Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

Summary of the best evidence for the management of dysphagia in elderly patients

OBJECTIVE

To search for and summarize the best evidence for themanagement of elderly patients with dysphagia.

METHODS

Clinical decisions, recommended practices, evidence summaries, clinical practice guidelines, expert consensus, and systematic reviews on the management of dysphagia among elderly patients were systematically reviewed from domestic and foreign guideline websites, association websites, and Chinese and English databases according to the 6S model of evidence-based resources. The search period was between January 1, 2010 and November 1, 2023. Two researchers evaluated the quality of the included literature respectively and extracted evidence.

RESULTS

A total of 14 literatures were identified, including 2 guidelines, 2 clinical decisions, 5 evidence summaries, 3 expert consensus statements, and 2 systematic reviews. Twenty-four pieces of evidence from 7 aspects were summarized, including assessment, treatment and rehabilitation, medication care, nutrition management, oral care, complication management, and psychological care.

CONCLUSION

The best evidence-based recommendations for the management of dysphagia in elderly patients is summarized, it is suggested that the best evidence should be selected according to the actual situation of patients, and a personalized management plan should be formulated to improve the quality of life of patients and achieve high-quality nursing.

Characteristics of older adults receiving enteral feeding at a geriatric medical center

BACKGROUND

Malnutrition is a prevalent and hard-to-treat condition in older adults. enteral feeding is common in acute and long-term care. Data regarding the prognosis of patients receiving enteral feeding in geriatric medical settings is lacking. Such data is important for decision-making and preliminary instructions for patients, caregivers, and physicians. This study aimed to evaluate the prognosis and risk factors for mortality among older adults admitted to a geriatric medical center receiving or starting enteral nutrition (EN).

METHODS

A cohort retrospective study, conducted from 2019 to 2021. Patients admitted to our geriatric medical center who received EN were included. Data was collected from electronic medical records including demographic, clinical, and blood tests, duration of enteral feeding, Norton scale, and Short Nutritional Assessment Questionnaire score. Mortality was assessed during and after hospitalization. Data were compared between survivors and non-survivors. Multivariate logistic regressions were performed to identify the variables most significantly associated with in-hospital mortality.

RESULTS

Of 9169 patients admitted, 124 (1.35%) received enteral feeding tubes. More than half of the patients (50.8%) had polypharmacy (over 8 medications), 62% suffered from more than 10 chronic illnesses and the majority of patients (122/124) had a Norton scale under 14. Most of the patients had a nasogastric tube (NGT) (95/124) and 29 had percutaneous endoscopic gastrostomies (PEGs). Ninety patients (72%) died during the trial period with a median follow-up of 12.7 months (0.1-62.9 months) and one-year mortality was 16% (20/124). Associations to mortality were found for marital status, oxygen use, and Red Cell Distribution Width (RDW). Age and poly-morbidity were not associated with mortality.

CONCLUSION

In patients receiving EN at a geriatric medical center mortality was lower than in a general hospital. The prognosis remained grim with high mortality rates and low quality of life. This data should aid decision-making and promote preliminary instructions.

Association of follow-up neutrophil-to-lymphocyte ratio and systemic inflammation response index with stroke-associated pneumonia and functional outcomes in cerebral hemorrhage patients: a case-controlled study

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and systemic inflammation response index (SIRI) at admission are independent diagnostic biomarkers in stroke-associated pneumonia (SAP). Our study aimed to investigate the association between NLR, SIRI, specifically follow-up NLR and SIRI, and SAP, as well as their relationship with functional outcomes.

PATIENTS AND METHODS

We retrospectively included 451 consecutive intracerebral hemorrhage patients from May 2017 to May 2019. We conducted univariate and multivariable analyses to identify the factors independently associated with SAP and poor functional outcomes.

RESULTS

Compared to 127 (28.16%) patients diagnosed with SAP, those without SAP had both lower baseline and follow-up NLR and SIRI values ( P <0.001). After adjustments, we found that baseline NLR [OR, 1.039 (95% CI, 1.003-1.077); P =0.036] and follow-up NLR [OR, 1.054 (95% CI, 1.011-1.098); P =0.012] were independently associated with SAP. The follow-up NLR was also associated with a higher mRS [OR, 1.124 (95% CI, 1.025-1.233); P =0.013] and lower ADL-MBI score [OR, 1.167 (95% CI, 1.057-1.289); P =0.002] at discharge. Multivariable analysis indicated that advanced age and nasogastric tube feeding were independently associated with SAP ( P <0.05). We constructed a dynamic nomogram to identify SAP risk. Further subgroup analysis revealed that baseline NLR [OR, 1.062 (95% CI, 1.007-1.120); P =0.026] is independently associated with SAP in the nasogastric feeding group, while follow-up NLR [OR, 1.080 (95% CI, 1.024-1.139); P =0.005] was associated with the occurrence of SAP in non-nasogastric feeding patients.

