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Intensive and Critical Care Nursing (2004) 20, 330—343

ORIGINAL ARTICLE

A review of the nursing care of enteral feedingtubes in critically ill adults: part I

Teresa A. Williamsa,∗, Gavin D. Leslieb,1

a Royal Perth Hospital, PO Box X2213, Perth, WA 6847, Australiab Centre for Nursing Evidence Based Practice, Education and Research, Royal Perth Hospital, PO Box

X2213, Perth, WA 6847, Australia

Accepted 9 August 2004

KEYWORDS

Enteral tube;

Feeding;

Intensive care

Summary Enteral tubes are frequently used in critically ill patients for feedingand gastric decompression. Many of the nursing guidelines to facilitate the careof patients with enteral tubes have not been based on current research, but onritual and opinion. Using a computerised literature search and an evidence-basedclassification system as described by the Joanna Briggs Institute for Evidence BasedNursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tubemanagement.

Several nursing practices related to enteral tube management are described. Ev-idence to support alternate methods of tube placement assessment other than ab-dominal X-ray was inconclusive. Enteral feeding should continue if gastric residualvolumes are not considered excessive, as feeding is often withheld unnecessarily.Frequency of checking gastric residual volumes is largely opinion based and variesconsiderably, but prokinetics that aid gastric emptying should be used if absorptionof feeds is problematic. Other recommendations include continuous rather thanintermittent feeding, semi-recumbent positioning to reduce the risk of airway aspi-ration and diligent artificial airway cuff management. Contamination of feeds canbe minimised by minimal, meticulous handling and the use of closed rather thanopen systems. Generally, there was little high quality evidence to support prac-tice recommendations leaving significant scope for further research by nurses in themanagement of patients with enteral tubes.© 2004 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +61 08 9224 2601;fax: +61 08 9224 3196.

E-mail addresses: [email protected](T.A. Williams), [email protected] (G.D. Leslie).

1 Tel.: +61 08 9224 8081; fax: +61 08 9224 1958.

Introduction

Enteral tubes are frequently used in the criti-cally ill patient for gastric decompression, de-livery of medications and food substitutes. Al-though enteral feeding is beneficial, as with mosthealthcare interventions, there are risks and po-

0964-3397/$ — see front matter © 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2004.08.002

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A review of the nursing care of enteral feeding tubes in critically ill adults 331

tential adverse events inherent with their clinicalapplication.

Nursing care of patients with enteral feedingtubes has often been based on ritual and opinionrather than current research (Booker et al., 2000;Edwards and Metheny, 2000; Metheny, 1993). Bestpractice is based on the highest levels of evidenceto facilitate the benefits and minimise the harm as-sociated with any therapy. The systematic and rig-orous approach to the analysis and grading of re-search findings in terms of level of evidence facili-tates the development of specific guidelines, stan-dards and recommendations to provide the bestpossible care for every patient. In part I of thistwo part paper, the current research findings forthe nursing care of critically ill patients with en-teral feeding tubes is reviewed. Nursing care of pa-tients to prevent aspiration is described. In part 2of this paper, nursing management and recommen-

dations for implementing evidence-based protocolsfor tube and feeding management are discussed.

Data sources and levels of evidence

Several methods were used to identify relevant ar-ticles for this review. A computerised literaturesearch of online databases MEDLINE (1966—2003),EMBASE (1966—2003), CINAHL (1982—1996), andthe Cochrane Library (1992—2003) was conducted.

Searches were restricted to the English language,adults and humans. Relevant abstracts were re-viewed and identified articles assessed. The ref-erence lists of all articles were examined for ad-ditional papers not previously identified. The ev-idence base applied in classifying literature wasadapted from the recommendations of The JoannaBriggs Institute for Evidence Based Nursing andMidwifery (The Joanna Briggs and Institute, 2002)(Table 1).

