issues in enteral feeding:...
TRANSCRIPT
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Issues in Enteral Feeding:
Aspiration
Presented by:
Kathleen Stoessel, RN, BSN, MS
Clinical Education Specialist
A webinar for HealthTrust Members
February 11, 2019
Co-sponsored by
HealthTrust and VNOS
Continuing Education Provider
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Disclosures
• The presenter serves as a clinical education consultant for
VNOS through Kelly Outsourcing and Consulting Group.
• This program may contain the mention of drugs or brands
presented in a case study or comparative format using
evidence-based research. Such examples are intended for
educational and informational purposes and should not be
perceived as an endorsement of any particular supplier, brand
or drug.
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Issues in Enteral Feeding:
Aspiration
Objectives
• Identify complications associated with enteral nutrition
• Explain the potential consequences of aspiration in
patients receiving enteral nutrition
• Discuss steps that can be taken to prevent aspiration
• Describe best practices for the management of aspiration
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Indications for Enteral Nutrition
Enteral nutrition is provided to patients who:
• Have intact and functional digestive tracts
• Cannot maintain adequate nutrition by oral intake
of food and/or oral nutritional supplements
• Cannot eat or drink safely
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Indications for Enteral Feeding
• Swallowing disorders
• Upper gastrointestinal (GI) obstruction
• GI dysfunction, malabsorption
• Increased nutritional requirements
• Mental health issues
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Enteral Nutrition
Types of Feeding Tubes
• Nasogastric
• Nasoduodenal
• Nasojejunal
• Orogastric
• Orojejunal
• Transesophageal
• Gastrostomy (G-tube)
• Percutaneous endoscopic
gastrostomy (PEG)
• Jejunostomy (J-tube)
• Percutaneous endoscopic
jejunostomy (PEJ)
• Gastrojejunostomy
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Enteral Nutrition
Types of Feeding Tubes
Transnasal tubes (i.e., naso-gastric, -duodenal, -jejunal)
are:
• less invasive and less expensive than other methods
• best suited for short term (< 6 weeks) enteral feeding
• often poorly tolerated by conscious or confused patients
• subject to complications including mucositis, paranasal
sinusitis, reflux esophagitis, pressure ulcers8
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Enteral Nutrition
Types of Feeding Tubes
Percutaneous endoscopic tubes (i.e., PEG, PEJ) are:
• Preferred over Transnasal for longer term enteral
nutrition
• More invasive; relatively higher in cost
• Subject to peri-stomal infection or leakage at the
insertion site
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Which of the following is a potential complication
of enteral feeding?
A. diarrhea
B. metabolic disturbances
C. aspiration
D. all of the above
Polling Question 1
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10
Which of the following is a potential complication
of enteral feeding?
A. diarrhea
B. metabolic disturbances
C. aspiration
D. all of the above
Polling Question 1
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Complications of Enteral Feeding
• Adverse drug interactions
• Diarrhea
• Epistaxis
• Intestinal ischemia
• Metabolic disturbances
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Complications of Enteral Feeding
• Adverse drug interactions
• Diarrhea
• Epistaxis
• Intestinal ischemia
• Metabolic disturbances
• Mechanical complications
• Nasopharyngeal lesions
• Pulmonary complications
• Sinusitis
• Tube obstruction
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Complications of Enteral Feeding
• Adverse drug interactions
• Diarrhea
• Epistaxis
• Intestinal ischemia
• Metabolic disturbances
• Mechanical complications
• Nasopharyngeal lesions
• Pulmonary complications
• Sinusitis
• Tube obstruction
Aspiration
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Definition of Aspiration
• Aspiration: the inhalation of oropharyngeal secretions or
gastric or small-bowel contents into the larynx and lower
respiratory tract
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15
Aspiration often occurs without obvious evidence
of vomiting or regurgitation.
A. true
B. false
Polling Question 2
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16
Aspiration often occurs without obvious evidence
of vomiting or regurgitation.
A. true
B. false
Polling Question 2
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Definition of Aspiration
• Aspiration: the inhalation of oropharyngeal secretions or
gastric or small-bowel contents into the larynx and lower
respiratory tract
• Silent microaspiration: asymptomatic aspiration of small
volumes of oropharyngeal secretions or gastric fluid into
the lungs
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Incidence of Aspiration
Aspiration:
o Occurs in up to 89% of critically ill patients fed via
nasoenteral tube
o Is common in patients with impaired consciousness or
poor gag reflexes
o Has occurred in:
up to 30% of patients with tracheotomies
12.5% of neurology patients
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Potential Consequences of Aspiration
Consequences of Pulmonary Aspiration range from:
o asymptomatic normal physiologic clearance, to
o potentially life-threating conditions
- Aspiration pneumonitis
- Aspiration pneumonia
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Potential Consequences of Aspiration
• Aspiration pneumonitis: • Acute lung injury after aspiration of
acidic gastric contents, causing
chemical burns of the trachea-
bronchial tree and pulmonary
parenchyma.