CONCLUSIONS

We found elevated baseline and follow-up NLR values were associated with SAP occurrence, and increasing follow-up NLR indicated poor functional outcomes. Inflammatory markers at different stages may offer individualized guidance for patients receiving various treatments.

Trends and challenges in home enteral feeding methods for children with gastrointestinal disorders: an expert review on bolus feeding delivery methods

INTRODUCTION

New evidence supports the benefits of bolus feeding for children receiving home enteral feeding (HEN). Current home methods of bolus feeding have certain limitations, particularly in mobile or restless patients. Therefore, innovative delivery methods have been introduced to provide more flexible methods of reducing feeding time and formula handling.

AREAS COVERED

This manuscript presents an expert review of the updates in HEN for children and the results of an online user experience questionnaire about an innovative new cap-based bolus feeding system. A literature bibliographic search was conducted on Medline via PubMed up to September 2023 to collect relevant studies. We presented recent evidence demonstrating a dramatic increase in HEN use among children requiring EN and its benefits on patients' nutritional status and quality of life. In addition, the article examined the clinical and social benefits of bolus feeding and current challenges in delivery methods. We described the benefits of the new system and its user experience.

EXPERT OPINION

The uses and indications for bolus feeding in HEN are increasing among children. However, there are still some unmet needs regarding traditional delivery methods. Innovative techniques can improve flexibility, reduce feeding time, and improve user experience and quality of life.

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula.

AIM

This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics.

METHODOLOGY

This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient).

RESULTS

The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant.

CONCLUSION

The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke

Background

Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke.

Methods

In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing.

Results

The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG.

Conclusions

Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

[ESPEN practical guideline: Home enteral nutrition]

Introduction

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

The Effect of Nasogastric Feeding after Surgery in Patients with Head and Neck Cancers - Retrospective Single Center Experience

This study aimed to assess clinical factors that could predict the need for nasogastric feeding after surgery in patients with head and neck cancer (HNC) and evaluate the effect of tube feeding on selected laboratory parameters.This single-center retrospective study included 153 patients who underwent surgery for HNC. Data on patient and tumor characteristics were collected, along with laboratory measurements. Logistic regression was used to identify the predictors of the need for nasogastric feeding. Laboratory parameters were compared between patients who required nasogastric feeding vs those who did not.Nasogastric feeding was required in 90 patients (59%). Significant predictors of nasogastric feeding in HNC patients after surgery, which were revealed by univariate regression analysis, included low body mass index (odds ratio [OR] = 0.84), squamous cell carcinoma histology (OR = 8.05), T2 tumor stage (OR = 2.27), red blood cell count (M/µL) (OR = 0.44), hemoglobin levels (g/dL) (OR = 0.80), and mean corpuscular volume (fL) (OR = 1.10). Multivariate analysis showed that low BMI (OR = 0.87) and red blood cell count (M/µL) (OR = 0.32) were prognostic factors for nasogastric feeding. A significant percentage increase in white blood cell count from admission to discharge was noted in patients who required nasogastric feeding vs those who did not (p = 0.003).Determining factors that predict the need for nasogastric feeding in HNC patients after surgery may support more personalized treatment planning to optimize clinical outcomes.

Simulation based training versus non-simulation based training in anesthesiology: A meta-analysis of randomized controlled trials

Background

Simulation based training (SBT) has become an important tool in medical education, yet a comprehensive review of its effect in anesthesiology is currently lacking. This study was aimed to compare the effect of SBT versus non-simulation based training (NSBT) in anesthesia education.

Methods

Data were derived from PubMed, Ovid (EMBASE and MEDLINE), China National Knowledge Infrastructure (CNKI) and China Biology Medicine (CBM) from database inception up to June 2022. We included published randomized controlled trials (RCTs) that assessed the impact of Simulation-Based Training (SBT) on anesthesiology training and compared it to Non-Simulation-Based Training (NSBT).

Results

25 eligible studies were included, with a total sample size of 1621 medical students. SBT was associated with improved theoretical scores [mean difference (MD):5.28, 95%CI 3.06 to 7.49, P < 0.01] and skill scores (MD: 7.63, 95% CI 5.7 to 9.57, P < 0.01) in comparison with NSBT. And SBT significantly improved teaching effects, including success rate, analytic skill in clinical setting, learning interest, learn efficiency and satisfaction survey. Also, a dramatic promotion was observed in the evaluation of non-technical ability consisting of cooperative ability, problem solving ability and situational awareness after trainees with SBT.