Background

Nursing management of patients with enteral feed-ing tubes has a key role in ensuring the successof enteral feeding (Marshall and West, 2004; Perry,1997). Enteral feeding benefits ICU patients by de-

creasing catabolic response to injury, maintainingbowel mucosal integrity, decreasing translocationof gut bacteria, improving wound healing and re-ducing septic complications (Bower et al., 1995;Cerra et al., 1997; Galban et al., 2000; Hadfieldet al., 1995; Heyland et al., 1995; Heyland etal., 1996; King and Kudsk, 1997; Lipman, 1998;Moore et al., 1989; Romito, 1995; Sax, 1996). Al-though, some studies have demonstrated no clearbenefit of enteral nutrition over parenteral nutri-tion (Braunschweig et al., 2001; Lipman, 1998), ingeneral, enteral feeding is accepted to be safer,physiologically more compatible, associated withbetter patient outcomes, and more economicalthan parenteral nutrition, making it the preferredand most popular route for nutrient administration(Anonymous, 1994; ASPEN Board of Directors andthe Clinical Guidelines Task, 2002; Cerra et al.,1997; Frost and Bihari, 1997; Reignier et al., 2002;Sands, 1991). Enteral nutrition is recommended tocommence as soon as possible after initial patientresuscitation (Alexander, 1999; Carr et al., 1996;Cerra et al., 1997; Kompan et al., 1999; Lewis etal., 2001; Taylor et al., 1999).

A wide variety of enteral tubes are commonly

used in ICU patients for the delivery of nutri-tion (Heyland et al., 1995). Tubes may be wide ornarrow-bore, gastric or intestinal. Typically theyare inserted nasally but oropharyngeal placementmay also be used. Wide bore tubes (e.g. 12 or14 Fr) placed into the stomach are easy to insertand aspirate but may be poorly tolerated becauseof pharyngitis, otitis, tracheal—oesophageal ero-sion and oesophageal sphincter incompetence (Fry,1985). Narrow-bore tubes inserted into the stomach

Table 1 Levels of evidence.

Level Description

Level I Evidence obtained from a systematic review of all relevant randomized controlled trialsLevel II Evidence obtained from at least one properly designed randomized controlled trialLevel III.1 Evidence obtained from well-designed controlled trials, not randomizedLevel III.2 Evidence obtained from comparative studies such as cohort studies, case—control studies

preferably from more than one centre or research groupLevel III.3 Evidence obtained from multiple time series with or without the intervention. Dramatic

results in uncontrolled experimentsLevel IV Evidence from opinion of respected authorities, based on clinical experience, descriptive

studies, or reports of expert committees

Reproduced from: The Joanna Briggs and Institute (2002).

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332 T.A. Williams, G.D. Leslie

or small intestine increase patient tolerance, re-duce the risk of aspiration (Treloar and Stechmiller,1984) and improve delivery of nutrition, but are dif-ficult to aspirate, rupture, knot, block easily, andtend to migrate unnoticed out of position (Marcuardand Stegall, 1990; Powell et al., 1993; Treloar andStechmiller, 1984). Most patients commence feed-ing via a gastric tube (Preiser et al., 1999), whichis considered safe and efficient (Neumann and De-Legge, 2002), however, patients who develop gas-tric intolerance whilst being fed via this route maybe changed to an intestinal tube (Montejo et al.,2002).

Complications of enteral tubes and feeding

Complications occur with enteral feeding (Cerra etal., 1997) whatever type of tube is used (Table 2).

The incidence of complications varies considerablyand is largely unknown.

Pulmonary aspiration of oropharyngeal or gastriccontents is an important complication reported tooccur in 0.8—95% of critically ill patients (Cataldi-Betcher et al., 1983; Winterbauer et al., 1981), al-though the true incidence is unknown due to lack of definition standardisation (Neumann and DeLegge,2002) and silent aspiration. What is important iswhether the patient develops nosocomial pneumo-nia as a result of aspiration. Aspiration events areoften not accompanied by coughing or other signs of

