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Background Nasogastric (NG) feeding tubes are used to deliver nutrition, hydration, and medications to hospitalized infants and children but the ongoing use of non-evidence-based practice (EBP) methods to confirm NG tube (NGT) placement has been associated with adverse patient events. Methods A study was undertaken to ascertain if practice changes have occurred since findings from a previous study were published by the New Opportunities for Verification of Enteral tube Location (NOVEL) project. The NOVEL project was an initiative of the American Society of Parenteral and Enteral Nutrition (ASPEN). A survey was distributed to member organizations participating in the NOVEL project. Respondents were also asked if and when a change in practice occurred in the policy for NGT placement verification, if there was variation within the institutional units and if there were barriers to practice change. Findings Respondents were primarily nurses (205/245) from 166 institutions that provided care to combined adult/pediatric/neonatal (122/166) patients. Respondents indicated a radiograph (64%) or pH measurement (24%) were best practice but in actual practice 42% use pH measurement and 23% use a radiograph to verify NGT placement. There was variability within institutions, with the Neonatal Intensive Care Unit (NICU) most often using aspiration and direct eye visualization to verify placement and the other units within the institutions using EBP method(s). Discussion Comparing these results to previous work by the NOVEL project shows an increase toward the use of EBP method(s) to verify NGT placement verification. Application to practice This study demonstrates variation within units at the same facility using methods unsupported by the literature, demonstrating that many centers still rely on non-EBP methods of NG placement confirmation, despite cautions issued by many major healthcare organizations.

Background: Surgical feeding ostomies (SFO, e.g. gastrostomy) have replaced natural orifice feeding tubes (NOFT, e.g. nasogastric feeding tube) as the preferred route for long-term enteral nutrition. Reports of complication rates for SFO vary. Many hospitalized patients are required to accept SFO before hospital discharge due to skilled nursing facilities (SNFs) policy, and without supportive data. We compare adverse event rates between SFO and NOFT. Methods: A prospective cohort study of enterally fed inpatients using semiweekly focused physical exam, scripted survey, and chart review. Findings: Over the course of nine weeks, 226 unique patients were seen an average of 6.25 times each for a total of 1118 unique observations. Demographic data were comparable between subgroups. There were 148 subjects with NOFT and 113 subjects with SFO. 35 NOFT crossed over to SFO during the study. More NOFT than SFO observations took place in ICUs (p

In Pereira et al letter "Misplacement of a nasogastric feeding tube: a case report" we found some debatable concepts about the frequency of pleural and pulmonary injuries due to accidental access of the feeding tubes in the airway and techniques for placing feeding tubes. We clarify that the frequency of injuries due to accidental entry into the airway is not as low as the authors state and that blind placement should be avoided.

Background Several studies have shown that the nose‐earlobe‐xiphoid distance (NEX) is inadequate to estimate the insertion length of nasogastric tubes. An alternative approach tested in these studies, which leads to > 90% well‐placed nasogastric tubes, used a corrected calculation of the NEX: (NEX × 0.38696) + 30.37. The primary aim of this study was to determine whether using the corrected NEX was more successful than the NEX in determining the insertion length. The secondary aim was to investigate the likelihood to successfully obtain gastric aspirate. Methods Adult patients in a general hospital (N = 215) needing a nasogastric tube were randomized to the control (NEX) or intervention group (corrected NEX). Tip positioning was verified using X‐ray. Correct tip positioning was defined as between 3 and 10 cm under the lower esophageal sphincter (LES). Results In >20% of all patients, both methods underestimated the required tube length for correct positioning. The NEX showed an overestimation (17.2%) of the insertion length (>10 cm under the LES) compared with the corrected NEX (4.8%). There was no difference (P = 0.938) between the 2 groups in obtaining gastric aspirate (55.6% vs 56%). However, correct tip positioning resulted in a fourfold increase of obtaining gastric aspirate. Conclusions Both methods resulted in a high risk of incorrectly placed tubes due to malposition of the tip near the LES or distal esophagus. This may increase the risk of reflux and pulmonary aspiration. Based on these results, the development of more reliable methods requires consideration. ispartof: NUTRITION IN CLINICAL PRACTICE vol:33 issue:6 pages:843-850 ispartof: location:United States status: published

