What are the recommendations for non-invasive ventilation (NIV) with feeding?

Recommendations for Non-Invasive Ventilation (NIV) with Feeding

In patients receiving non-invasive ventilation (NIV), oral nutritional supplements (ONS) should be considered first, followed by enteral nutrition (EN) if nutritional needs cannot be met orally. If there are limitations for the enteral route, peripheral parenteral nutrition (PN) should be considered. 1

Nutritional Management Based on NIV Setting

Non-Intubated Patients on NIV

• For patients not reaching energy targets with oral diet, oral nutritional supplements (ONS) should be considered as the first intervention 1
• In patients with dysphagia, texture-adapted food can be considered. If swallowing is proven unsafe, enteral nutrition (EN) should be administered 1
• For patients with dysphagia and very high aspiration risk, postpyloric EN or temporary parenteral nutrition (PN) is recommended 1
• During non-invasive ventilation, airway complications may occur with nasogastric tube placement, potentially compromising NIV effectiveness 1
• Parenteral nutrition should be considered when enteral nutrition is not possible due to risk of air leakage that may compromise NIV effectiveness 1

Specific Recommendations for Different NIV Types

• Patients receiving flow nasal cannula or high flow nasal cannula support may resume oral feeding unless nutritional needs are unmet 1
• If EN is used during NIV, smaller-bore nasoenteric feeding tubes (<12 Fr) should be considered to improve mask seal 1
• Patients on NIV with dysphagia should be referred for swallowing evaluation to prevent oral nutrition complications 1

Contraindications and Precautions

Contraindications to Enteral Feeding During NIV

• Recent upper gastrointestinal surgery 1
• Inability to protect the airway 1
• Copious respiratory secretions 1
• Severe vomiting 1
• Bowel obstruction 1

Risk Considerations

• Enteral nutrition during NIV has been associated with higher 28-day mortality (adjusted HR, 2.3; 95% CI, 1.2-4.4) and increased invasive mechanical ventilation needs (adjusted HR, 2.1; 95% CI, 1.1-4.2) 2
• Approximately 78% of patients on NIV meet less than 80% of their nutritional requirements, especially with increasing time on NIV 1
• Patients requiring NIV for more than 48 hours who are incapable of oral intake may need enteral feeding, though this has been associated with increased airway complications 1

Practical Implementation

Monitoring and Assessment

• Regular assessment of nutritional status and intake should be performed 1
• Patients should be monitored for signs of feeding intolerance, including vomiting, gastric retention, and aspiration 1
• Semi-recumbent position (head of bed elevated between 30-45 degrees) is recommended to limit aspiration risk 1
• Patients should not be fed enterally while supine 1

Special Considerations

• For patients at high risk of extubation failure receiving NIV, nutritional support should be carefully planned as part of the weaning strategy 3
• In frail patients, who often have poor appetite and nutritional intake, special attention should be given to nutritional support 1
• For patients transitioning from invasive to non-invasive ventilation, nutritional support should be continued but the route may need to be adjusted 1

Common Pitfalls to Avoid

• Delaying nutritional support in patients on NIV, as nearly 60% of patients receiving NIV may fast for the first 2 days 2
• Using standard-sized nasogastric tubes that may compromise the NIV mask seal 1
• Failing to assess swallowing function in patients on NIV before initiating oral feeding 1
• Overlooking the risk of aspiration, especially in patients with altered mental status or excessive secretions 1
• Underestimating nutritional requirements in patients on NIV, which can lead to malnutrition and related complications 1

By following these recommendations, clinicians can optimize nutritional support while minimizing complications in patients receiving non-invasive ventilation.