respiratory distress and may not be evident even toskilled clinicians (Arrowsmith, 1993; Elpern, 1997;Metheny et al., 1990). Critically ill patients with en-teral tubes are at greater risk for aspiration becauseof altered sensorium, sedative and narcotic med-ications, unstable physiological status and physi-cal disruptions of the gastrointestinal tract (Bookeret al., 2000). The enteral tube bypasses the pro-tective mechanisms of the oesophagus impingingon the lower oesophageal sphincter increasing therisk of gastro-oesophageal reflux (Cook and Kollef,1998; Ibanez et al., 1992; Orozco-Levi et al., 1995).Oropharyngeal secretions have been found to be theprincipal source of aspiration (Valles et al., 1995),however, migration of bacteria along the tube fromthe stomach to the upper airway may contaminateoral secretions and increase the risk of pneumo-nia from aspiration (Anonymous, 1996; Ewig et al.,1999; Inglis et al., 1993; Torres et al., 1992), al-

though this process has been disputed (Bonten etal., 1994; de Latorre et al., 1995). Despite frequentsuctioning, small volumes of pharyngeal secretionsmay still be aspirated into the lower respiratorytract increasing the risk of nosocomial pneumonia(Finucane and Bynum, 1996). Risk factors associ-ated with nosocomial pneumonia include organ sys-tem failure, method of airway management, age,antibiotic exposure, level of consciousness and po-sitioning of the patient (Kearns et al., 2000).

Intestinal feeding may be used for patients whoaspirate frequently or with a higher risk of gastric

Table 2 Complications of enteral feeding in critically ill patients.

Complication Study/results

Pulmonary aspiration Cataldi-Betcher et al. (1983): 1%; Elpern et al. (1987): 77%of ventilated patients; Esparza et al. (2001): 10% of patients enterally fed; Metheny et al. (1986): 6% and 22%;Mullan et al. (1992): 4%; Strong et al. (1992): 31—40%;Treloar and Stechmiller (1984): 0/30 (0%)

Other pulmonary complications (pulmonary haem-orrhage, pneumothorax, pleural effusion, oe-sophageal perforation, pneumonitis)

Eisenberg (1991); Metheny et al. (1990)

Intolerance of feeding (such as high residual gastric

volumes, regurgitation, vomiting and diarrhoea)

Adam and Batson (1997): 17% delivery interruption;

Cataldi-Betcher et al. (1983): 6.2%; Mentec et al. (2001):upper digestive disorder 46%; McClave et al. (1999): 45%;Montejo (1999): 63%

Mechanical Adam and Batson (1997): 14% delivery interruptionBlocked feeding tubes Cataldi-Betcher et al. (1983): 3%; Pinilla et al. (2001): 7%Inadvertant respiratory placement Aronchick et al. (1984): 4 cases in 3 months; Dorsey and

Cogordan (1985): 2 cases in 4 months; Harris and Huseby(1989): 5.4%; Metheny et al. (1990): 10 cases in 2 years;Valentine and Turner (1985): 0.3%

Small bore tubes rupture, knot and block easily andtend to migrate unnoticed out of position

Marcuard and Stegall (1990); Powell et al. (1993); Treloarand Stechmiller (1984)

Nonocclusive bowel necrosis Marvin et al. (2000): 0.3% in ICU trauma patients

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Table 3 Studies assessing intestinal vs. gastric feeding.

Study Design Results

Davies et al. (2002) exploredwhether nasojejunal feedingimproved tolerance of enteralnutrition by reducing gastric

residual volumes

Randomised, prospective, clinicalstudy of 73 ICU patients

Demonstrated jejunal feedingreduced gastric residual volumesand tended to improve feedingtolerance

De Jonghe et al. (2001) assessedthe amount of nutrients required,prescribed and delivered to criti-cally ill patients

Prospective cohort design in 51consecutive patients who receivednutritional support either enterallyor intravenously for 2 days

Inadequate delivery of enteralnutrition. Large volumes of enterally fed nutrients wastedbecause of inadequate timing instopping and restarting enteralfeeding

Esparza et al. (2001) assessed thedifference in aspiration rates be-tween gastrically and transpylori-cally fed patients in the ICU

Prospective study in 54 critically illpatients

Clinical suspicion of aspiration wasinsensitive and detected only 60%of isotopically documentedaspirations. No difference inaspiration rates betweengastrically and transpylorically fed

critically ill patientsHeyland et al. (2001) determinedthe extent to which postpyloricfeeding reduces gastroesophagealregurgitation and pulmonary mi-croaspiration in critically ill pa-tients