Aim. To explore individual quality of life in patients with head and neck cancer from diagnosis up to 3 months after termination of radiotherapy. Research questions: 1) Which areas in life are important to quality of life, and which are influenced by the disease and by having oral or enteral nutrition; and 2) Which areas in life are influenced by having a nasogastric feeding tube (NGT) or a percutaneous endoscopic gastrostomy (PEG) tube? Material and methods. Data were collected in 36 patients. Semi-structured interviews were conducted using an extended version of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) and analysed with content analysis. Results. Negative and positive experiences of quality of life in general were about relation to family, own health, and leisure activities. Negative impacts on physical, psychological, existential and social problems, but also positive experiences are described by the patients related to the disease. More than half expressed eating-related problems. Enteral nutrition entailed negative and positive experiences, and no greater variations were described by the patients with NGT or PEG tube. Overall, there were interindividual variations. Conclusions. The patients’ perception of general or disease-related quality of life was not affected by whether they had enteral nutrition or not. From the patients’ perspective neither of the two feeding tubes (NGT or PEG) was clearly in favour. We suggest that more studies are needed on how the choice of enteral feeding tube can be evidence-based, and incorporating the patients’ perspective.

Introduction Maintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements. Methods Medical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements. Results A total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group. Conclusion The commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

ObjectivesThe existing British National Patient Safety Agency (NPSA) safety guideline recommends testing the pH of nasogastric (NG) tube aspirates. Feeding is considered safe if a pH of 5.5 or lower has been observed; otherwise chest X-rays are recommended. Our previous research found that at 5.5, the pH test lacks sensitivity towards oesophageal placements, a major risk identified by feeding experts. The aim of this research is to use a decision analytic modelling approach to systematically assess the safety of the pH test under cut-offs 1–9.Materials and methodsWe mapped out the care pathway according to the existing safety guideline where the pH test is used as a first-line test, followed by chest x-rays. Decision outcomes were scored on a 0–100 scale in terms of safety. Sensitivities and specificities of the pH test at each cut-off were extracted from our previous research. Aggregating outcome scores and probabilities resulted in weighted scores which enabled an analysis of the relative safety of the checking procedure under various pH cut-offs.ResultsThe pH test was the safest under cut-off 5 when there was ≥30% of NG tube misplacements. Under cut-off 5, respiratory feeding was excluded; oesophageal feeding was kept to a minimum to balance the need of chest X-rays for patients with a pH higher than 5. Routine chest X-rays were less safe than the pH test while to feed all without safety checks was the most risky.DiscussionThe safety of the current checking procedure is sensitive to the choice of pH cut-offs, the impact of feeding delays, the accuracy of the pH in the oesophagus, as well as the extent of tube misplacements.ConclusionsThe pH test with 5 as the cut-off was the safest overall. It is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximise safety and to minimise the use of chest X-rays.Trial registration numberISRCTN11170249; Pre-results.

Introduction The exposed section of a traditional nasogastric (NG) tube can interfere with patients' social activities and thereby result in distress. This study was conducted to evaluate the feasibility and safety of a novel two-piece NG tube for patients with dysphagia. Methods Ten patients with dysphagia were recruited between November 2011 and May 2012. Patients who were unconscious or in critical condition, had a traditional NG tube 60 cm in fixed length, or were unable to follow instructions or sign consent forms were excluded. The two-piece NG tube, which was placed in the patients for one week, comprised a removable external tube that can be joined to an internal tube via a T-connector, which was placed close to the naris. Events related to safety (e.g. nasal pressure sores, number of unplanned extubation, displacement and spontaneous migration of the NG tube, other unpredictable injuries) and effectiveness (e.g. liquid food spills, tube obstruction, perfusion rate, other adverse circumstances) were assessed daily. Results All patients received feeding without complication using the two-piece NG tube and none experienced premature removal of the tube. No serious NG tube complications or malfunctions were observed. Conclusion The results of this study indicate that the two-piece NG feeding tube is a feasible option for patients with dysphagia. Future improvements to the connector may help enhance its performance. A rigorous randomised controlled trial to examine the effects of the two-piece NG tube on patients' quality of life and quality of medical care is being planned.

