Tube Feedings in Elderly Patients

Omerprazole and other proton pump inhibitors: pharmacology, efficacy, and safety, with special reference to use in children.

High-Dose Oral Erythromycin Decreased the Incidence of Parenteral Nutrition-Associated Cholestasis in Preterm Infants

Percutaneous endoscopic gastrostomy (PEG) and nasogastric (NG) tubes are commonly used for long‐term enteral feeding in older patients with swallowing difficulties. We conducted a nationwide cohort study (2002–2018) comparing complications between PEG and NG tubes using a 1:1 new‐user design. Post‐procedure outcomes included peritonitis, peptic ulcer, gastrointestinal bleeding, and aspiration pneumonia. The incidence rates per 1000 person‐years for PEG versus NG groups were 3.52 versus 4.53 for peritonitis, 4.67 versus 8.62 for peptic ulcer, 7.65 versus 8.59 for GI bleeding, and 15.4 versus 9.04 for aspiration pneumonia. After adjusting for confounders, PEG was not associated with significant risks compared to NG. However, patients with chronic kidney disease (CKD) had a higher risk of aspiration pneumonia with PEG feeding (HR 3.03, 95% CI 1.02–8.99). Our findings suggest that PEG is the recommended approach for patients needing extended tube feeding support and careful patient selection and close monitoring, especially for CKD patients, are crucial post‐PEG placement. These real‐world data contribute to clinical decision‐making on enteral access options, but further studies on interventions to reduce complications are needed.

Enteral nutrition support has been commonly used to improve nutrition status in acute stroke patients. The purpose of this study was to examine whether significant alterations in fluid and serum Na+ and K+ levels due to nasogastric tube feeding depended on patient age. This study was conducted by retrospective review of the medical records of tube-fed patients with acute brain infarction who had been hospitalized in a university hospital. Rates of overhydration were high before tube feeding in both elderly and nonelderly stroke patients. This overhydration rate became more prevalent after iso-osmolal tube feeding in the elderly but decreased somewhat in the nonelderly subjects, and this difference in fluid balance after tube feeding between the elderly and nonelderly was statistically significant. Contrary to fluid balance, serum Na+ and K+ concentrations were no different in the elderly and nonelderly patients after tube feeding. Although the results showed that overhydration state was prominent after tube feeding in the elderly, it appeared that there was a very mild clinical impact because the osmolality and serum sodium were not changed in this group. However, more attention to the maintenance of fluid balance in the elderly tube-fed stroke patients is needed because elderly patients have great difficulty in maintaining a normal fluid balance.

Aspiration pneumonia is common in older people. To reduce the risk of aspiration pneumonia, maintenance of good oral hygiene is important and medications affecting salivary flow or causing sedation are best avoided, if possible. The use of H2 blockers and proton-pump inhibitors should be minimised. Different compensatory and facilitation techniques can be applied during oral feeding. Hand feeding should be tried before consideration of tube feeding. The use of tube feeding is the last resort and is mainly for improving nutrition and hydration. Prevention of aspiration pneumonia and increasing survival rates should not be the rationales for tube feeding. Feeding via both gastrostomy and nasogastric tube has similar risks for aspiration pneumonia, and continuous pump feeding is not better than intermittent feeding. Jejunal feeding might decrease the chance of aspiration pneumonia in selected high-risk patients. If older patients are on angiotensin-converting enzyme inhibitors without intolerable cough, continuing the drug may be beneficial. Folate deficiency, if present, needs to be promptly corrected. Further better-designed studies are warranted to find the best ways for prevention of aspiration pneumonia.

Withholding and Withdrawing Nutrition and Hydration: Surrogates Can Make This Decision for Incompetent Patients

Recent animal studies indicate that immediate enteral feeding may be beneficial in patients with major burns. Yet, largely because of the fear of complications, immediate enteral feeding is not commonly performed in patients with major burns until after the resuscitation period. The purpose of this study was to evaluate the safety and efficacy of immediate enteral tube feedings in patients with burns larger than 20% of their body surface area. The daily intake of enteral feedings begun immediately (less than 6 hours) after burn was measured during the first 7 days after burn in 106 consecutive patients with a mean +/- SD burn size of 40% +/- 21%. The incidence of complications related to enteral feeding was low; aspiration pneumonia did not occur. Vomiting was the major complication observed and occurred 21 times in 16 patients during the 745 study days (2.8% daily incidence). The mean number of calories absorbed enterally increased daily and met the patient's calculated resting energy expenditure (REE) on day 3 after burn (99% +/- 7% REE). The results of this study indicate that immediate enteral feeding is a safe and effective method of delivering nutritional support to burn victims with major burns.

