By James Collier BSc (Hons) - Consultant in Nutrition and Moderator of Dietetics.co.uk
Enteral tube feeding has become a widely used health care technology both in the hospital and community settings, and its increasing use is associated with a range of different routes and systems for delivery of nutrition. But the fact that more patients are being fed in the community, is not matched by education and training for those providing care.
Enteral tube feeding (ETF) is considered 'routine' by many health care professionals involved with it, but can still be a daunting thought for patients and carers. Careful consideration should be given to pre-discharge planning and training.
Enteral feeding literally means using the gastrointestinal tract for the delivery of nutrients, which includes eating food, consuming oral supplements and all types of tube feeding. The routes of ETF most often used are naso-gastric tubes (NGT) and percutaneous endoscopic gastrostomy (PEG) tubes. Other routes that are increasingly being used include naso-jejunal and jejunostomy feeding, which may be the only feasible route if it is not appropriate to feed via the stomach.
Growth of home enteral tube feeding
ETF in the community has increased considerably in the last few years. Recent figures show a 26% growth in adults in the community on home ETF (HETF) from 1998 to 1999 (Elia, et al 2000). The average growth rate prior to 1998 has been estimated at 20-25% per year (Elia, et al 1994). This includes patients in residential and nursing homes on HETF. Figures from 1999 show 37.4% adults with HETF reside in nursing homes and 2.3% in residential care (Elia, et al 2000). At any one time (point prevalence in 1998) it is estimated that over 10,000 patients receive ETF in the community, more than twice that in hospital (Elia 1998).
Several reasons have contributed to the rapid growth of HETF including reduction in the number of hospital beds, developments in artificial nutrition, higher proportion of elderly subjects in the population, promotion and marketing of HETF by commercial companies and increased awareness of therapeutic nutrition (Elia 1998).
Starting home enteral tube feeding
Dysphagia is the most common primary reason for initiating ETF commonly as a result of cerebrovascular accident, multiple sclerosis, motor neurone disease and cerebral trauma (Parker, et al 1996). Other common reasons for ETF include aiming to improve or maintain nutritional status, malabsorption and anorexia (Elia, et al 2000).
More commonly, ETF is initiated in hospital and the patient is subsequently discharged into the community. However, more GPs are now referring electively for HETF (Elia 1998), and patients are having PEG tubes sited as day-patients. A number of complications post PEG insertion have been recently identified, so overnight admission is recommended.
In the community PEG tubes are the most common and easiest to manage. Tubes are placed usually under local anaesthetic, with a small incision made in the abdominal wall, and the tube is inserted with the help of an endoscope. PEG tubes vary in size from 9-28FG, and normally last for 18 months to 2 years when it may be advisable to replace them by repeat endoscopy. When PEG tubes are no longer required, they may be removed by traction, repeat endoscopy or they can be cut and allowed to pass naturally, although this remains controversial (Rollins 1998).
It is important that a patient's tube is correctly identified in respect of type, size and manufacturer by staff caring for the patient. This allows appropriate replacement parts to be provided when required. However, from experience, information about tubes is frequently not handed over when a patient transfers districts (Mensforth and Spalding 1998). Gastrostomy ends frequently break or are lost, and spares of the appropriate end should be easily accessible.
One of the most important things patients/carers need to be taught is caring for the feeding tube correctly. This includes flushing the tube with water immediately after any feed or medication has been administered via it. The most common cause of blocked tubes is leaving too long a time between feeding and flushing. Should a tube block, there are a variety of different tactics which may help unblock it including flushing with fizzy drinks, pineapple juice or sodium bicarbonate, whilst manipulating the tube between the fingers. There are also enzyme preparations which can be used in extreme cases. Inserting a sharp object down the tube to remove a blockage is discouraged.
The external fixation plate on a gastrostomy prevents the tube from being drawn into the gastro-intestinal tract by peristalsis. It should not be removed, and replaced if faulty. It needs to be turned 90° daily to allow the site to be inspected and cleaned. The tube should also be rotated and pushed slightly to prevent it from becoming adherent to the gastric mucosa of the abdominal wall and epithelialised (Rollins 1998), which is known as bumper syndrome.
Balloon retained gastrostomy tubes are increasingly becoming the choice of feeding for long term community feeders, as they can be replaced more easily and by the patient or carer. Generally, these are only sited when a stoma has already been formed by prior PEG insertion. A balloon inflated by sterile water holds the tube in place, which needs re-inflating about once a week; although some more modern tubes may be checked less frequently. Balloon gastrostomy tubes need replacing every 2-3 months and arrangements should be made for further supplies of spares. Prompt replacement is crucial to avoid closure of the stoma. Balloon gastrostomy tubes are particularly favourable in those HETF patients for whom the endoscopy procedure is traumatic or the practicality of transporting the patient to hospital is hard.
There are complications associated with PEG feeding: Soreness at the stoma site is not uncommon, and this may involve redness, inflammation and sometimes smelly discharge. Some neurological patients have reported feeling very poorly for a few days following the procedure, which may be a consequence of the anaesthetic. Blocked tubes are a common problem, though good practice of caring for the tube should prevent this; unfortunately in the nursing home environment, with frequently changing staff and bank nurses, the incidence of blocked tubes is quite high (Collier 1999). Intolerance of feed may be reported, which may be iatogenic or pathogenic in origin, or may be helped by changing the feed, on which the dietitian will advise.
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