Conclusions

Simulation-based training is an effective method for improving theoretical scores, skill scores, teaching effects and non-technical ability. Yet, further good-quality RCTs are required to confirm these changes translate to improved patient outcomes. Furthermore, it is important to carefully consider the cost-benefit effect to conduct simulation-based in anesthesiology education.

Iranian clinical practice guideline for amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegeneration involving motor neurons. The 3-5 years that patients have to live is marked by day-to-day loss of motor and sometimes cognitive abilities. Enormous amounts of healthcare services and resources are necessary to support patients and their caregivers during this relatively short but burdensome journey. Organization and management of these resources need to best meet patients' expectations and health system efficiency mandates. This can only occur in the setting of multidisciplinary ALS clinics which are known as the gold standard of ALS care worldwide. To introduce this standard to the care of Iranian ALS patients, which is an inevitable quality milestone, a national ALS clinical practice guideline is the necessary first step. The National ALS guideline will serve as the knowledge base for the development of local clinical pathways to guide patient journeys in multidisciplinary ALS clinics. To this end, we gathered a team of national neuromuscular experts as well as experts in related specialties necessary for delivering multidisciplinary care to ALS patients to develop the Iranian ALS clinical practice guideline. Clinical questions were prepared in the Patient, Intervention, Comparison, and Outcome (PICO) format to serve as a guide for the literature search. Considering the lack of adequate national/local studies at this time, a consensus-based approach was taken to evaluate the quality of the retrieved evidence and summarize recommendations.

Evaluation of 644 Percutaneous Endoscopic Gastrostomy Patients in a Single Center

OBJECTIVE

Our study aimed to review and evaluate the indications, complications, complication-related risk factors, and mortality rates of percutaneous endoscopic gastrostomy (PEG) performed in a single university hospital.

METHODS

We retrospectively examined hospital records of all 819 patients who underwent PEG between January 2010 and January 2019. Patients whose information was not available for various reasons, who had a history of gastrectomy, who were under 18 years old, and/or who had undergone PEG before, were excluded from the study.

RESULTS

The mean age of the patients was 65.12 ± 15.42 years, and the majority of the patients (60.6%) were female. In the vast majority of patients, the PEG indication was due to neurological causes (71.5%), among which the majority was a stroke. The overall complication rate in our study was 11.2%. The most common was a peristomal infection in 37 (5.7%) patients. Patients who were not under any antibiotic treatment and/or had diabetes mellitus had a higher risk for peristomal infection. Dementia increased the risk of tube dislodgement. The use of clopidogrel, the simultaneous use of aspirin and clopidogrel, and hypertension were independent risk factors for bleeding complications. The one-year mortality risk was significantly higher in patients who underwent PEG due to neurological causes compared to those who underwent PEG due to malignancy or other reasons (p = 0.021, p = 0.038, respectively).

CONCLUSION

The PEG procedure is a safe and feasible technique due to its low complication and mortality rate in patients with swallowing disorders who need long-term nutritional support.

Factors Contributing to Complete Oral Intake in Dysphagic Stroke Patients with Enteral Feeding Tubes in Convalescent Rehabilitation Wards

Objectives:

This study investigated the factors contributing to complete oral intake (COI) in dysphagic stroke patients with enteral feeding tubes in the local clinical setting.

Methods:

Data of patients with percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NGT) feeding on admission to convalescent rehabilitation wards (CRWs) were extracted from the Kaga Regional Cooperation Clinical Pathway for Stroke database for multiple centers including 19 acute care hospitals and 11 hospitals with CRWs. Patients were divided into two groups based on their status regarding COI or incomplete oral intake (ICOI) at discharge. Logistic regression analysis with forced-entry variables was used to identify factors contributing to COI.

Results:

On discharge from CRWs, COI and ICOI were observed in 140 and 207 cases, respectively. The COI group was younger, had a higher rate of initial stroke, higher Functional Oral Intake Scale (FOIS) scores, higher Functional Independence Measure (FIM) motor and cognitive scores, higher Body Mass Index (BMI), lower rate of patients with PEG, and shorter stays in acute care wards. Logistic regression analysis with forced entry revealed that younger age; initial stroke; higher FOIS score, FIM cognitive score, and BMI; and shorter stay in the acute care ward contributed to COI.

Conclusions:

The primary factors contributing to COI in dysphagic stroke patients with enteral feeding tubes were younger age, initial stroke, higher swallowing and cognitive function, good nutritional status, and shorter stay in the acute care ward.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

Factors Associated with In-Hospital Mortality in Elderly Internal Medicine Patients with Nasogastric Tube Feeding

Purpose

To evaluate demographic, clinical, and laboratory variables, and their associations with in-hospital mortality, among elderly internal medicine patients with nasogastric tube (NGT) feeding.