Nasogastric tubes (NGTs) are used for decompression in patients with acute small bowel obstruction (SBO); however, their role remains controversial. There is evidence that NGT use is still associated with high incidence of aspiration pneumonia. The aims of this study were to define the prevalence of aspiration pneumonia in patients with SBO managed with an NGT and estimate the association of aspiration pneumonia with 30-day mortality rates, length of stay (LOS), and hospital costs. A retrospective cohort study was done using Medicare Inpatient Standard Analytic Files from 2016 to 2018. Patients hospitalized with SBO and managed with NGT were identified using an algorithm of ICD-10-CM codes. The key exposure was aspiration pneumonia. Outcome measures included 30-day mortality rates, LOS, and hospital costs. 53715 patients hospitalized with SBO and managed with an NGT were identified and included in the analysis. We observed a prevalence of aspiration pneumonia of 7.3%. The 30-day mortality rate was 31% for those who developed aspiration pneumonia vs. 10% for those without pneumonia (P < .001). Those with aspiration pneumonia, on average, were hospitalized 7.0days longer (P < .001) and accrued $20,543 greater hospitalization costs (P < .001) than those without pneumonia. Controlling for hospital size and hospital teaching status, we noted a significant association between aspiration pneumonia and increased mortality (P < .001), longer length of stay (P < .001), and higher hospital costs (P < .001). Among patients hospitalized for SBO who required an NGT, aspiration pneumonia was associated with a higher mortality rate, longer hospital LOS, and higher total hospital costs. vv.

Aspiration pneumonia in patients who received enteral feeding via a nasogastric tube may result from retrograde colonization from the stomach, and this may be more likely when the gastroesophageal reflux is severe and the gastric pH is relative high. We investigated 11 elderly patients fed via nasogastric tube with suspected recurrent aspiration pneumonia by means of esophageal scintigraphy, 24-h pH monitoring, gastric pH and concentrations of gram-negative bacilli in gastric aspirates. The grade of respiratory tract infection (RTI) was evaluated by the frequency of episodes of fever with respiratory symptoms. The correlation between the grade of RTI and reflux index by scintigraphy was statistically significant (p < 0.05), but the correlation between the grade of RTI and reflux rate by 24-h pH monitoring was not statistically significant. Although the correlation between gastric pH and log (base 10) concentration of gram-negative bacilli/ml of gastric aspirates was statistically significant (p < 0.001), the correlation between the grade of RTI and gastric pH was not statistically significant. Scintigraphy was superior for evaluation of gastroesophageal reflux resulting in aspiration pneumonia in the tube-fed elderly patients.

PurposeWe retrospectively compared the complications, blood biochemical indexes and outcomes in patients with swallowing disturbances receiving nasogastric tube (NGT) feeding and percutaneous endoscopy gastrostomy (PEG).MethodsAmong 160 patients, 72 cases received PEG and 88 cases received NGT. All patients were followed up for two years. We collected their clinical data from the medical records. Indicators, such as body mass index (BMI), white blood cell (WBC), hemoglobin (HGB), complications, including recurrent aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and outcomes (survival or death) were compared between the two groups semi-annually.ResultsSAt both six months and one year after receiving treatment, there was no statistical difference between the two groups in indicators, complications and outcomes, with all P >0.05. It can be seen that, when the patients were followed up for one and a half years18 months, ALB was lower in the NGT group (33.81±0.46) compared with the PEG group (36.14±0.50) (P <0.05). After two years of follow-up, differences between the NGT and PEG group could be seen in a variety of indicators, including BMI (20.08±0.27 vs 21.03±0.25), WBC (9.12±0.56 vs 7.08±0.29), ALB (33.11±0.43 vs 35.75±0.49), creatinine (55.07±1.83 vs 63.21±2.94), and the complications, such as aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and electrolyte disorder, in the PEG group were significantly reduced compared to the NGT groupthan that in its counterpart, P <0.05. In the two-year follow-up period, there were 13 and 22 patients died in the PEG group and NGT group, respectively.ConclusionBoth techniques are safe and effective in the short term. However, on a longer-term basis, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications for patients with swallowing disturbances.