Background Establishing postnatal nutrition delivery is challenging in neonates with immature sucking and swallowing ability. Enteral feeding is the gold standard for such patients, but their small size and fragility present challenges in nasogastric (NG) feeding tube placement. Feeding tubes are typically placed with x-ray guidance, which provides minimal soft tissue contrast and exposes the baby to ionizing radiation. This research investigates magnetic resonance (MR) guidance of NG feeding tube placement in neonates to provide improved soft tissue visualization without ionizing radiation. Materials and methods A novel feeding tube incorporating 3 solenoid coils for real-time tracking and guidance in the MR environment was developed. The feeding tube was placed 5 times in a rabbit with conventional x-ray guidance to assess mechanical stability and function. After x-ray procedures, the rabbit was transferred to a neonatal MR system, and the tube was placed 5 more times. Results In procedures guided by x-ray and MR, the feeding tube provided sufficient mechanical strength and functionality to access the esophagus and stomach of the rabbit. MR imaging provided significantly improved soft tissue contrast versus x-ray, which aided in proper tube guidance. Moreover, MR guidance allowed for real-time placement of the tube without the use of ionizing radiation. Conclusions The feasibility and benefits offered by an MR-guided approach to NG feeding tube placement were demonstrated. The ability to acquire high-quality MR images of soft tissue without ionizing radiation and a contrast agent, coupled with accurate 3-dimensional device tracking, promises to have a powerful impact on future neonatal feeding tube placements.

Objective Pulmonary misplacement during the blind insertion of enteral feeding tubes is frequent, particularly in ventilated and neurologically impaired patients. This is probably the first clinical study using the Kangaroo Feeding Tube with IRIS technology (IRIS) which incorporates a camera designed to provide anatomic landmark visualization during insertion. The study aim was to evaluate IRIS performance during bedside gastric placement. Methods This is the first prospective study to collect data on the use of IRIS. Twenty consecutive unconscious patients requiring enteral nutrition were recruited at a single center. IRIS placement was considered complete when a clear image of the gastric mucosa appeared. Correct placement was confirmed using a contrast-enhanced abdominal X-ray. To evaluate the device performance over time, the camera was activated every other day up to 17 d postplacement. Results In 7 (35%) patients, the trachea was initially visualized, requiring a second placement attempt with the same tube. The IRIS camera allowed recognition of the gastric mucosa in 18 (90%) patients. The esophagogastric junction was identified in one patient, while in a second patient the quality of visualization was poor. Contrast-enhanced X-ray confirmed the gastric placement of IRIS in all patients. IRIS allowed identification of gastric mucosa in 14 (70%) patients 3 d after placement. Performance progressively declined with time (P = 0.006, chi-square for trend). Conclusion IRIS placement could have spared X-ray confirmation in almost all patients and prevented misplacement into the airway in about one third. Visualization quality needs to be improved, particularly after the first week.

Introduction: Preliminary study on the evaluation of weight restoration by using a nasogastric feeding tube begun in hospital, for ambulatory anorexia nervosa treatment Methods: A retrospective review of patients’ folders from outpatient department of eating disorders of the Pellegrin University Hospital Center, has been performed. The study includes the adults from April 2015 to January 2016, who had a low BMI (, Introduction : Étude préliminaire sur l’évaluation du gain de poids par l’utilisation d’une sonde nasogastrique à domicile, instaurée initialement à l’hôpital, comme thérapie de renutrition chez des patients souffrant d’anorexie mentale. Méthode : Un examen rétrospectif des dossiers des patients, consultant dans le service des troubles du comportement alimentaire du Centre Hospitalier Universitaire de Pellegrin, d’avril 2015 à janvier 2016, a été réalisé. Les patients inclus avaient un IMC < 15 kg/m² et une perte de poids très rapide. Étaient exclus les patients ayant des troubles du comportement alimentaire atypique, une autre affection psychiatrique chronique sévère non traitée, une maladie somatique responsable d’une dénutrition, ou les patients refusant le traitement. Le critère d’évaluation principal était le gain de poids hebdomadaire. Résultats : 7 patients ont été inclus. La population était composée exclusivement de femmes, d’une moyenne d’âge de 28 ans, ayant un IMC moyen à 12,81 kg/m². Il y a eu un refus de poursuivre le traitement. 6 patients ont donc été étudiés. La durée moyenne d’hospitalisation était de 39 jours, avec une sortie acceptée pour un IMC moyen à 15,03 kg/m². Le gain moyen hebdomadaire était de + 1,25 kg/semaine (écart-type : 0,51). À domicile, le gain de poids moyen était de + 0,84 kg/semaine, avec une durée moyenne de 38,8 jours, la sonde étant retirée à un IMC moyen à 16,16 kg/m². Au total un gain de poids hebdomadaire de +0,86 kg a été obtenu, pour une durée totale de traitement par SNG de 77,8 jours. Le gain moyen d’IMC sur la durée totale du traitement était de +3,24 kg/m². Aucun syndrome de renutrition inapproprié n’a été observé. Conclusion : La nutrition entérale à domicile a permis un gain de poids régulier, en accord avec les recommandations internationales et les dernières données de la science, chez des patients souffrant d’anorexie mentale, sans augmenter le risque de syndrome de renutrition inapproprié, et en réduisant de façon importante la durée d’hospitalisation.