Patients and Methods

Demographic, clinical, and laboratory data were collected retrospectively for 129 patients aged ≥80 years who initiated NGT feeding during their hospitalization in internal medicine wards. The data were compared between survivors and non-survivors. Multivariate logistic regressions were performed to identify the variables most significantly associated with in-hospital mortality.

Results

The in-hospital mortality rate was 60.5%. Compared to survivors, non-survivors more often presented with pressure sores (P=0.005) and lymphopenia (P<0.001), were more often treated with invasive mechanical ventilation (P<0.001), and less often underwent geriatric assessment (P<0.001). Non-survivors demonstrated higher mean levels of C-reactive protein, and lower mean values of serum cholesterol, triglycerides, total protein, and albumin (P<0.001 for all comparisons). On multivariate analysis, the following variables were most significantly associated with in-hospital mortality in the entire cohort: the presence of pressure sores (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.68-11.48; P=0.003) and lymphopenia (OR, 4.09; 95% CI, 1.51-11.08; P=0.006), and serum cholesterol (OR, 0.98; 95% CI, 0.96-0.99; P=0.003).

Conclusion

Among elderly acutely ill patients who initiated NGT feeding during hospitalization, in-hospital mortality was extremely high. The factors most strongly associated with in-hospital mortality were the presence of pressure sores and lymphopenia, and lower serum cholesterol levels. These findings may provide useful prognostic information for decision-making regarding initiation of NGT feeding in elderly hospitalized patients.

Comparison Between Percutaneous Endoscopic Gastrostomy and Nasogastric Feeding in 160 Patients with Swallowing Disturbances: A Two-Year Follow-Up Study

Purpose

We retrospectively compared the complications, blood biochemical indexes and outcomes in patients with swallowing disturbances receiving nasogastric tube (NGT) feeding and percutaneous endoscopy gastrostomy (PEG).

Methods

Among 160 patients, 72 cases received PEG and 88 cases received NGT. All patients were followed up for two years. We collected their clinical data from the medical records. Indicators, such as body mass index (BMI), white blood cell (WBC), hemoglobin (HGB), complications, including recurrent aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and outcomes (survival or death) were compared between the two groups semi-annually.

Results

SAt both six months and one year after receiving treatment, there was no statistical difference between the two groups in indicators, complications and outcomes, with all P >0.05. It can be seen that, when the patients were followed up for one and a half years18 months, ALB was lower in the NGT group (33.81±0.46) compared with the PEG group (36.14±0.50) (P <0.05). After two years of follow-up, differences between the NGT and PEG group could be seen in a variety of indicators, including BMI (20.08±0.27 vs 21.03±0.25), WBC (9.12±0.56 vs 7.08±0.29), ALB (33.11±0.43 vs 35.75±0.49), creatinine (55.07±1.83 vs 63.21±2.94), and the complications, such as aspiration pneumonia, gastrointestinal bleeding, reflux esophagitis, and electrolyte disorder, in the PEG group were significantly reduced compared to the NGT groupthan that in its counterpart, P <0.05. In the two-year follow-up period, there were 13 and 22 patients died in the PEG group and NGT group, respectively.

Conclusion

Both techniques are safe and effective in the short term. However, on a longer-term basis, PEG is shown to be superior to NGT feeding in improving nutrition and preventing common complications for patients with swallowing disturbances.

Practice Patterns and Attitudes Among Speech-Language Pathologists Treating Stroke Patients with Dysphagia: A Nationwide Survey

Dysphagia management is a core component of quality stroke care. Speech-Language Pathologists (SLPs) play a key role in the management of post-stroke dysphagia. We sought to elicit perceptions, attitudes, and practice patterns regarding post-stroke dysphagia management among SLPs in the United States. We conducted a survey among SLPs registered with the American Speech-Language-Hearing Association who indicated that they care for acute stroke patients. A total of 336 participants completed the survey. Over half of the participants (58.6%) indicated that they obtain objective swallow testing in ≥ 60% of their post-stroke dysphagia patients. Almost 1 in 5 SLPs indicated that they are often unable to perform objective dysphagia testing due to limited resources (18.8% indicated resource limitations; 78.9% indicated no resources limitations; 2.4% were unsure). SLPs in hospitals without stroke center certification had higher odds of indicating limited resources compared to SLPs in certified stroke centers (OR 2.08, 95% CI 1.11-3.87). Over 75% indicated that percutaneous endoscopic gastrostomy (PEG) tubes after stroke are placed too early. SLPs who obtain objective swallow testing in ≥ 60% of patients had higher odds of indicating that PEG tubes are placed too early (OR 1.70, 95% CI 1.13-2.56). While 19.4% indicated that the optimal timing for PEG after stroke is < 7 days after admission, 25.0% indicated that the optimal timing is > 12 days. Almost 35% indicated that health care system pressures influence their recommendations, and 47.6% indicated that ≥ 25% of PEGs could be avoided if patients were given up to 7 more days for swallowing recovery.

Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project

Background

Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN—with weight loss and mortality.

Methods

A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff.

Results

The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31–1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments.

Conclusions

Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Gastroenterologist's Guide to Gastrostomies

Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.

ICU tracheotomies in patients with COVID-19: a lesson learned for future viral pandemic

INTRODUCTION

The coronavirus SARS-CoV-2 pandemic has resulted in a large number of patients requiring intubation and prolonged mechanical ventilation. The current knowledge on the tracheotomies regarding the time form intubation, method and ventilatory parameters optimal for their performance in the mechanically ventilated patients with COVID ARDS are scarce; thus, the aim of this study is to present new data regarding their safety, adverse events and timing.

MATERIALS AND METHODS

This retrospective observational study is based on the data of 66 critically ill COVID patients including demographic data, timing and technique of tracheotomy, ventilatory parameters in the time of procedure, as well as complication and survival rate.

RESULTS

A number of 66 patients with COVID-related pneumonia were included in the study, among whom 32 were tracheotomized-25 patients underwent an early tracheotomy and 7 patients had late tracheotomy. The median duration of mechanical ventilation before the tracheotomy in the early group was 8 days (IQR 6-10) compared to 11 days (IQR 11-12.5.) p < 0.001) in late group. Risk of death in tracheotomy patients was significantly growing with growing level of PEEP and FiO2 at the moment of decision on tracheotomy, OR = 1.91 CI₉₅ (1.23;3.57); p = 0.014 and OR = 1.18 CI₉₅(1.03;1.43); p = 0.048, respectively.

CONCLUSION

Early percutaneous tracheotomy is safe (both in terms of risk of viral transmission and complication rate) and feasible in COVID-19 patients. Stability of gas exchange, and ventilatory parameters are the main prognostic factors of the outcome.

Nationwide Prevalence and Outcomes of Long-Term Nasogastric Tube Placement in Adults

Tube feeding (TF) is commonly used for patients with severe swallowing disturbance, and patients with chronic dysphagia are often provided with a long-term nasogastric tube (NGT). However, nationwide epidemiological data on long-term NGT placement are limited. The present study identified the prevalence and outcomes of patients with long-term NGT placement in Taiwan. Data were obtained from the Longitudinal Health Insurance Database. Patients with NGT placement for more than 3 months between 2000 and 2012 were enrolled in this cohort study. An NGT cohort of 2754 patients was compared with 11,016 controls matched for age, sex, residential area, and comorbidities. The prevalence rate of long-term NGT reached 0.063% in 2005 and then remained stable at 0.05-0.06%. The major causes of NGT placement were stroke (44%), cancer (16%), head injury (14%), and dementia (12%). Men (63%) were more likely to have long-term NGT placement than women (37%). The adjusted hazard ratios were 28.1 (95% CI = 26.0, 30.3) for acute and chronic respiratory infections; 26.8 (95% CI = 24.1, 29.8) for pneumonia, 8.84 (95% CI = 7.87, 9.93) for diseases of the esophagus, stomach, and duodenum; and 7.5 (95% CI = 14.7, 20.8) for mortality. Patients with NGT placement for more than 6 months had a higher odds ratio (1.58, 95% CI = 1.13, 2.20) of pneumonia than those with NGT placement for less than 6 months. Only 13% and 0.62% of the patients underwent rehabilitation therapy and percutaneous endoscopic gastrostomy, respectively. Long-term NGT use was associated with a higher risk of comorbidities and mortality. Stroke was the main illness contributing to long-term NGT use. Further interventions are necessary to improve the negative effects of long-term TF.

Evaluation of Oropharyngeal Dysphagia in Older Patients for Risk Stratification of Pneumonia

Objective

Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed older patients with oropharyngeal dysphagia. Aspiration pneumonia is the most common cause of death in these patients. This study aimed to evaluate the role of oropharyngeal dysphagia in older patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Methods

We performed modified flexible endoscopic evaluation of swallowing to evaluate oropharyngeal dysphagia in older patients and conducted prospective follow-up for pneumonia requiring hospitalization. A total of 664 oral-feeding patients and 155 tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of pneumonia requiring hospitalization.

Results

Multivariate analyses showed that the risk of pneumonia requiring hospitalization significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia. Subgroup analysis revealed that the risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia (adjusted hazard ratio 0.26, 95% confidence interval: 0.11–0.63, P = 0.003).

Conclusions

For older patients with oropharyngeal dysphagia requiring long-term enteral tube feeding, PEG is a better choice than NGT. Further research is needed to elucidate the role of oropharyngeal dysphagia in enteral feeding in older patients.

