From the Guidelines
Post-pyloric tubing does offer advantages in preventing aspiration, particularly in patients at high risk of aspiration, such as those with a history of recurrent aspiration, severe gastroparesis, feeding intolerance, or refractory medical treatment 1.
Key Points
- Post-pyloric feeding tubes can improve feeding intolerance in patients with gastroparesis, consequently reducing the risk of aspiration 1.
- The use of post-pyloric tubes may be justified in patients at high risk of aspiration, as it can reduce the risk of aspiration and its associated complications, such as pneumonia and respiratory failure 1.
- Strategies to reduce aspiration include elevation of the head of the bed, post-pyloric feeding, and administration of motility agents to promote gastric emptying 1.
- Post-pyloric feeding should be performed in patients at high risk for aspiration, as recommended by the ESPEN guideline on clinical nutrition in the intensive care unit 1 and the ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection 1.
Important Considerations
- The magnitude of benefit of post-pyloric feeding tubes may be small, and there is uncertainty about the effect on other patient-important outcomes 1.
- Cost-effectiveness studies that describe the economic consequences of using post-pyloric feeding tubes are lacking 1.
- Mechanical complications, such as dislodgement and obstruction of the tubes, are more frequent in nasal tubes, especially nasojejunal tubes, than in PEG tubes 1.
From the Research
Advantages of Post-Pyloric Tubing
- Post-pyloric feeding has been shown to have a lower incidence rate of pulmonary aspiration, gastric reflux, and pneumonia compared to gastric-tube feeding 2.
- It is associated with fewer interruptions once enteral nutrition has been started, may reach goal calorie provision sooner, and may reduce the risk for gastroesophageal reflux and aspiration 3.
- Moderate-quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding 4.
- Post-pyloric feeding can deliver higher proportions of estimated energy requirement and reduce the gastric residual volume (GRV) 5.
Comparison with Gastric Tube Feeding
- Post-pyloric feeding appears to be the safer and more effective choice compared to gastric-tube feeding among critical patients 2.
- However, overall differences in outcome between the two methods of feeding are minimal 3.
- There is no significant difference in mortality, duration of mechanical ventilation, or length of stay in the ICU between post-pyloric and gastric tube feeding 4, 5.
Safety and Complications
- Low-quality evidence shows that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion 4.
- Placement of the post-pyloric tube can present challenges, requiring expertise and sophisticated radiological or endoscopic assistance 4.
- Various bedside techniques are available to facilitate transpyloric feeding tube passage, including air insufflation, pH assisted, and spontaneous passage with or without motility agents 6.