GROUP 7

1. BOBBO HALIMA ILIYASU 2022 08 12476

2. ELISHA BENARD 2022 08 12714
3. Kolibi James. 2022-08-11513
TUBE FEEDING
 TUBE FEEDING
Tube feeding is a therapy where a feeding tube supplies nutrients to people
who cannot get enough nutrition through eating. A flexible tube is inserted
through the nose or belly area to provide nutrients by delivering liquid
nutrition directly into the stomach or small intestine. It is also called Enteral
Nutrition.
Enteral nutrition uses the gastrointestinal tract to supply nutrients. This can
be accomplished by feeding by mouth or through a feeding tube.

Advantages of enteral nutrition over parenteral nutrition include: safety,

effectiveness, decreased risk of infection, decreased cost, prevents gut
atrophy, and preserving the barrier function of the gut.
Artificial nutrition refers to the provision or
supplementation of daily metabolic nutrition
requirements in patients with contraindications to
feeding through the mouth or those with inadequate
oral intake. Artificial nutrition is provided through
parental or enteral access. Parenteral nutrition is
provided through a large vein in the central venous
system.
Enteral nutrition uses the gastrointestinal (GI) tract to
provide nutrition.
Enteral access can be obtained by passing a feeding tube
through the nose (nasogastric and nasojejunal) and
mouth (orogastric) at the bedside.
It can also be achieved by surgically implanting a feeding
tube into the gut, such as a feeding gastrostomy
(stomach) or a feeding jejunostomy (jejunum).
 INDICATIONS OF TUBE FEEDING
Enteral tube feeding is indicated in patients who cannot main adequate oral intake of food or
nutrition to meet their metabolic demands. Healthcare professionals commonly use enteral feeding
in patients with dysphagia. Patients with dysphagia sometimes cannot meet their daily nutritional
needs, even with modification of food texture and/or consistency.