Randomised trial with 33 patients Post pyloric feeding is associatedwith a significant reduction ingastro-oesophageal regurgitationand a trend toward lessmicroaspiration

Heyland et al. (2002) compared gas-tric with postpyloric feeding

Systematic review evaluated 10randomised controlled trials

Patients who regurgitated weremuch more likely to aspirate thanthose who did not regurgitate.Intestinal feeding moreadvantageous. Gastro-oesophagealregurgitation was reduced,nutrient delivery increased, target

nutrition met in shorter time andventilator-associated pneumoniareduced with intestinal feeding.Small sample size threatensinternal validity. Use of surrogateendpoint (>100counts/min/g) maynot be clinically important

Kearns et al. (2000) investigated therate of ventilator acquired pneu-monia and adequacy of nutrientdelivery of gastric vs. small intes-tine feeding

Prospective, randomised,controlled trial. Medical ICU 44endotracheally intubated,mechanically ventilated patients

No clear difference in theincidence of ventilator acquiredpneumonia in small intestinecompared with gastric enteralnutrition. Small intestine feedingreceived higher calorie and protein

intakesKortbeek et al. (1999) evaluatedtranspyloric feeds in ventilatedtrauma patients

Randomised controlled trial of duodenal vs. gastric feeds of 80patients

Length of stay and ventilator dayswere not significantly different.Transpyloric-duodenal feedssignificantly reduced the timerequired to achieve targetedenteric nutrition

McClave et al. (1999) evaluated fac-tors that impact on the delivery of enteral tube feeding

Prospective study 44 medical ICUand coronary care units

Half the patients received theircaloric requirements—–underordering or frequent andoften inappropriate cessation of feeding

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complications may lead to underfeeding or loss of other benefits afforded by early enteral feeding.Placement of intestinal tubes may be difficult andtime consuming, due to the technical expertiseand equipment that is required which may in turnfurther delay feeding (Maykel and Bistrian, 2002).Feeding via an intestinal tube has been reportedto provide a higher caloric intake than the gastricroute (Kearns et al., 2000; Kortbeek et al., 1999;Montecalvo et al., 1992; Montejo et al., 2002), al-though other investigators report no nutritional ad-vantages (Spain et al., 1995; Strong et al., 1992).Other reasons for not meeting nutritional needs in-clude fasting, procedures, staffing shortages, un-availability of feeds/equipment, low priorities forfeeding, variations in feed prescriptions (Adam andBatson, 1997; Briggs, 1996; De Jonghe et al., 2001;Marshall and West, 2004; McClave et al., 1999;Spain et al., 1999) and blockages in feeding tubes

(Pinilla et al., 2001). Despite the risks and uncer-tainty of the best route of administration for en-teral feeds, diligent tube maintenance is clearly anursing responsibility essential to the administra-tion of enteral feeding.

Reducing the risk of aspiration

Residual gastric volumes

Nurses frequently assess gastro-intestinal functionby checking gastric residual volumes, listening forbowel sounds and observing for abdominal disten-sion in an attempt to reduce the risk and severityof aspiration (Beattie et al., 1996; Eisenberg, 1994;Jolliet et al., 1998; Kirby et al., 1995). The presenceof bowel sounds to confirm gastrointestinal functionis questionable (Anonymous, 1994). High residualvolumes may indicate delayed gastric emptying, in-tolerance to enteral feeding and increase the risk of regurgitation and aspiration (McClave et al., 1992;Metheny, 1993). Many conditions decrease gastricmotility, including drugs such as opioids, surgery,

trauma, shock and respiratory failure (Bosscha etal., 1998; Dive et al., 1994; Tarling et al., 1997).

The measuring of gastric residual volume by as-piration with a syringe is a popular approach, al-though this has not been validated (Chapman et al.,2000). Using a mobile gamma camera, scintigraphy,is noninvasive, well tolerated, and may not inter-fere with nursing care (Horowitz and Dent, 1991),however, its use in ICU is impractical (Chapman etal., 2000). Methods that may be used in the futureinclude continuous monitoring of oesophageal tone,electrogastrograms and tonometry (Alston, 2001).