Endoscopic gastrostomy for nutritional support in post-stroke dysphagia

Introduction

Introduction: persistent dysphagia affects 15 % of stroke patients and contributes to malnutrition, aspiration, and death. This study aimed to characterize patients with post-stroke dysphagia who underwent percutaneous endoscopic gastrostomy (PEG), and to assess the impact of PEG feeding on nutritional status and outcome. Methods: an observational and retrospective study using records from patients with post-stroke dysphagia who underwent PEG. Body mass index (BMI), serum albumin, transferrin, and cholesterol were recorded at the time of PEG insertion (T0) and 3 months later (T3). The evolution of these parameters was analyzed and compared to survival. Results: we obtained data from 158 patients (53.2 % males) with a median age of 75 years. Most strokes were ischemic (n = 135, 85.4 %). Median time between stroke and PEG was 2 months. Median survival after gastrostomy was 16 months. At admission, 41.6 % of patients had low BMI, 62.3 % low albumin, 68.6 % low transferrin, and 59.6 % low cholesterol levels. The prevalence of low albumin and low transferrin was higher in the patients who underwent PEG more than 2 months after stroke. A significant increase in albumin and transferrin, and a normalization of cholesterol levels was observed after 3 months of PEG feeding. Mortality was 12.9 %, 27.7 %, and 40 % at 1, 3, and 12 months, respectively. Survival was lower in patients with low albumin, transferrin or total cholesterol at admission. Conclusions: the prevalence of malnutrition is high among patients with post-stroke dysphagia. PEG feeding improves albumin, transferrin, and cholesterol levels. Early post-PEG mortality is high and must be considered on an individual basis.

Can Videofluoroscopic Swallowing Kinematic Analysis Predict Recovery of Oral Intake in Postoperative Oral Cancer Patients Requiring Nasogastric Tube Feeding?

This retrospective study determined the significant predictive factors for the number of days required to remove nasogastric tubes (NGTs) after surgery in patients with oral cancer (OC). In this study, patients underwent a videofluoroscopic swallowing study (VFSS) approximately 2 weeks after surgery. Videofluoroscopic images were analyzed, and variables such as swallowing and swallowing kinematics were measured. Patient characteristics, swallowing kinematics, and swallowing results were assessed using a Cox proportional hazards model. This study assessed 129 participants (66 men, 63 women, mean age: 69.0 ± 14.1 years) with nine types of cancer. The Cox proportional hazard ratio revealed that sex, body mass index before surgery, radiotherapy and/or chemotherapy, dysphagia before surgery, normalized pharyngeal constriction ratio, upper esophageal sphincter (UES) opening, and laryngeal vestibule disclosure (LVC) disorder were predictive factors for the removal of NGTs when adjusted for age. The study identified several predictive factors for the removal of NGTs and oral intake recovery in patients with OC. Regarding swallowing kinematics, UES opening is the most significant predictive factor. After surgery for OC, VFSS should be performed to assess safe eating methods and predict the recovery of oral intake and removal of the NGT.

Clinician's attitude to enteral nutrition with percutaneous endoscopic gastrostomy: a survey in China

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians' opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding.

METHODS

A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses.

RESULTS

Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians' choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80).

CONCLUSIONS

Doctors' insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

CT-guided gastrostomy tube placement-a single center case series

PURPOSE

The role of computed tomography (CT)-guided gastrostomy tube placement is still evolving. It is a valuable alternative to guide gastrostomy tube placement in a few selected patients, who are not candidates for the established endoscopy- or fluoroscopy-guided gastrostomy tube placement. Our objective was to describe our institutional experience placing gastrostomy tubes using CT guidance and to conduct a review of literature for similar studies to provide the best current evidence on success rates and complications.

METHODS

We identified gastrostomy tubes placed under CT guidance at our institution using a comprehensive case log. We also identified studies in the literature, through a systematic search of PubMed. In both the local and literature analyses, we recorded success and complication rates.

RESULTS

A total of 31 patients underwent 33 attempted CT-guided gastrostomy tube placements at our institution, with 32 successful procedures yielding a success rate of 97%. The overall rate of successful gastrostomy tube placement using CT-guidance was 94.9% (634/668), as reported in the existing literature.

CONCLUSION

CT-guidance is an effective method for gastrostomy tube placement and may play an important role in patients for whom endoscopic or fluoroscopic gastrostomy tube placement is not feasible.

Percutaneous Endoscopic Gastrostomy Reduces Aspiration Pneumonia Rate in Stroke Patients with Enteral Feeding in Convalescent Rehabilitation Wards

OBJECTIVES

The effect of percutaneous endoscopic gastrostomy (PEG) on the prevention of aspiration pneumonia and improvements in activities of daily living (ADL) for enteral feeding-dependent stroke patients is unclear. We sought to clarify differences in the rates of aspiration pneumonia and ADL improvement between stroke patients receiving PEG and those receiving nasogastric tube feeding (NGT) in convalescent rehabilitation wards.