For enteral feeding to be successful, the GI tract should be accessible and functional. Inaccessible
GI tracts, malabsorption, and severe GI losses might make enteral feeding a challenge. The
alternative is parenteral feeding.
INDICATIONS;
Comatoseneuromuscular disorder affecting swallowing reflex: Parkinson's disease, multiple sclerosis,
cerebrovascular accident.
Severe anorexia from chemotherapy, HIV, sepsis
Upper GI obstruction esophageal stricture or tumor
Conditions associated with increased metabolic and nutritional demands include sepsis, cystic
fibrosis, and burns
Mental illness like dementia
patients on mechanical ventilation or with a severe head injury
A Gastrointestinal dysfunction
Head and neck cancers that make swallowing difficult or require throat surgery
Gastrointestinal issues such as an obstructed bowel
Neurological disorders including stroke and paralysis
 GASTROINTESTINAL DYSFUNCTION
Gastrointestinal dysfunction refers
to a wide range of conditions that
affect the digestive system, which
includes the stomach, intestines,
liver, gallbladder, and pancreas. It
can result from various factors
such as infections, inflammation,
autoimmune disorders, food
intolerances, and genetic
disorders.
 Symptoms of gastrointestinal dysfunction may include abdominal pain, bloating, diarrhea,
constipation, nausea, vomiting, and weight loss. Some of the most common gastrointestinal
disorders include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD),
gastroesophageal reflux disease (GERD), and celiac disease.
 HEAD AND NECK CANCERS
Head and neck cancers are
tumors that develop in the
mouth, throat, or neck area.
These cancers can make
swallowing difficult by narrowing
the opening through which food
and liquid pass, or by causing
pain or discomfort.
In some cases, surgery may be required to
remove the cancerous tissue, which can also
affect the ability to swallow. Swallowing
difficulties can impact a person’s ability to eat,
drink, and take medications, and may require
the assistance of a speech-language
pathologist or other healthcare provider to
manage.
 GASTROINTESTINAL ISSUES
Gastrointestinal issues refer to problems that occur in the digestive
system, which includes the esophagus, stomach, small and large
intestines, and rectum.
An obstructed bowel occurs when something, such as a tumor, scar
tissue, or impacted feces, blocks the normal flow of food and waste
through the intestines. This can cause symptoms such as abdominal
pain, cramping, bloating, and constipation, and may require medical
intervention such as bowel rest, medication, or surgery.
 NEUROLOGICAL DISORDERS
Neurological disorders are conditions that affect the nervous system, which includes
the brain, spinal cord, and nerves. Stroke occurs when blood flow to the brain is
disrupted, causing brain cells to die. This can result in a range of symptoms such as
paralysis, weakness, difficulty speaking or understanding language, and difficulty with
coordination or balance.
Paralysis is the loss of muscle function in part or all of the body, and can result from a
range of neurological conditions including stroke, spinal cord injury, and multiple
sclerosis. Treatment for neurological disorders may involve medication, physical
therapy, or surgery, depending on the specific condition and severity of symptoms.
 TYPES OF NASOGASTRIC TUBES
The two main types correspond to the two main purposes
of the nasogastric tube.
1. Single Lumen nasogastric tube
2. Double Lumen nasogastric tube
1. Single lumen
The single-lumen NG tube has a single, narrow channel for
delivering medications and nutrition one way into your
stomach. The channel has a small diameter (“small bore”) to
make it as comfortable as possible, since it may be in place
for up to several weeks. The Levin and the Dobhoff are the
two main models in use. The main difference between them
is that the Dobhoff tube has a weight on the end.
Double lumen
The double-lumen NG tube is specially designed for
suctioning, but it can also be used for other
purposes. It has two channels: a wider one to suction
through and a narrower one that acts as an air vent
to relieve the vacuum pressure. This helps prevent
the tube from adhering to your stomach lining while
suctioning. There are several models, but the Salem
Sump™ may be the most common one.
 COMPLICATIONS OF FEEDING
TUBE
Incorrect installation causes relatively VI. Irritation to your stomach lining.
minor complications and side effects . They VII.The tube becoming entangled or
might include: dislodged.
I. Discomfort VIII. Electrolyte imbalances, such as
II. Sinus infection. hypokalemia (low potassium).
III. Nosebleeds. IX. Gastrointestinal bleeding from
IV. Sore throat. prolonged use.
V. Pressure ulcers. X. These complications resolve when the
tube is safely removed.
Mechanical Complication

Tube placement for enteral feeding might cause mechanical complications. Some mechanical complication
from tube feeding is listed below.
 Tube malposition
 Tube obstruction
 Accidental dislodgment of tube
 Breakage of the feeding tube
 Leakage of the feeding tube
 Erosion and ulceration near the site of insertion
 Intestinal obstruction
 Bleeding

Tube for enteral feeding can be inserted nasally through the guided percutaneous application or surgical
technique.

Nasoenteral insertion is mostly done blindly by the bedside, with about 0.5% to 16% mispositioning in the
pleura, trachea, or bronchial trees. This can cause the infusion of enteral feeds in the tracheobronchial tree
causing a pulmonary abscess or pneumothorax. Installation of air or auscultation is not an accurate method
of determining proper tube placement. The best confirmation is with radiography.The failure of bedside
nasoenteral tube placement indicates fluoroscopy or endoscopy-guided tube insertion.
Infectious Complications
 Infection at the site of tube insertion
 Aspiration pneumonia
 Ear and nasopharyngeal infection
 Infective gastroenteritis with diarrhea
 Peritonitis
Tube placement in enteral feeding is sometimes associated with the infectious processes listed above.
Aspiration pneumonia is reported in 89% of patients on enteral feeding with no clear benefit of
gastroenteric feeding over nasogastric. Distal duodenal or jejunal feeding might prevent the regurgitation of
enteral feeds.

Complications from the enteral feeding tube also depend on the following:
The size of the tube
The tube material
The diameter of the tube
Gastrointestinal Complications
Enteral feeding is associated with several GI complications
 Nausea and vomiting
 Diarrhea
 Constipation
 Cramps and bloating
 Regurgitation and aspiration.
Nausea

Nausea and vomiting are common after the initiation of enteral feeding, about 20% to 30%. Non-occlusive bowel necrosis
and aspiration can also occur. This is associated with high mortality.