Wide variation exists in the literature as to whatconstitutes an excessive gastric residual volume.The value that is considered to be acceptable orexcessive (Table 4 ) has not been established by con-trolled trials and is often based on opinion (McClaveet al., 1992; Metheny, 1993; Pinilla et al., 2001).Measuring residual gastric volumes is an imprecisemethod of determining gastric emptying and up-per digestive functioning (Alston, 2001; Chapmanet al., 2000), with the volume of salivary and gas-tric secretions often not taken into account. In ad-dition, gastric residual volume and the presence of bowel sounds may not correlate with gastric emp-tying (Goldhill et al., 1997). Having high residualgastric volumes does not always imply gastric sta-sis (Jooste et al., 1999) suggesting the rationale forusing gastric residual volumes is flawed (Burd andLentz, 2001; McClave and Snider, 2002). The cur-rent practice of stopping enteral feeding if gastric

residual volumes are less than 400—500 ml is notphysiologically or clinically appropriate (Lin and VanCitters, 1997). Decreasing the designated thresholdof gastric residual volume at which feeds shouldbe withheld does not decrease the risk of aspira-tion (Lukan et al., 2002; McClave and Snider, 2002;Pinilla et al., 2001; Powell et al., 1993).

Despite few randomised controlled trials beingconducted regarding the management of gastricresidual volumes (Booker et al., 2000), current re-search supports continuation of feeding if possi-ble (Davies et al., 2002; Jolliet et al., 1998; Mc-

Clave and Snider, 2002; Mentec et al., 2001). El-evated residual volumes should alert clinicians topotential problems, but a single high gastric resid-ual volume should not result in automatic cessa-tion of feeding. Feeding should continue whilstthe patient is closely monitored (McClave et al.,1992). Cessation of enteral feeding due to highresidual volumes is a frequent avoidable actioncontributing to inadequate caloric intake (Spainet al., 1999). It has been recommended that onlypatients demonstrating overt regurgitation, vomit-ing or aspiration should have their feeds abruptlyceased (McClave and Snider, 2002). If gastric aspi-

rates exceed 500ml, then it has been recommendedthat feeds should be withheld and the patient re-assessed (McClave et al., 2002). Gastric aspirates of 500 ml or less should be returned. If the aspirate is200—500 ml, careful bedside assessment using a de-cision algorithm to manage enteral nutrition deliv-ery is recommended (McClave et al., 2002). Feedingshould continue whilst reducing the rate of feedingand administering prokinetics considered (Mentecet al., 2001). Further studies are needed to deter-mine the amount of gastric residual volume that isexcessive.

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Table 4 Studies investigating gastric residual volumes.

Study Design Comments

Burd and Lentz (2001) estimatedgastric volume

Mathematical model Evaluation of gastric residual volume isan unreliable method to monitor feeding

intoleranceCohen et al. (2000) assessed theeffect of continuing enteralnutrition in patients with anelevated gastric residual volumebut normal gastric emptying bythe paracetamol absorption test

Prospective study of 32 criticallyill patients

25% of patients with high gastric residualvolumes (greater than 150 ml or morethan twice the hourly nutritionaladministration rate) had normalparacetamol absorption tests for gastricempting

Davies et al. (2002) comparednasojejunal to nasogastricfeeding in critically ill patients

Prospective study Accepted gastric residual volumes of 250 ml more than the amount deliveredsince the previous gastric aspirationbefore ceasing feeding. Complicationswere rare and they had a much higherrate of tolerated enteral nutrition whencompared to other studies

Goldhill et al. (1997) investigatedthe absorption of cisapride, andits effect on gastric emptyingand the usefulness of clinicalsigns of gastric emptying

RCT involving 27 patients Large variation in gastric emptying wasobserved. The volume of gastric aspirateand the presence of bowel sounds did notcorrelate with gastric emptying

Jolliet et al. (1998) assessed asimple approach to optimiseenteral nutrition modalitieswith practical application.

