Management of Feeding Tube Complications in the Long-Term Care Resident
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Introduction
In long-term care (LTC) residents with impaired caloric or fluid intake and a functional gastrointestinal tract, enteral nutrition through the use of a feeding tube is an important option.1-4 Year 2006 Minimum Data Set (MDS) data from New York State revealed that 8.1% of all nursing home residents were receiving tube feedings. State-to-state rates varied widely, with Nebraska having the lowest rate of 3.8% and the District of Columbia having the highest rate of 44.8%. Enteral nutrition may be provided to patients utilizing nasoenteral, gastrostomy, and jejunal feeding tubes.3 These tubes are easy to insert and suitable for short- and long-term use. However, feeding tubes are associated with various complications that require close monitoring.5,6
Feeding Tube Types
Nasoenteral feeding includes nasogastric, nasoduodenal, and nasojejunal tubes.1 Most common are the nasogastric tubes.3 They may be used in patients with competent lower esophageal sphincter, lack of involvement of the stomach by the primary disease process, and normal gastric emptying. The large reservoir capacity of the stomach is an advantage for their use. Nasoduodenal and nasojejunal tubes may be used in patients who cannot tolerate gastric feedings or who need to lie flat, (ie, ileus, critically ill patients).3
Gastrostomy tubes are used when a patient cannot or will not eat for a prolonged time course (longer than 4 wk) and has a functional gut.7 Gastrostomy tubes are generally placed in the procedure commonly known as percutaneous endoscopic gastrostomy (PEG).7 Gastrostomy tubes may also be placed surgically, and more recently via a computed tomography–guided procedure.4 In the year 2000, more than 216,000 gastrostomy tubes were placed in the United States alone.7
Jejunostomy is indicated for patients who need long-term enteral nutrition and have chronic aspiration, gastric outlet obstruction, or stomach or duodenal disease, or for patients with prior gastrectomy.2-4 Jejunal feedings may be achieved using direct endoscopic techniques or with jejunal extension of a feeding tube through an existing PEG.
Feeding Tube Complications
Aspiration
Aspiration is one of the most important and controversial complications in patients receiving enteral nutrition, and is among the leading causes of death in tube-fed patients due to aspiration pneumonia.7-10 However, differentiation of aspiration from oropharyngeal or gastric contents is difficult to assess.11 The rate of aspiration pneumonia in tube-fed patients ranges from approximately 5% to 58%.7-9 Aspiration often occurs without obvious evidence of vomiting or regurgitation and is recognized by the development of clinical signs of respiratory compromise or pneumonia.9,10 Nasoenteral and gastrostomy tubes are used by some to prevent aspiration, although evidence is lacking to support this belief.9 Additional risk factors for the development of aspiration pneumonia include advanced age, the presence of esophagitis on endoscopy, gastroesophageal reflux, prior history of aspiration or pneumonia, impaired level of consciousness, neurologic deficits, poor oral hygiene, and sedative medications.10 Treatment includes stopping the feed, attempts at aspirating the feed from the lungs, and antibiotics if signs of infection are evident. Feeding beyond the duodenum likely lowers the incidence of aspiration, although no conclusive evidence supports this premise.9,10
The goal in the LTC setting is to use preventive measures to decrease the incidence of aspiration and its development into pneumonia by targeting modifiable risk factors. To minimize the risk of aspiration, patients should be fed sitting up or at a 30- to 45-degree semirecumbent body position.8,11 They should remain in the position at least one hour after feeding is completed. Iso-osmotic feeds may be preferred since high-osmolality feeds can delay gastric emptying.
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My son has chronic aspiration and needs long-term enternal nutrition, he is awaiting a kidney transplant, and has other complications. He has Gastrostomy tubes. It is a lot of work. But I am happy that he is still alive and functioning well.
Reply to this comment »This article was very informative.
Reply to this comment »The article was very informative and helped me a lot. Thanks!
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