Diarrhea

This is the most gastrointestinal complication seen in enteral feeding. Diarrhea in enteral feeding is a result of many
factors. Using antibiotics and other medications in enteral feeding is a common cause of diarrhea—medications like
antacids, oral magnesium or phosphate, antacids, and prokinetic agents.
Constipation

This is a less common complication that is associated with enteral feeding.

Constipation is more common in patients on long-term enteral feeds. Some studies
suggest that using fiber supplementation might help reduce the percentage of
patients reporting constipation in enteral feeding.

Aspiration Pneumonia

This is a potentially life-threatening complication from enteral feeding. It occurs

because of aspiration of oral secretion and or gastric with enteric secretions.
Aspiration is more common when patients are fed via a nasogastric tube in a supine
position. The cause of aspiration pneumonia in enteral feeding are multifactorial.
METABOLIC COMPLICATIONS

• Feeding syndrome

Patients with anorexia nervosa, hyperemesis, alcoholism, and malabsorption syndrome like short bowel
syndrome who are started on enteral feeding are prone to refeeding syndrome.

The pathophysiology of the refeeding syndrome is still poorly understood. In a period of starvation, the
cellular membrane system downregulates with the loss of intracellular potassium, phosphorus, magnesium,
and calcium. The total body content of these ions is depleted. Intake of sodium and water by the cell is also
increased. The sudden reversal of malnutrition with enteral feeding is due to an uptake of potassium,
phosphorus, magnesium, and calcium back by the cell with simultaneous movement of water and sodium
out of the cells. The undernourished kidney is also impaired and cannot handle the sodium and water load.

Hypophosphataemia is the hallmark of refeeding syndrome. Hypophosphatemia can cause rhabdomyolysis,

cardiac failure, arrhythmia, muscular weakness, leukocyte dysfunction, seizure, coma, and sudden death.

The phenomenon is more common in enteral than parenteral feeding.

Awareness of the syndrome is the key to treatment and prevention.

Patients at Risk for Re-feeding Syndrome

 Chronic alcoholism
 Anorexia nervosa
 Postoperative patients
 Elderly patients
 Prolonged fasting
 Morbid obesity associated with profound weight loss
 Malabsorption syndrome: Cystic fibrosis, inflammatory bowel disease, and short bowel syndrome

To manage refeeding syndrome, the cardiovascular status of the patient should be monitored closely, preferably in the
ICU. Judicious monitoring of electrolytes and micronutrients should also be implemented.
COMLICATIONS ASSOCIATED WITH PEG Placement

Peristomal Wound Infection

Wound infection occurs after PEG placement with an incidence of about 3 to 70%. Wound site infection
can be caused by the technique of placement, obesity, malnutrition, steroid, or immunosuppressive
therapy.

Clogged Feeding Tube

Clogging occurs when very thick feeds and medications are delivered through a relatively thin feeding
tube. Repeated gastric aspiration is discouraged since the low pH of gastric fluid can promote protein
coagulation

Peristomal Leakage

This is also a complication of PEG tube placement for enteral feeding. Several factors can contribute to
leakage. Excessive pulling and tugging and increased gastric secretion inhibit wound healing, like
malnutrition, diabetes, and immunodeficiency. This can be prevented using antisecretory agents like
proton pump inhibitors (PPI). Skin protectants and barrier creams can also be used.
Bleeding

This might be secondary to mucosal tears or damage to a local vessel. Risk factor for bleeding includes
the use of antiplatelet or anticoagulation therapy. Based on the current recommendations, aspirin can be
continued in high-risk patients. Warfarin is recommended to be discontinued, and unfractionated heparin
can be used as a bridge.