Literature review by the workinggroup on nutrition and metabolismof the European Society forIntensive Care Medicine

Rrate of feeding should be decreased if gastric residual volumes were greaterthan 300 ml

Jooste et al. (1999) assessed theeffect of metoclopramide ongastric motility in critically illpatients

Prospective, controlled,single-blind cross-over trial in 10patients

High residual gastric volume did notalways imply gastric stasis.Metoclopramide effective prokineticagent

Lin and Van Citters (1997) testedhypothesis that gastric residualvolume increases with slowergastric emptying and fasterformula delivery but reaches aplateau volume

Computer simulation modelling Practice of stopping enteral feeding if gastric residual volumes were less than400—500 ml not physiologically orclinically appropriate

McClave et al. (1992) investigatedthe gastric residual volume thatindicates intolerance orinadequate gastric emptying

Assessed 20 healthy normalvolunteers, 8 stable patients withgastrostomy tubes and 10critically ill patients prospectivelyfor 8 h while receiving enteralnutrition

Wide range of residual volumes (even upto 400 ml) were seen with no obviousintolerance such as regurgitation.Residual volumes were higher with higherfeeding rates. Should be wary whenresidual volumes exceed 200 ml. Smallsample size and narrow sampling timeframe (6h following fasting for 2 h)

threaten the internal validity of thisstudy. Rate of feeding may not beappropriate for patients who have beenfasting

McClave and Snider (2002)summarised results from studiesthat evaluated the practice,interpretation, and impact onpatient outcome from use of gastric residual volume

Systematic review Use of gastric residual volumes as amarker of impending clinicaldeterioration is limited by the fact thatthe timing of increases in GRV isunpredictable and high GRVs do notcorrelate independently to adverseoutcome. Practice of GRV may in factimpede delivery of ETF by promotinginappropriate cessation and reducingpotential infusion time

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Table 4 (Continued.)


Mentec et al. (2001) investigatedthe frequency of and riskfactors for increased gastricresidual volume and upperdigestive intolerance (definedas vomiting or increased gastricresidual volumes) and theircomplications

Prospective observational study in153 patients receiving nasogastrictube feeding. Aspirate wasreturned to the patient unless itexceeded 500 ml

High residual gastric volumes werefrequent, occurred early and morefrequent in patients receivingcatecholamines or sedation. High residualgastric volumes were an early marker of upper digestive intolerance, which wasassociated with a higher incidence of nosocomial pneumonia, longer stays inthe intensive care unit and a higher ICUmortality rate. Rather than discontinuefeeding, the investigators recommendedmore aggressive use of prokinetics

Spain et al. (1999) determinedwhether the use of an infusionprotocol could improve thedelivery of enteral tube feedingin ICU

Prospective study, 31 patients inthe protocol group with 44patients in the control group

Cessation of enteral feeding due to highresidual volumes was a frequentavoidable problem contributing toinadequate caloric intake

Tarling et al. (1997) described therange and factors that mayaffect gastric emptying in thecritically ill patient using aparacetamol absorption test

Validation study of 27 ICU patients Observed a wide range of volumes ingastric emptying. Over 50% of patients ina validation sample had normal gastricresidual volumes despite abnormalparacetamol absorption tests for gastricemptying

Enhancing gastric motility by the use of proki-netic agents, with differing pharmacological prop-erties, have been supported by randomised trials(Boivin and Levy, 2001; Booth et al., 2002; Chap-man et al., 2000; Heyland et al., 1996; Jooste etal., 1999; MacLaren et al., 2000; Spapen et al.,1995; Yavagal et al., 2000). Metoclopramide is aselective dopamine-2 receptor antagonist that en-hances cholinergic induced peristaltic contractil-ity of the upper gastrointestinal tract (MacLaren etal., 2000). Cisapride acts by selectively enhancingcholinergic motor activity throughout the gastroin-testinal tract (MacLaren et al., 2000). Eythromycinenhances motilin release from the duodenal ente-rochromaffin cells (MacLaren et al., 2000). A sys-tematic review of promotility drugs concluded thatprokinetics are effective in promoting gastric emp-

tying in ICU patients (Booth et al., 2002; MacLarenet al., 2000). Introducing prokinetic agents earlyhas been suggested when the pre feeding residualvolume exceeds 20 ml or during feeding if resid-ual volumes exceed 100 ml, (Mentec et al., 2001).Mandatory use of prokinetics reduces the incidenceof enteral feeding intolerance (Pinilla et al., 2001).Whether these drugs improve the amount of nutri-tion patients receive is not proven (Pinilla et al.,2001). There are concerns regarding their safetyand lack of effect on clinical outcomes such as sur-vival (Booth et al., 2002).