Objective:To evaluate the ability of capnography to document proper placement of nasoesophageal (NE) and nasogastric (NG) feeding tubes. This study was conducted in 3 phases. Phase I of this study was designed in order to test the efficacy of capnography to distinguish placement of a feeding tube in the alimentary tract versus the respiratory tract. Phase II was designed in order to document that carbon dioxide (CO2) could be measured through a polyvinyl chloride (PVC) feeding tube. Phase III was performed in order to evaluate the technique of continuous monitoring during insertion of the feeding tube into the esophagus and stomach as would be performed during a clinical‐tube placement.Design:Prospective study.Setting:Research laboratory.Animals:24 adult dogs.Interventions:In Phase I, sedated dogs were instrumented with an intratracheal catheter and an 8 French feeding tube placed nasally into the distal esophagus and later advanced into the stomach. In Phase II, dogs were anesthetized and an 8 French feeding tube was placed down the endotracheal tube, then into the esophagus and later advanced into the stomach. In Phase III, sedated dogs were instrumented with an 8 French feeding tube inserted intranasally and then advanced to the level of the nasopharynx, distal esophagus and, lastly, the stomach. Fluoroscopy was used in order to determine location of the feeding tube.Measurements and main results:Phase I measurements included respiratory rate and CO2from the trachea, esophagus, and stomach and pH of gastric fluid sample. Phase II measurements included respiratory rate and CO2from the endotracheal tube, feeding tube in the endotracheal tube, feeding tube in the distal esophagus, and feeding tube in the stomach. Phase III data collection included respiratory rate and CO2as the tube was passed through the nasal cavity, nasopharynx, esophagus and stomach. Phase I fluid samples were collected from 5 of the 9 dogs and had pH values from 1.68 to 4.20. In both phases, values for the respiratory rate and CO2from the esophagus and stomach were 0 ± 0, significantly lower (P &lt; 0.001) than the values from the trachea. In Phase II, there was no significant difference between the respiratory rates (P = 0.886) and CO2(P = 0.705) readings obtained from the endotracheal tube compared to readings from the feeding tube in the endotracheal tube. In Phase III, there was a significant difference (P &lt; 0.001) between the respiratory rates and CO2readings obtained from the nasal cavity and the nasopharynx when compared to those readings obtained from the esophagus and stomach. Measurement of CO2and respiratory rate resulted in a reading of 0 every time the feeding tube was in the esophagus or stomach.Conclusions:Capnography may be used in order to detect airway placement of NE and NG tubes.

The challenge pays off: Early enhanced nutritional intake for VLBW small-for-gestation neonates improves long-term outcome