Background Nasogastric feeding tube (NGT) placement is a common practice performed in intensive care units (ICUs). Complications due to the improper placement of NGT are well known. In this prospective descriptive study, the effectiveness of ultrasound (US)-guided NGT placement was investigated. Materials and methods Fifty-six mechanically ventilated patients monitored in the ICU were included. A linear US probe was transversely placed just cranial to the suprasternal notch, and the concentric layers of the esophagus were attempted to be viewed on the posterolateral side of the trachea (generally left) by shifting the probe. If the esophagus can be seen, an attempt was made to insert the NGT under real-time visualization of ultrasonography. Furthermore, gastric placement of the NGT tip was confirmed with abdominal radiograph. Results A total of 56 patients were included in the study. For 52 (92.8%), the NGT image was obtained during placement within the esophagus. For 3 (5.3%), the esophagus could not be seen by US, and NGT was placed blindly. For 1 patient, we could not detect passing of the NGT into the stomach despite the successful visualization of esophagus. In this patient, NGT was radiographically detected in the trachea after the procedure. Conclusion This study revealed that passing of the NGT through the esophagus could be visualized at a high rate in real-time US among ICU patients. These data suggest that ultrasonographic visualization of the upper esophagus during NGT insertion can be used as an adjuvant method for confirmation of correct placement.

Summary Objective To review current methods for confirming nasogastric tube position and their efficacy in relation to the need to feed. Design and methods This paper reviews current guidelines and techniques to safely confirm tube position balanced against the need to provide nutrition quickly. All new information was incorporated from electronic database searches up to 7.4.2012. Findings Tube misplacement per se, feeding through undetected misplaced tubes and the potentially fatal complications that arise from both appear to be underestimated. Misplacement occurs due to failure to confirm tube position, lack of expertise in interpretation or inability of the confirmation method to differentiate safe placement from misplacement. Inability to confirm tube position is a major cause of delay to feeding and risks malnutrition. Discussion Theoretically, X-ray is the gold standard for confirming tube position. However, because X-ray is associated with misinterpretation and delays feeding, it should in most cases be the second-line confirmation technique after other methods fail. Currently, pH offers the most practical first-line confirmation method with a threshold of ≤5.0 indicating gastric position. A pH threshold ≤4.0 increases false negatives, excess X-ray use and misinterpretation and delay to feeding whereas a threshold >5.0 can fail to detect lung, oesophageal or intestinal placement. Traumatic injury on misplacement can be pre-empted by use of capnography/capnometry or X-ray at a 35 cm tube depth or an electromagnetic (EM) trace. The EM trace guides real-time placement and re-positioning until gastric position is attained but a larger evidence-base is required to confirm this potential. Conclusions and recommendations Research is urgently required on how to avoid tube misplacement. This must be balanced against risk of delayed feeding and cumulative nutritional deficit leading to subsequent complications and mortality.

To evaluate bedside sonographic confirmation of weighted-tip nasogastric feeding tube position, by comparison to radiography. Single-center, double-blind prospective study in a 14-bed medical intensive care unit (ICU) in a 780-bed teaching hospital. Thirty-three ICU patients undergoing nasogastric tube insertion for enteral feeding. The tip of the nasogastric tube was located both by sonography and standard radiography. The accuracy and procedure times of sonography and radiography for nasogastric tube tip location were compared during 35 procedures in 33 patients. The nasogastric tube tip was visualized by sonography in 34 of 35 procedures (sensitivity 97%) and by radiography in all procedures. The median length of the entire procedure was 24 min and 180 min with sonography and radiography, respectively. Bedside sonography performed by nonradiologists is a sensitive method for confirming the position of weighted-tip feeding nasogastric feeding tubes. It is more rapid than conventional radiography and can easily be taught to ICU physicians. Conventional radiography could be reserved for cases in which sonography is inconclusive

Nasogastric tube placement is desirable for the short-term administration of calories when oral feeding is not possible. Enteral nutrition is superior to parenteral nutrition. In some patients this method of feeding is impossible because of repeated failure of nasogastric tube placement, necessitating either general anaesthesia for enteral access, or total parenteral nutrition. We describe a new method for nasogastric tube placement aided by a fibre-optic nasendoscope which has resulted in the successful placement of over 20 nasogastric tubes in our unit and the avoidance of more invasive methods of establishing nutrition with their associated complications.

