-tidal CO2 detector to end of the tube. If indicator turns yellow (positive for CO2), remove tube and reposition. If indicator remains purple (negative for CO2), proceed.

• Advance feeding tube to 55 cm and tape in place if intend to initiate gastric feeding.
• If intend to initiate gastric feeding:

• Check position of the tube.
• Use stethoscope to auscultate left upper quadrant.
• Insufflate air into tube using syringe.
• If passage of air into stomach is heard, tape tube in place and confirm position with CXR. If unable to hear passage of air, reposition tube.

• If intend to initiate post-pyloric feeding:

• Place patient into right lateral decubitus position.
• Administer pro-motility agent.
• Advance tube to 80 to 100 cm.

• Other adjuncts for assistance with positioning of tube:

• Magnets
• Endoscopy
• Bedside fluoroscopy

image After Procedure

Postprocedure Care

• Obtain CXR to confirm position of tube.
• Remove stylet.
• Attach tube securely to nose using tape.
• Consider placing bridle.

Complications

• Common:

• Unplanned removal of feeding tube

• Infrequent:

• Trauma from insertion of tube
• Bleeding from nasal turbinates
• Retropharyngeal hematoma

• Serious and rare:

• Inadvertent placement into cranium, trachea/bronchus
• Perforation of bronchus (pneumothorax), esophagus, stomach

image Outcomes and Evidence

• Early nutrition support therapy, especially using the enteral route, improves patient outcomes by reducing complications, length of stay in the ICU, and possibly reducing disease severity.
• Placement of nasoenteric feeding tube results in complications in approximately 2% to 5% of cases. Experienced practitioners who verify placement of the tube prior to initiating feeding can reduce the incidence of adverse sequelae resulting from inadvertent insertion of tubes into unintended locations.
• The decision to initiate gastric versus postpyloric feeding remains controversial. Evidence of aspiration or intolerance of gastric feeding should prompt physicians to consider placing a postpyloric feeding tube.

Suggested Reading

Dobbie RP, Hoffmeister JA. Continuous pump-tube enteric hyperalimentation. Surg Gynecol Obstet. 1976;13:273-276.

Martindate RG, McClave SA, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med. 2009;37:1757-1761.

Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. Chest. 1991;100:1643-1646.

Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med. 2009;37:1866-1872.

Peter JV, Moran JL, Phillips-Hughes J. A meta-analysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med. 2005;33:213-220.

Burns SM, Carpenter R, Truwit JD. Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurement. Crit Care Med. 2001;29:936-939.

Seder CW, Stockdale W, Hale L, et al. Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in the surgical intensive care unit: a randomized controlled trial. Crit Care Med. 2010;38:797-801.

Marderstein EL, Simmons RL, Ochoa JB. Patient safety: Effect of institutional protocols on the incidence of pneumothorax after feeding tube placement in the critically ill. American College of Surgeons papers session. J Am Coll Surg. 2004;199:39-47.

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