Enteral and Parenteral Nutrition;
Tube Feeding

Artificial supplied nutrition and hydration are medical treatments to be considered in the same light as other technological procedures and not considered life support in the medical field. Literature supports PEG placement in patients recovering from a traumatic accident or expected to make a recovery process. It is considered a medical intervention, not obligatory care.  Meaning this is not a treatment for aspiration but a temporary solution for patients who cannot feed orally.  Properly used it can be helpful, however with everything there are always risks.  Recent studies identify frequent regurgitations, micro-aspirations and aspirations in tube fed patients.  Therefore tube feeding is not a treatment to be used to decrease the risk of aspiration as to necessarily decrease the risks of aspiration but to do so while maintaining the pt's nutrition long term (or short term if naso-gastric). It is also important to take the risk of infection to the site of the tube opening area into consideration as that is a big factor. 

Please see Patient Advanced Directives for more information and help on the Patient & family's rights on these life saving decisions.  

A Feeding Tube Does Not Mean You Will Not Eat Or Drink Again!

Often, individuals with a feeding tube with at some point (hopefully sooner than later) with therapy begin to eat small amounts and drink orally with the hopes of progressing further orally. It's important to note that that there is a high risk of aspiration with placement of a feeding tube due to the face that we mostly aspirate things going up than going down (ie, reflux). It's also to consider age and Quality of Life.  Tube placements are very painful and can get infected very easily.  However, if it is the only way to get nutrition into your loved one. it is a strong consideration.  A person with feeding tube should at some point during therapy begin feeding orally again while the tube is in (when and if appropriate) so they can practice feeding, begin using their swallowing muscles (because in essence, the best way to practice swallowing, is to swallow!), and beyond all, Quality of Life - pleasure feeds.  


Enteral Feeding (EN)

Refers to tube feeding.  Ultimately it is the Patient/family's decision, with the physician's advice, who makes the decision regarding tube placement.

Parenteral Feeding (PN)

Refers to feeding via IV route used in patients who cannot meet their nutritional goals by the oral or enteral route.


Types of Nonoral Feeding

Nasogastric Tube (NG Tube)

Thin flexible tube inserted into the nasal cavity through the pharynx, esophagus, down into the stomach. Usually consider for a short-term/temporary alternative. The diameter of the tube varies, however a narrow tube is preferred to create minimal irritation in the pharynx. Disadvantages of the NG tube are the physical presence in the pharynx and esophagus and the potential for regurgitation. Dobhoff tube is designed to reduce the potential for reflux and aspiration by extending into the jejunum. Tracheal placement of the tube is common in patients with a reduced gag reflex. Due to the fact that each anatomy is different the effect of the presence of an NG tube will vary patient to patient.

PPN/TPN

TPN is Total Parenteral Nutrition and PPN is Peripheral Parenteral Nutrition both of which are provided by IV. It is used in patients who cannot meet their nutritional goals by the oral or enteral route. When the gut is not working, PN is also used for long-term nutrition support in the home setting. PN should only be initiated in patients who are hemodynamically stable and who are able to tolerate the fluid volume, protein, carbohydrate, and lipid doses necessary to provide adequate nutrients.   The gastrointestinal tract is always the preferred route of support, i.e., "If the gut works, use it". Most would agree that EN is safer, more cost effective, and more physiologic that PN. Improvements over the past few years have greatly expanded choices in enteral formulas, equipment, and techniques.      

Orogastric Tube 

Inserted via mouth through the pharynx, esophagus, and into the stomach.  Used in premature infants and eliminates the risk for potential obstruction of the nasal airway.  Provides short-term nutritional maintenance.  Disadvantages of the Orogastic Tube is that it proves interference with lip-closure and tongue function in the early stages of development and presence of a foreign body in the pharynx and esophagus.  

Nasoduodenal Tubes

Inserted into the nasal cavity, through the pharynx, guided into the esophagus and through the stomach into the duodenum.  Primarily used when there is a problem with reflux and long - term feeding problems.  

Nasojejunal Tube

 Inserted into the nasal cavity through the pharynx, guided into the esophagus and through the stomach into the jejunum.  The Nasojejunal Tube is typically used for patients who need a long - term feeding solution.  The tube poses an inability to completely close off the soft palate which may result in reduced intraoral pressure needed for effective sucking and swallowing.  

Percutaneous Endoscopic Gastrostomy 

Also known as G- Tubes.  Surgical procedure that creates an external opening in the abdomen that leads to the stomach. 125,000 procedures are performed annually. A soft flexible tube is inserted into this opening that leads into the stomach. It is performed under general anesthesia. Blended foods or other specially prepared nutritional supplements can be given with a catheter-tip syringe or feeding pump through G-tube or PEG. Considered more long term, but not permanent. Often causes reflux and may lead to further surgeries to reduce gastroesophageal reflux.  Sometimes there can be leakage around the tube site which can cause discomfort.  

Jejunostomy Tube (J Tube)

Inserted into the jejunum (the portion of the small intestine between the duodenum and the ileum).  The J- Tube is less likely to cause reflux, however there can also be leakage around the tube site.  

Gastrostomy Jejunostomy Tube (G-J Tube)

A connected tube with one end inserted into the stomach and the other into the jejunum which allows for removal of stomach contents and nutrition to be delivered to the jejunum.  G-J Tube surgery is a more invasive procedure as two sites are being exposed therefore increasing the chances of leakage around both (2) tube sites.  


Decreasing the Risks of Aspiration with Tube Feeding

Despite multiple risk factors, enteral nutrition remains the safest and most cost effective means to promote nutritional requirements in the hospitalized patients who cannot take nutrition orally (Braunschweig et al, 2001). Implementation of prevention strategies is a key factor for improving safety if tube feeding and decreasing risk of aspiration.

· Maintain HOB above 30 degrees at all times

· Routinely verify tube placement

· Remove Naso/oroenteric tubes as soon as possible

· Clinical assessment of GI tolerance including Abdominal distention, Fullness, Discomfort, Excessive residual trends