From the Guidelines
To ensure a Nasogastric (NG) tube is not contributing to prolonged pneumonia in a patient with Herpes Simplex Virus-1 (HSV-1) Encephalitis, regular chest X-rays, pH testing of aspirated gastric contents, and checking residual volumes before each feeding are crucial tests to be performed. These tests help verify proper tube placement, detect aspiration, and assess gastric emptying 1. Additionally, cultures of tracheal secretions should be obtained to identify any pathogens that might suggest aspiration pneumonia. Daily assessment of the patient's respiratory status, including oxygen saturation monitoring and auscultation of breath sounds, is essential. The tube insertion site should be examined for signs of irritation or infection.
In patients with encephalitis who may have impaired swallowing, a bedside swallow evaluation and possibly a modified barium swallow study should be considered to assess aspiration risk 1. It is also important to consider the potential complications of NG tubes, including mechanical complications such as dislodgement and obstruction, which are more frequent in nasal tubes than in percutaneous endoscopic gastrostomy (PEG) tubes 1.
The use of PEG tubes instead of NG tubes for long-term needs (at least 4-6 weeks) is recommended to reduce mechanical complications, as suggested by the ESPEN guideline on home enteral nutrition 1. This recommendation is based on a Cochrane systematic review that demonstrated a lower probability of intervention failure with PEG feeding compared to nasogastric tube feeding 1.
Overall, a comprehensive approach to monitoring and managing NG tubes in patients with HSV-1 encephalitis is necessary to minimize the risk of complications, including pneumonia, and ensure optimal patient outcomes.
From the Research
Tests to Ensure Nasogastric Tube is Not Contributing to Prolonged Pneumonia
To determine if a Nasogastric (NG) tube is contributing to prolonged pneumonia in a patient with Herpes Simplex Virus-1 (HSV-1) Encephalitis, several tests and considerations can be taken into account:
- Bedside tests such as air insufflation, CO2 detection (capnography), aspirate pH testing, and point of care ultrasound (POCUS) can be used to verify the correct placement of the NG tube 2
- Radiographic imaging is considered the gold standard for verifying NG tube placement, but the use of multiple bedside tests can increase sensitivity and specificity for detection of improperly placed tubes 2
- The presence of a nasogastric feeding tube is associated with colonization and aspiration of pharyngeal secretions and gastric contents, leading to a high incidence of Gram-negative pneumonia in patients on enteral nutrition 3
- Metoclopramide, a prokinetic agent, has been studied for its potential to reduce the incidence of pneumonia in patients fed via nasogastric tubes, but its efficacy is controversial 4, 5, 6
- Clinical signs of pneumonia, such as high inflammatory markers and new infiltrates on the chest radiograph, should be monitored daily in patients with NG tubes 6
Prevention of Pneumonia in Patients with NG Tubes
Some studies suggest that metoclopramide may reduce the rate of pneumonia and improve other clinical outcomes in patients with subacute stroke fed via nasogastric tube 6
- However, other studies have found that metoclopramide does not significantly reduce the incidence of pneumonia in patients fed via nasogastric tubes 4, 5
- The use of metoclopramide may delay the development of nosocomial pneumonia, but its effectiveness in reducing the frequency rate of pneumonia is unclear 4, 5