METHODS

We assessed 10 years of data from the Kaga Regional Cooperation Clinical Pathway for Stroke, which covers patients in the southern district of Ishikawa Prefecture of Japan. Logistic regression analysis with propensity score adjustment was used to examine how the enteral feeding method affected aspiration pneumonia rates. Linear regression analysis, adjusted by propensity scores, was also performed to ascertain the effect of the enteral feeding method on ADL improvement.

RESULTS

Overall, 47 patients with PEG and 49 patients with NGT were analyzed. The incidence of aspiration pneumonia was 4.67 times higher in the NGT group than in the PEG group in the propensity score-adjusted logistic regression analysis (odds ratio 4.67, 95% confidence interval 1.30-16.67, P=0.02). The enteral feeding method had no significant effect on ADL improvement in the propensity score-adjusted linear regression analysis.

CONCLUSIONS

In convalescent rehabilitation wards, aspiration pneumonia was more likely to occur in stroke patients with NGT than in those with PEG; however, the enteral feeding method did not affect ADL improvement. These results provide a basis for determining the appropriate enteral feeding method for stroke patients who cannot take adequate nutrition orally during convalescence/rehabilitation.

Cui bono? PEG feeding

Percutaneous endoscopic gastrostomy (PEG) provides long-term nutritional support to those unable to tolerate intake orally. The benefits of a PEG depend on the indication and the individual, and are considered when it has the potential to improve mortality, nutritional status or quality of life. Often, family members and healthcare professionals have to act on behalf of the patient. It is difficult for their personal values and emotions to not be a factor when deciding if to proceed with a PEG. This may result in unnecessary PEG placement. For certain indications (dementia for example), there is limited evidence of any benefits a PEG may give and may actually cause harm. Guidance to improve patient selection and increase education for healthcare professionals is essential in achieving the best outcome for the patient.

Pneumonia prevention in the elderly patients: the other sides

Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death; preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehydration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk-benefit of the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physiotherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favoring the colonization of respiratory pathogens than can then be aspirated into the lungs.

Percutaneous endoscopic gastrostomy feeding effects in patients with neurogenic dysphagia and recurrent pneumonia

Background:

Percutaneous endoscopic gastrostomy (PEG) feeding provides enteral nutrition to patients with neurological dysphagia. However, the conditions in which PEG should be applied to prevent pneumonia remain unclear. We aimed to evaluate the effect of PEG for patients with neurological dysphagia in preventing pneumonia.

Methods:

We undertook a retrospective data review of 232 patients with neurological dysphagia who had undergone PEG from January 2008 to December 2018 at Inha University Hospital, in Incheon, Korea. We excluded patients who had not been followed up 6 months pre- and post-PEG feeding. In total, our study comprised 42 patients. We compared pneumonia episodes and incidence pre- and post-PEG.

Results:

During the median post-PEG follow-up period, the 6-month pneumonia incidence among patients who had undergone PEG had decreased [median 0.3 (interquartile range (IQR) 0.0–0.7) versus 0.1 (IQR 0.1–0.3) episodes, p = 0.04]. In a multiple mixed model, PEG did not decrease the incidence of pneumonia (p = 0.76). However, the association between PEG and the incidence of pneumonia differed significantly depending on the presence or absence of recurrent pneumonia (p < 0.001).

Conclusions:

PEG could effectively reduce the incidence of pneumonia in patients with neurogenic dysphagia, especially in those who had experienced recurrent pneumonia.

The reviews of this paper are available via the supplemental material section.

Nasogastric- vs. percutaneous gastrostomy tube for prophylactic gastric decompression after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with postoperative gastroparesis and ileus. In 2015, our practice shifted from using percutaneous gastrostomy tubes (PGT), to nasogastric tubes (NGT) for prophylactic gastric decompression after CRS-HIPEC. This study aimed to compare these methods for length of stay (LOS) and associated complications.

Methods

Patients that underwent CRS-HIPEC for peritoneal metastases from colorectal cancer between 2014 and 2019 were included. Cases were grouped based on receiving NGT or PGT postoperatively. Multivariable linear regression determined the independent effect of decompression method on LOS, thereby adjusting for confounders.

Results

In total, 179 patients were included in the analyses. Median age was 64 years [IQR:54–71]. Altogether, 135 (75.4%) received a NGT and 44 (24.6%) received a PGT. Gastroparesis occurred significantly more often in the PGT group (18.2 vs. 7.4%, p=0.039). Median LOS was significantly shorter for patients with a NGT (15 [IQR:12–19] vs. 18.5 [IQR:17–25.5], p<0.001). PGT was independently associated with longer LOS in multivariable analysis (Beta=4.224 [95%CI 1.243–7.204]). There was no difference regarding aspiration, pneumonia and postoperative mortality between groups.

