Gastric or Duodenal Feeding Tubes: Does It Matter?
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this randomized study of nasoduodenal vs nasogastric feeding tubes in the medical ICU, patients who received the former met nutritional goals better, had less vomiting, and experienced a lower incidence of ventilator-associated pneumonia.
Source: Hsu CW, et al. Duodenal versus gastric feeding in medical intensive care unit patients: A prospective, randomized, clinical study. Crit Care Med 2009;37:1866-1872.
In this study examining both the attainment of nutritional goals and the incidence of complications related to enteral feeding, patients in the medical ICU of a university-affiliated tertiary hospital in Taiwan were randomized to nutritional support via nasoduodenal (ND) vs nasogastric (NG) tubes. Patients who did not have any of a substantial list of exclusion criteria, and who were anticipated to require enteral feeding for at least 3 days, were enrolled. Placement of feeding tubes in the stomach or duodenum was confirmed radiographically, and endoscopic positioning was used if duodenal placement could not otherwise be established. Nutritional support was devised and supervised by a clinical dietician, with infusion rates adjusted by a standardized protocol. The primary outcomes were daily caloric and protein intake and time to achievement of nutritional goals. Secondary outcomes included blood glucose levels and complications such as vomiting, diarrhea, tube-related problems, and ventilator-associated pneumonia (VAP).
One hundred twenty-one patients were enrolled during the 2-year study period, and those randomized to ND (n = 59) and NG (n = 62) feeding were not different in terms of demographic or clinical criteria, diagnoses, or drugs received. All patients were mechanically ventilated and the overall hospital mortality rate was approximately 40%. The ND group had higher caloric and protein intakes (P < 0.05) beginning on the second day after enrollment. Throughout the study period the ND patients received more calories per day (1658 vs 1426 kcal), more grams of protein per day (68 v 59 g), a higher mean percentage of daily caloric goal (95% vs 83%), and more rapid attainment of goal intake (32 vs 51 hours) than the NG patients, respectively, with all differences being statistically significant. Patients in the NG group had a higher rate of vomiting (13% vs 2%; P = 0.01), and also a higher rate of VAP (8.6 vs 3.1 per 1000 ventilator days; P = 0.01). No significant differences between the groups were observed for any of the other variables examined. The authors concluded that patients fed by the ND route have higher calorie and protein intake, reach nutritional goals faster, and have fewer complications than patients fed by the NG route.
Commentary
How best to provide nutritional support to critically ill patients remains a difficult and contentious topic. Parenteral feeding can commence such support promptly but is invasive and associated with both important complications and high cost. Enteral feeding has many theoretical advantages but is hard to accomplish effectively in everyday practice. Tubes come out or fail to go where they are intended. Trips to the radiology department to assess tube location or for fluoroscopically guided placement are time-consuming, aggravating for staff, and expensive. The feedings are poorly tolerated thanks to the effects of critical illness and drugs, and high gastric residuals increase the likelihood of regurgitation and aspiration. And numerous studies have demonstrated that, unlike the findings reported here, target levels of nutritional support are generally not met with enteral feeding — often by a wide margin — despite our best intentions.
This study, although positive, does not settle the argument about ND vs NG enteral feeding. In an accompanying editorial, Jeejeebhoy nicely summarizes the reasons for this.1 He lists 15 randomized controlled trials of gastric vs intestinal feeding, nearly all of them too small individually to demonstrate clinically important differences, and cites 2 meta-analyses of largely the same data that draw different conclusions about which route is better. He points out that, although most studies have shown higher caloric delivery to patients fed by the intestinal route, the differences are only about 200-300 kcal/day (as in the present study), and hence unlikely to exert major effects on overall nutritional status. The potential tie-breaker may turn out to be VAP. Even if there proves to be no clear advantage to intestinal feeding in terms of nutritional outcomes, a lower incidence of VAP, if additional studies confirm the findings of Hsu et al, may justify the preferential use of this route.
Reference
- Jeejeebhoy KN. Enteral feeding: Shorter versus longer tubes. Crit Care Med 2009;37:2098-2099.
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