Colonic Fistulae

Misplacement of PEG for enteral feeding might lead to the formation of gastrocolic, colocutaneous, and
gastro colocutaneous fistulae. A gastrocolic fistula connects the wall of the stomach and the colon.
Gastro colocutaneous fistula is an epithelial connection between the wall of the stomach, colon, and skin
that can occur because of iatrogenic puncture or direct erosion of the PEG into the colon wall and the
skin

Pneumoperitoneum

This can occur in about 8% to 18% of PEG tube placements. This is a relatively benign condition that does
not warrant any intervention
 NG TUBE INSERTION PROCEDURE
Items required are Salem-Sump,
SBFT, Dobhoff tube.
Personnel
While an experienced provider
can place a tube by themselves,
having an assistant nearby can be
helpful in case extra supplies
need to be obtained during the
placement procedure, such as a
basin if the patient begins to have
emesis.
Technique
The individual placing the tube should put on
nonsterile gloves and lubricate the tip of the tube.
The tip should instead be directed parallel to the
floor, directly toward the back of the patient’s
throat. At this time, the patient can be given a cup
of water with a straw in it to sip from to help ease
the passage of the tube.
The tube should be advanced with firm, constant
pressure while the patient is sipping. If there is a
great deal of difficulty in passing the tube, a
helpful maneuver is to withdraw the tube and
attempt again after a short break in the
contralateral nares as the tube may have become
coiled in the oropharynx or nasal sinus.
Once the tube has been advanced to the estimated
necessary length correct location is often made obvious
by aspirating out a large amount of gastric contents.
Pushing 50 cc of air through the tube using a large syringe
while auscultating the stomach with a stethoscope is a
commonly described maneuver to determine the location
of the tube, but it is of questionable efficacy.
Misplaced NG tubes placed in the left mainstem and small
bowel can sound similar to adequately placed NG tubes.
In intubated patients, the use of reverse Sellick’s
maneuver (pulling the thyroid cartilage up rather than
pushing it down during intubation) and freezing the NG
tube may help facilitate placement of the tube. Once the
tube has been inserted an appropriate length, typically
around 55 cm as previously noted, it should be secured to
the patient’s nose with tape.
Taking an abdominal x-ray is the best way to confirm the location of the tube, even if there is the
aspiration of gastric contents as the tube may be placed past the pylorus where it will aspirate not just
gastric secretions but also hepatobiliary secretions leading to persistently high output even when the
patient’s acute issue has resolved.
If feeding is planned through the tube, then it is imperative to confirm its location as placing feeds into
the lungs can cause potentially fatal complications. The ideal location for an NG tube placed for suction is
within the stomach because placement past the pylorus can cause damage to the duodenum. The ideal
location for an NG feeding tube is postpyloric to decrease the risk of aspiration.

The removal of an NG tube is usually a simple procedure. However, the tube should not be forcefully
removed as it can become knotted.
 TUBE FEEDING CARE
 Nasogastric tubes are part of the standard of care for many routine
health issues. Physicians should be readily able to place nasogastric
tubes if indicated, and nursing staff should be able to manage them
effectively.
 Given the potential for major complications to occur, particularly if
medications or tube feeds are given intrapulmonary, with inappropriate
nasogastric tube placement, the entire healthcare team must know the
indications, contraindications, possible complications, and appropriate
work-up to confirm placement.

 As mentioned above, while it is helpful to have at least one assistant
nearby when placing a nasogastric tube, an experienced healthcare
provider can generally place one by themselves without much difficulty.
Where interprofessional care comes into play with nasogastric tubes is
in maintaining them.
 Physicians should check that the nasogastric tube is functioning and not
clogged or otherwise malfunctioning when they round.
 Nursing staff should also routinely inspect their patients’ nasogastric
tubes to ensure they are functioning and have a high index of suspicion
for potential aspiration events.
 Frequent examinations by all healthcare providers to ensure the tube is
securely in place and properly positioned can also reduce injuries
associated with nasogastric tubes.
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Volpe A, Malakounides G. Feeding tubes in children. Curr Opin Pediatr. 2018 Oct;30(5):665-670. [PubMed]
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