The frequency of checking gastric residual vol-umes varies from 2 to 24 hourly (Arrowsmith,1993; Bowers, 1996; Cataldi-Betcher et al., 1983;Goodwin, 1996), and is opinion based. Aspirationregimes include 4 hourly on the first day of feed-ing and then 8 hourly (Fellows et al., 2000); 3 to 4hourly when feeding was commenced then checkingdaily once full volume and tolerance is established(Goodwin, 1996; Jolliet et al., 1998; Kleibeuker andBoersma-van Ek, 1991); and 4 to 12 hourly (Edwardsand Metheny, 2000; Metheny, 1993; Payne-James,1992). The risk of aspiration during continuous na-sogastric tube feeding has been reported as great-est during the first few hours of administration(Kleibeuker and Boersma-van Ek, 1991). It may benecessary to monitor residuals more closely duringthe early phase of feeding, and then less frequently

once feeding is established. In patients with estab-lished feeding and where volume of aspirate is nota problem, consideration may be given to less fre-quent aspirations (Fellows et al., 2000). Althoughthere are no established guidelines indicating howoften enteral tubes should be aspirated, most insti-tutions follow some type of protocol although com-pliance issues have been identified (Breach and Sal-danha, 1988; Sands, 1991).

Discarding gastric aspirate may result in loss of gastric fluid and electrolytes (Cataldi-Betcher etal., 1983) but reduces the potential for contami-

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Table 5 Studies investigating return of gastric aspirates.


Booker et al. (2000) studied theeffects of discarding vs. returninggastric residual volumes on bodyweight, electrolyte levels, and

complications associated withtube feeding

Randomised controlled trial, 35patients but only 18 sets of useabledata obtained

No significant differences betweenthe discard group or return group.Both groups had substantialnumbers of complications,

including feeding delays due tohigh gastric residual volumes (7 inthe discard group and 8 in thereturn group). Although electrolytelevels did not differ significantlybetween the 2 groups, potassiumlevels tended to be lower in thediscard group. Small sample size,many data being collectedretrospectively and the effect of fluid intake and output not beingmeasured that may have influencedelectrolyte status threatened

internal validityMcClave and Snider (2002)summarised results from studiesthat evaluated the practice,interpretation, and impact onpatient outcome from use of gastric residual volume

Systematic review Recommended that aspirates bereturned

nation during the aspiration process and cloggingof enteral tubes when aspirate is returned. A RCTfound no significant differences in outcomes be-tween the discard group or return group (Booker et

al., 2000), although potassium levels tended to belower in the discard group (Table 5). Small samplesize, many data being collected retrospectively andthe effect of fluid intake and output that may haveinfluenced electrolyte status not being measured,threatened study internal validity.

Patient positioning during enteral feeding

Continuous feeding increases the risk of aspira-tion as the oesophageal sphincter remains open,therefore, nursing the patient at a minimum of

30—45◦ elevation has been recommended to re-duce this risk (Table 6) (Arrowsmith, 1993; Bow-ers, 1996; Drakulovic et al., 1999; Elpern, 1997;Ibanez et al., 1992; Kirby et al., 1995; Kollef, 1993;Orozco-Levi et al., 1995; Potts et al., 1993; TheJoanna Briggs and Institute, 2002; Torres et al.,1992; Treloar and Stechmiller, 1984). Some inves-tigators believe that elevating the head of the beddoes not prevent aspiration (Elpern et al., 1987),however, the semi-recumbent position may reducethe risk. Because the head up position is diffi-cult to achieve at all times, aspiration may occur

during those times when a patient has to lie flat(Metheny, 1993).