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Potential Consequences of Aspiration
• Aspiration pneumonitis:
• Aspiration pneumonia:
• Acute lung injury after aspiration of
acidic gastric contents, causing
chemical burns of the trachea-
bronchial tree and pulmonary
parenchyma.
• An infectious process characterized
by inhalation of colonized
oropharyngeal material into the
respiratory tract.
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22
Aspiration of gastric contents is most likely to
result in:
A. Aspiration pneumonitis
B. Aspiration pneumonia
C. Vomiting
D. Diarrhea
Polling Question 3
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23
Aspiration of gastric contents is most likely to
result in:
A. Aspiration pneumonitis
B. Aspiration pneumonia
C. Vomiting
D. Diarrhea
Question 3 Response
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Diagnosis of Aspiration
• No bedside test available
• Diagnosed via clinical signs
o Dyspnea
o Cyanosis
o Tachycardia
o Hypotension
o X-ray changes
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Causes of Aspiration
• Causes include
o Gravitational back-flow
o Impairment of lower esophageal sphincter (LES)
o Infrequent esophageal contractions
o Feeding tube across the gastric cardia
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Device-Related Risk Factors for
Aspiration
• Malposition of the feeding tube
• Mechanical ventilation
• Nasogastric tube
• High bolus feeding volumes
• High gastric residual volume (GRV)
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Patient- Related Risk Factors for
Aspiration
• Supine position
• Sedation
• Vomiting
• Presence of high risk disease or injury
• Poor oral health
• Advanced age
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Risk Factors for Aspiration
• Nursing staff level
• Patient transferred for procedures to
other units and facilities
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Risk Factors for
Aspiration Pneumonia
• Esophagitis
• Gastroesophageal reflux
• History of aspiration or pneumonia
• Impaired level of consciousness
• Neurologic deficits
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Supine Positioning
• Study compared incidence of nosocomial pneumonia
in intubated, mechanically ventilated patients
• The incidence of pneumonia was:
o Lower incidence in semi-recumbent
o Highest for supine position
Source: Drakulovic, M. B., A. Torres, et al. (1999). "Supine body position as a risk factor for nosocomial pneumonia in
mechanically ventilated patients: a randomised trial." Lancet 354(9193): 1851-1858. 32
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Supine Positioning
• Study compared incidence of nosocomial pneumonia
in intubated, mechanically ventilated patients
• The incidence of pneumonia was:
o Lower incidence in semi-recumbent
o Highest for supine position
Source: Drakulovic, M. B., A. Torres, et al. (1999). "Supine body position as a risk factor for nosocomial pneumonia in
mechanically ventilated patients: a randomised trial." Lancet 354(9193): 1851-1858.
Supine body position and enteral nutrition were
independent risk factors for nosocomial pneumonia
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Supine Positioning
• Methany and colleagues compared care:
o 88% of patients aspirated with usual care
o 39% of patients aspirated under ARRP* protocol:
Elevate HOB 30 or higher
Distal small bowel feeding tube placement
Algorithmic approach for patients with high GRV
Source: Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter
Enteral Nutr. 2017;41(1):15-103.
*ARRP: Aspiration risk-reduction protocol
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Elevate the Head of the Bed
For patients at high risk of aspiration pneumonia:
• Elevate HOB 30º to 45º, unless contraindicated
• Keep HOB elevated for at least an hour after feeding
• If necessary to lower the HOB, return the patient to HOB
elevated position ASAP
• Infants under 1 year of age should sleep on their backs and
should not have the head of the bed elevated
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Sedation
Sedation decreases or eliminates the swallowing or
coughing reflex
To reduce the risk for aspiration in patients receiving
enteral feeding, it is advisable to use the minimum level of
sedation needed for patient comfort.
