From the Guidelines
The recommended technique for initiating nasogastric (NG) tube feeding involves starting with a slow continuous infusion at a low flow rate, such as 10 mL/h, and increasing the feeding rate carefully and individually due to limited intestinal tolerance, as recommended by the ESPEN guideline 1. This approach allows the gastrointestinal tract to adapt to enteral nutrition, reducing complications like diarrhea, abdominal distension, and aspiration pneumonia while ensuring adequate nutritional support. Before beginning, proper tube placement should be confirmed by X-ray or pH testing of aspirate. The feeding solution should be at room temperature, and the patient should be positioned with the head of bed elevated 30-45 degrees during and for 30-60 minutes after feeding to reduce aspiration risk. Regular monitoring for feeding intolerance is essential, including checking for abdominal distension, nausea, vomiting, or large gastric residual volumes (typically >250 mL). If intolerance occurs, temporarily reduce the rate or hold feedings. Proper tube care includes flushing with 30 mL of water before and after feeding or medication administration to prevent clogging. According to the most recent ESPEN practical guideline on home enteral nutrition 1, the patient with a nasogastric tube can start feeding immediately according to the previously established nutritional care plan once appropriate tube placement has been confirmed, with no need for initial dilution of feeds unless additional liquid is required. Additionally, the ESPEN guideline on clinical nutrition in neurology 1 recommends early enteral nutrition in patients anticipated to have swallowing difficulties for more than seven days, with nasogastric tube feeding being a suitable option, especially in patients with uncertain prognosis or those who may not require long-term tube feeding. It is also recommended to use small diameter nasogastric feeding tubes (8 French) to minimize the risk of internal pressure sores and to ensure correct tube placement through x-ray, aspiration of gastric content, or measurement of gastric pH 1. Overall, the key to successful NG tube feeding is a gradual and individualized approach, careful monitoring, and proper tube care, as supported by the latest guidelines and research 1.
From the Research
Nasogastric Tube Feeding Technique
The recommended technique for initiating nasogastric (NG) tube feeding involves several steps to ensure safe and effective placement.
- Confirmation of tube placement is crucial to prevent complications such as aspiration or intestinal perforation 2.
- The use of prokinetic agents like metoclopramide has been studied to aid in the placement of NG tubes, but its efficacy is controversial 3, 4.
- Small bowel feeding tubes may be considered as an alternative to nasogastric feeding, especially in patients with gastrointestinal intolerance 5, 6.
Placement Techniques
- Bedside placement of nasointestinal tubes using electromagnetic guidance has been shown to be effective in achieving small intestine placement and improving enteral nutrition delivery 6.
- The use of Cortrak nasointestinal feeding tubes has been associated with increased success rates of small intestine placement and reduced need for prokinetic agents 6.
- Traditional methods of NG tube placement, such as the "blind" or "instructed" method, may still be used, but require careful confirmation of tube placement to prevent complications 2.
Challenges and Considerations
- Delays in feeding can result in worse patient outcomes, highlighting the importance of timely and accurate tube placement 2.
- The use of prokinetic agents, such as metoclopramide, may be associated with adverse reactions, and their effectiveness in facilitating tube placement is uncertain 3, 4.
- Innovative solutions, such as the use of new technologies or techniques, may be needed to improve the safety and outcomes of NG tube feeding in older patients 2.