Serous otitis media (SOM) is a common disease, the cause of which is not always clear. In this paper authors report the high incidence of SOM among the patients with amyotrophic lateral sclerosis (ALS). Furthermore, a comparative study about ALS and other diseases shows higher incidence of SOM in ALS. Our study indicates that SOM in ALS seems to be mainly due to muscular disturbance of eustachian tube caused by ALS, although the influence of long term supine position and nasopharyngeal irritation by nasogastric feeding tube cannot be denied in the development of SOM.

This is a report of an in vitro study evaluating clotting ability of some formulas with intact protein and hydrolyzed protein sources in a series of buffers ranging from a pH of 1 thru 10. The following 10 products were tested: Ensure Plus, Ensure, Enrich, Osmolite, Pulmocare, Citrotein, Resource, Vivonex TEN, Vital, and Hepatic Acid II. Protein (10 and 20 g/liter) was added to Citrotein and Ensure Plus. All formulas were tested at full and some at half strength. Clotting occurred only in premixed intact protein formulas (Pulmocare, Ensure Plus, Osmolite, Enrich, Ensure) and in Resource. No clotting was observed for Citrotein (intact protein formula in powder form), Vital, Vivonex TEN, and Hepatic Aid II. Adding protein did not cause or increase clotting. In summary, clotting of some liquid formula diet appears to be an important factor causing possible gastric feeding tube occlusion. The following measures may help in preventing this problem: flushing before and after aspirating for gastric residuals to eliminate acid precipitation of formula in the feeding tube, advance the nasogastric feeding tube into the duodenum if possible, and avoid mixing these products with liquid medications having a pH value of 5.0 or less.

We report here our clinical experiences of "fine bore" nasogastric feeding tubes. Data have been collated over a 7-year period (1978-1985). A total of 403 patients were intubated on 809 occasions. In the first retrospective study, the clinical use of 491 unweighted tubes was compared with that of fifty 3.5-g weighted tubes. No advantage was found in the use of the weighted tubes. In the second prospective controlled clinical trial, these results were confirmed. Forty-six patients were intubated on 76 occasions with an 85-cm open-ended, unweighted nasogastric feeding tube (Prima, Portex UK), and 57 patients were intubated on 79 occasions with a 91-cm 3.0-g weighted tube (Entriflex, Biosearch, Raritan, NJ). Mean duration of placement was similar in each case, and 62% of both types of tubes were inadvertently removed. Without exception, all the tubes remained in the stomach throughout. Disappointed with the similar and overall performance of both types of tubes, we initiated a design program which resulted in the development of two new nasogastric tubes, one weighted and one unweighted. The tubes were manufactured with polyurethane, rather than polyvinylchloride (PVC), which permitted an increase in diameter of the internal lumen which, in turn, was coated with water-activated lubricant to ease removal of the introducer wire. A specially modeled outflow port was incorporated into the tips of both tubes. The performance of the two new polyurethane nasogastric feeding tubes was assessed under controlled trial conditions; as a reference, a widely used PVC unweighted open-ended tube was used.(ABSTRACT TRUNCATED AT 250 WORDS)

A performance evaluation of a new polyurethane nasogastric feeding tube and stainless steel stylette (Nutriflex, No 8 French) was conducted at University Hospital. Thirty-eight tubes were successfully placed in 18 patients. Tubes remained in place less than 1-29 days and feedings were administered for a total of 196 patient days. Enteral formulas commonly available were administered via continuous drip. The tube use was surveyed for ease of insertion primarily; however, patency and comfort to the patient were felt to be positive with the use of this tube. With slight modifications the new feeding tube is a welcome addition to the expanding technology associated with enteral feedings.

Essential to the management of the head and neck cancer patient is carefully monitored nutritional support. Traditionally, enteral alimentation, using the nasogastric feeding tube, has been the mainstay of treatment. Tube feedings should provide ample amounts of essential nutrients, minerals, vitamins, and adequate calories and protein. Knowledge of the tube feedings available and problems associated with their administration helps to avoid the pitfalls which limit their effectiveness. The inadequacies of enteral alimentation preclude its use in selected circumstances of severe nutritional depletion. Parenteral hyperalimentation, as a primary or adjuvant mode of therapy, may be capable of rapidly reversing deficits, improving postoperative morbidity and increasing tolerance to radiation and chemotherapy. Postoperative deglutition abnormalities may prolong the nutritional problems of head and neck cancer patients as well.