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Ensure Correct Placement
• 1-2% of blindly placed, small-bore feeding tubes
enter airway
Increases risk of aspiration
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Ensure Correct Placement
• Modalities used to ensure correct placement:
o Fluoroscopic
o Endoscopic
o Electromagnetic
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Monitor Tube Placement
After correct initial
placement, ongoing
assessment is required
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Monitor Tube Placement
AACN recommends placement be assessed every 4 hours
o Observe location of marked portion
o Look at notes on radiography report
o Note any changes in aspirate volume
o Measure aspirate pH if feeding interrupted for 1 hour or more
o When in doubt, request radiograph
Source: American Association of Critical Care Nurses, Practice Alert, downloaded
from http://ccn.aacnjournals.org/ by AACN on January 25, 2019. e2042
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Post-Pyloric Feeding
• Consider Post-Pyloric Feeding
• Small-bowel feedings appropriate for patients with:
o Gastric obstruction
o Severe gastroparesis
o Known reflux, aspiration
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Feeding Tube Site
• Relationship between feeding tube site and
respiratory outcomes compared:
o 428 critically ill, ventilated patients
o 11.6% lower with tubes in first part of duodenum
o 13.2% lower in second/third part
o 18% lower in fourth part
Conclusion: Feeding in the distal small bowel reduced risk of aspiration
Source: Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy.
JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. 45
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Promotility Agents
• 50-60% of critical-care patients experienced delayed
gastric emptying
• Abdominal, bowel status assessment is a priority
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Promotility Agents
• 50-60% of critical-care patients experienced delayed
gastric emptying
• Abdominal, bowel status assessment is a priority
• Prokinetic, or promotility, agents (e.g., metoclopramide) help the
stomach empty more quickly
• Consider promotility agents in patients with delayed
gastric emptying
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Gastric Residual Volume (GRV)
• GRV used as an indicator for aspiration risk
• For continuous feedings, check GRV during
infusion
• For intermittent feedings, check after 1 hour
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Gastric Residual Volume (GRV)
A single high GRV result must be assessed in
relation to other indicators of gastrointestinal
intolerance to tube feedings (e.g., abdominal
distention, abdominal discomfort, nausea & vomiting)
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A Closer Look …
• Supine positioning
• Sedation
• Enteral tube placement
• Enteral feeding
• Promotility agents
• Gastric residual volume
• Long term feeding
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Long-term Feeding
Long term feeding via a PEG or PEJ tube may reduce risk
of aspiration, however …
regular assessment is needed to confirm:
- retention device is properly approximated
- no tube migration
- no excessive tension to exterior of tube
- condition of surrounding skin
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Long-term Feeding
Long term feeding via a PEG or PEJ tube may reduce risk
of aspiration, however …
regular assessment is needed to confirm:
- retention device is properly approximated
- no tube migration
- no excessive tension to exterior of tube
- condition of surrounding skin
Conduct post-extubation assessment if
intubated for more than 2 days54
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Prevention of
Aspiration
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Reducing the Risk of
Aspiration Pneumonia
• Evaluate patients for risk
• Employ steps to reduce risk
• Elevate the head of the bed 30°- 45° during
administration
• Keep sedation level to a minimum
• Verify feeding tube position every 4 hours
Source: Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral
Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. 56
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Reducing the Risk of
Aspiration Pneumonia
• For high risk patients …
o Insert or advance feeding tube tip into the small bowel
o Deliver enteral nutrition continuously
o Consider promotility agents
o Provide good oral hygiene
o Deliver long term feeding via PEG and PEJ tubes
o Conduct a post-extubation assessment
Source: Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral
Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. 57
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Management of
Aspiration
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Management of Aspiration
• If aspiration is witnessed/suspected
o Stop the feed
o Remove aspirated material
o Initial treatment with antibiotics
o Quantitative bacteriology using BAL sample
o Discontinue antibiotics if no bacterial growth is
observed
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Management of Aspiration
• Treatment consists of
o Supportive management for pneumonitis
o Antimicrobial therapy for pneumonia
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Management of Aspiration
Surgical Approaches for Intractable Aspiration:
• Laryngectomy
• Laryngotracheal separation
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Management of Aspiration
Surgical Approaches for Intractable Aspiration:
• Laryngectomy
o Results in loss of voice box
o Significant cosmetic deformity
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Management of Aspiration
Surgical Approaches for Intractable Aspiration:
• Laryngectomy
o Results in loss of voice box
o Significant cosmetic deformity
• Laryngotracheal separation
o Patient breathes through neck
o Requires alternate vocalization method
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Issues in Enteral Feeding:
Aspiration
Summary
• Enteral nutrition improves nutritional status for patients
• Aspiration is a risk factor for enteral nutrition
• Preventive measures that reduce the risk of aspiration
should be employed
• Treatment of aspiration may include suctioning, bacterial
culture and antibiotics, or surgical intervention64
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Issues in Enteral Feeding:
Aspiration
66© 2019 VNOS. All rights in this presentation are proprietary to VNOS and may not be reproduced or used without written permission.
Thank you!Kathleen Stoessel, RN, BSN, MS