Should Intubated Patients Be NPO?
No, intubated patients should NOT be kept NPO—early enteral nutrition (EN) should be initiated within 48 hours of ICU admission through a nasogastric tube, as the endotracheal tube cuff provides airway protection and EN reduces infectious complications and improves outcomes. 1
Rationale for Early Enteral Nutrition in Intubated Patients
Primary Recommendation
Intubated ICU patients should receive early EN (within 48 hours) through a nasogastric tube as the standard approach, with post-pyloric feeding reserved only for patients at high risk for aspiration. 1
The ESPEN ICU guidelines explicitly recommend early EN in multiple intubated patient populations including those receiving ECMO, with traumatic brain injury, stroke, spinal cord injury, severe acute pancreatitis, post-GI surgery, abdominal trauma with confirmed GI continuity, those receiving neuromuscular blocking agents, and patients in prone position. 1
Early EN reduces infectious complications in critically ill patients, particularly in severe acute pancreatitis and after GI surgery, with no evidence supporting delayed EN or early parenteral nutrition over early EN. 1
Timing and Progression
Start EN as soon as shock is controlled with fluids and vasopressors/inotropes, remaining vigilant for signs of bowel ischemia. 1
Begin with low-dose EN targeting 30% of measured energy expenditure (or 20 kcal/kg/day using predictive equations), then increase to 50-70% by day 2 and 80-100% by day 4. 1
Protein targets of 1.3 g/kg/day should be reached by days 3-5. 1
Airway Protection Considerations
The endotracheal tube cuff provides airway protection against aspiration, making NPO status unnecessary in stable intubated patients. 1
Recent research demonstrates no difference in aspiration events, desaturation, pneumonia, or reintubation rates between intubated patients kept NPO ≥6 hours versus <6 hours before surgery (aspiration: 5.8% vs 7.3%, p=0.66). 2
The traditional concern about aspiration in intubated patients is not supported by evidence—one study found no difference in aspiration incidence between intubated and non-intubated patients with low GCS scores. 3
When to Delay or Modify Enteral Nutrition
Absolute Contraindications
Temporarily discontinue EN in patients with uncontrolled life-threatening hypoxemia, hypercapnia, acidosis, or bowel ischemia/obstruction. 1
Delay EN in patients with abdominal compartment syndrome or when intra-abdominal pressure increases under EN. 1
High Aspiration Risk Modifications
Switch to post-pyloric feeding if gastric residual volume exceeds 500 mL or in patients at high risk for aspiration. 1
Consider parenteral nutrition only when EN is not tolerated or contraindicated, weighing this decision case-by-case during the first week in ICU. 1
Practical Implementation
Monitoring Requirements
Monitor blood glucose (target 6-8 mmol/L), triglycerides, and electrolytes including phosphate, potassium, and magnesium. 1
Regularly aspirate airways, preferably by sterile means, starting soon after intubation to manage secretions. 1
Verify endotracheal tube position repeatedly, as secretions may dislodge it. 1
Common Pitfall to Avoid
Do not keep intubated patients NPO for prolonged periods based on outdated aspiration fears—patients are commonly without enteric nutrition for periods much greater than necessary, missing the benefits of early EN. 2
The practice of routine NPO in intubated patients neither improves aspiration outcomes nor provides metabolic benefits, while delaying EN increases infectious complications and prolongs recovery. 1, 2