Management of artificial airways

Patients with artificial airways are at risk of aspira-tion. Decreased elevation of the larynx, obstructionby the cuff of the artificial airway, decreased sensa-tion of the larynx, reduced reflexes due to chronicairway diversion and uncoordinated laryngeal clo-sure due to chronic upper airway bypass have beennoted with the use of artificial airways (Goodwin,1996). Tracheostomy tube cuffs do not prevent as-piration, even when properly inflated (Elpern etal., 1987; Koeman et al., 2001). Whilst trial basedevidence is lacking, a cuff pressure maintained at20—25 cmH2O and regular oropharyngeal suctioningto the back of the mouth in intubated patients hasbeen well supported by expert opinion to minimisethe risk of aspiration (Elpern, 1997).

Mouth care

The risk for aspiration pneumonia is decreased byup to 60% in patients receiving aggressive oral hy-giene/decontamination (Koeman et al., 2001; Ter-penning et al., 2001; Yoneyama et al., 2002). Pa-

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Table 6 Studies evaluating patient position in patients receiving enteral nutrition.

Study Results

Drakulovic et al. (1999) The frequency of suspected and microbiologically confirmed pneumonia wassignificantly less in patients randomised to the semi-recumbent position

Elpern et al. (1987) The upright position was used 80% of the time in 31 intubated patients and anaspiration rate of 27% was observed

Ibanez et al. (1992) Randomised controlled trials demonstrated greater gastro-oesophageal refluxin patients with orotracheal intubation and naso gastric tube. Semirecumbencydoes not prevent GER, but there is less incidence than in the supine position

Kollef (1993) Three times increased risk of nosocomial pneumonia during the first 24 h of mechanical ventilation in cohort of patients nursed supine

Orozco-Levi et al. (1995) Prospective, randomised crossover design studies observed that the supinebody position had a higher rate of pulmonary aspiration but clinicallysignificant aspiration was not observed. Higher radioactive counts of technetium sulphur colloid, instilled into the stomach, in endobronchialsecretions in patients nursed supine

Potts et al. (1993) Patients with clinically significant aspiration were fed supine 98% of the time,patients who did not aspirate being fed supine only 21% of the time

Torres et al. (1992) Prospective, randomised crossover design studies observed that the supine

body position had a higher rate of pulmonary aspiration but clinicallysignificant aspiration was not observed. Higher radioactive counts of technetium sulphur colloid, instilled into the stomach, in endobronchialsecretions in patients nursed supine

Treloar and Stechmiller (1984) Zero incidence of aspiration when the head of the bed was elevated by 30—45◦

tients should receive regular mouth care (McClaveet al., 2002) but antiseptic solutions should be usedin preference to antimicrobials to decrease the pos-sibility of antimicrobial resistance (DeRiso et al.,1996).

Continuous versus intermittent feeding

Continuous feeding delivered via a peristaltic pumpis considered to reduce the risk of aspiration be-

Table 7 Continuous vs. intermittent feeding.


McKinlay et al. (2001) compared theeffect of recent changes in system

design on the levels and incidenceof bacterial contamination in en-teral tube feeds

Randomised study of 34neurological ICU patients

No differences in bowel activity,evidence of aspiration or meeting

caloric targets were found

McKinlay et al. (1995) compared thelevels and types of microorgan-isms present in residual nutrientcontainers and giving sets

Randomised study of 18 traumapatients

Continuous feeding facilitatednutrient delivery with lessgastrointestinal complications

Spilker et al. (1996) evaluatedthe effect of intermittent enteralfeeding on gastric pH and gastricmicrobial growth in mechanicallyventilated patients

13 patients converted fromcontinuous to intermittent feeding

No significant differences werefound between the 2 groups

cause of the assured constant delivery volume andsmaller volumes in the stomach at any one time(Ciocon et al., 1992; Kocan and Hickisch, 1986;Steevens et al., 2002). Intermittent feeding sup-posedly allows pH to restore itself between boluses

of food thus minimising gastric colonisation. How-ever, critically ill patients have higher than normalpH (Metheny et al., 1997). Studies evaluating in-termittent feeding have design and methodologicalflaws. Although no significant differences have beenfound between continuous and intermittent feeding

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