Introduction Nasogastric (NG) pump feeding is associated with risks of aspiration and subsequent pneumonia with previous studies in adult inpatients suggesting 2.4 aspiration episodes per 1000 tube-feeding days. However, there is little published data on outcomes of patients receiving home NG feeding. We analysed our long term home NG feeding cohort for evidence of aspiration related hospital admission. Methods This was a retrospective service evaluation of the home enteral tube feeding cohort at Portsmouth Hospitals NHS Trust. Data was obtained from hospital electronic databases, patient clinical notes and PAS patient management software. Data was analysed in SPSS 20. Results A total of 117 patients who had received home NG feeding over previous 5 years were evaluated. 30 patients (26%) were excluded due to incomplete datasets. 87 patients were recruited (Male [48%], Female [52%], age [mean 55.6; 95% confidence interval 51.8–59.2]) with a total of 12957 tube-feeding days (mean 150; 95% confidence interval 110–191 days). Indications include upper aerodigestive tract cancer, 32; malnutrition, 25; neurodegenerative disorders, 6; connective tissue disorders, 2; stroke, 1; lymphoma, 1; metabolic stabilisation of short bowel and or high output stoma, 16. Eight hospital admissions in separate patients were recorded; however, only 1 episode of pneumonia was recorded (0.08 aspiration episodes per 1000 tube-feeding days). There were no hospital admissions relating to misplaced/displaced NG tubes. Conclusion Home NG pump feeding represents a safe long-term alternative to gastrostomy feeding when supported by a robust specialist enteral tube feeding support service (ETFSS), in those deemed unsuitable for gastrostomy placement. A 30-fold lower incidence of aspiration episodes compared with published inpatient literature (0.08 vs. 2.4 episodes/1000 tube feeding days) reflects expertise of clinical nutrition nurse specialists within the ETFSS, with appropriate patient selection and outreach management. A daytime walk in service prevents unplanned hospital admissions through tube displacement. Disclosure of Interest None Declared

Early enteral nutrition through a feeding tube is essential for the management of severe acute pancreatitis (SAP). Nasojejunal tube nutrition has been preferred on the assumption that it provided pancreatic rest in comparison to the nasogastric tube. However, nasojejunal tube placement is complex, may delay feeding initiation and can increase hospital costs. Our aim was to compare the efficacy and safety of enteral feeding with a nasogastric tube versus nasojejunal tube in patients with SAP. We searched four databases (PubMed, Web of Science, Scopus, and Embase) until December 1, 2022. We included randomized controlled trials (RCTs) comparing enteral feeding by nasogastric and nasojejunal tubes in patients with SAP. Primary outcome was all-cause mortality. Secondary outcomes were organ failure, infection, complications, surgical intervention, duration of tube feeding and length of hospital stay. Risk of bias assessment was completed independently by two investigators using the Cochrane RoB 2.0 tool. We performed random effects model meta-analyses using the inverse variance method. Effect measures were reported as relative risks (RR) and their 95% CIs for dichotomous outcomes and mean differences (MD) and their 95% CIs for continuous outcomes. We included four RCTs involving 192 patients with SAP. The mean ages ranged between 36 and 62 years old. There was no significant difference in all-cause mortality between the nasogastric and nasojejunal feeding arms (18/98 vs. 23/93; RR 1.34, 95%CI 0.77–2.30; p=0.30). There were no significant differences in all secondary outcomes between feeding arms. There were three RCTs with some concerns of bias, in the randomization process. In conclusion, in patients with SAP, enteral feeding delivered by nasogastric tube was as efficacious and safe as nasojejunal tube. Further randomized controlled trials with more participants and better design are needed to confirm these findings.

The incidence of pneumonia among elderly people is increasing in aged countries, and both pulmonologists and non-pulmonologists treat such patients. The aim of this study was to assess prognostic differences between elderly patients treated by pulmonologists and those treated by non-pulmonologists. This study was a retrospective cohort using a propensity score analysis. Patients 65 years of age or over with pneumonia were consecutively included. The propensity score was estimated based on the patient's background and severity of pneumonia. The difference in 30-day and 90-day mortality depending on the attending physician's specialty was analyzed after adjusting for other variables, including the propensity score. We assessed 68 and 182 patients treated by pulmonologists and non-pulmonologists, respectively. The pulmonologists tended to be in charge of patients with hypoxemia, chronic obstructive pulmonary disease or dementia without aspiration pneumonia or renal dysfunction (area under receiver operating characteristic curve to predict treatment by a pulmonologist according to the propensity score = 0.737, P < 0.001). In the multivariate analysis, white blood count cell (adjusted hazard ratio, 1.000, P = 0.030) and the serum albumin level (0.382, P = 0.001) were associated with 30-day mortality, and a bedridden status (3.000, P = 0.013) and the serum albumin level (0.382, P < 0.001) were associated with 90-day mortality; however, the attending physician's specialty was not associated with these prognoses. The overall prognosis of pneumonia in elderly patients may not necessarily improve, irrespective of treatment by pulmonologists, and host factors seemed to be associated with mortality.