Conclusions

NGT should be preferred over PGT for gastric decompression after CRS-HIPEC as it is associated with fewer gastroparesis and shorter LOS.

Long-term prognosis of enteral feeding and parenteral nutrition in a population aged 75 years and older: a population-based cohort study

Background

Enteral feeding and parenteral nutrition (PN) using gastrostomy (GS) and a nasogastric tube feeding (NGT) and PN should be initiated for older patients based on their prognoses. This study aimed to investigate the long-term prognosis of patients aged ≥75 years who underwent enteral feeding via GS and NGT as well as PN.

Methods

A population-based cohort study was conducted using Japan’s universal health insurance claims in the Nara Prefecture. This study enrolled 3,548 patients aged ≥75 years who received GS (N=770), NGT (N=2,370), and PN (N=408) during hospital admissions between April 2014 and March 2016. The GS group was further categorized into secondary GS (N=400) with preceding NGT or PN within 365 days and primary GS (N=370) without preceding NGT or PN groups. In the secondary GS group, 356 (96%) patients received NGT (versus PN). The outcome was mortality within 730 days after receiving GS, NGT, and PN. Cox regression analyses in cases with or without malignant diseases, adjusted for sex, age, comorbidity, and hospital type, were performed to compare mortality in the groups.

Results

Of the 3,548 participants, 2,384 (67%) died within 730 days after the initiation of GS and NGT and PN. The 2-year mortality rates in the secondary GS, primary GS, NGT, and PN groups were 58%, 66%, 68%, and 83% in patients without malignancies and 67%, 71%, 74%, and 87% in those with malignancies, respectively. In the non-malignant group, Cox regression analysis revealed that secondary GS (hazard ratio (HR) = 0.43, 95% CI: 0.34–0.54), primary GS (HR = 0.51, 95% CI: 0.40–0.64), and NGT (HR = 0.71, 95% CI: 0.58-0.87) were statistically significantly associated with lower mortality compared with PN.

Conclusions

Approximately 58% to 87% patients aged ≥75 years died within 730 days after initiation of nutrition through GS, NGT, or PN. Patients with non-malignant diseases who received secondary GS exhibited better 2-year prognosis than those who received NGT or PN. Healthcare professionals should be aware of the effectiveness and limitations of enteral feeding and PN when considering their initiation.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

[Management of tracheostomy patients during the COVID-19 pandemic: review of the literature and demonstration]

BACKGROUND

Since emergence of the new coronavirus in China in December 2019, many countries have been struggling to control skyrocketing numbers of infections, including among healthcare personnel. It has now been clearly demonstrated that SARS-CoV‑2 resides in the upper airways and transmits easily via aerosols and droplets, which significantly increases the risk of infection when performing upper airway procedures. Ventilated COVID-19 patients in a critical condition in the intensive care unit may require tracheotomy for long-term ventilation and to improve weaning. However, the risk of secondary infection of medical personnel performing subsequent tracheostomy care remains unclear.

OBJECTIVE

This study aimed to evaluate the risk of droplet dispersion during tracheostomy tube change and overview tracheostomy tube change in COVID-19 patients.

MATERIALS AND METHODS

The current literature was reviewed, quantitative and qualitative analyses of droplet formation during tracheostomy tube change in n = 8 patients were performed, and an overview of and checklist for tracheostomy tube change were compiled.

RESULTS

This study demonstrates that tracheostomy tube change, in particular insertion of the new tube, may cause significant droplet formation. The aerosolization of particles smaller than 5 µm was not analyzed.

CONCLUSION

Our data, together with the current literature, clearly emphasize that tracheostomy care is associated with a high infection risk and should only be performed by a small group of well-trained, maximally protected healthcare personnel.

Association Between Active Gait Training for Severely Disabled Patients with Nasogastric Tube Feeding or Gastrostoma and Recovery of Oral Feeding: A Retrospective Cohort Study

PURPOSE

This study evaluates the effect of introducing active gait training (AGT) to patients who are severely disabled with nasogastric tube feeding or gastrostoma on the recovery of oral feeding.

PATIENTS AND METHODS

We conducted a historical cohort study at a single rehabilitation center in Japan between January 2013 and December 2019. In this study, 154 severely disabled patients with nasogastric tube feeding or gastrostoma due to neurological diseases or disuse syndrome admitted in a rehabilitation ward were included, and their median age was 84 years. AGT was systematically implemented in August 2016, which consisted of using orthosis or assistance from physical therapists. We compared the recovery of oral feeding between periods before (Pre-AGT) and after (Post-AGT) the introduction of AGT.

RESULTS

Among the 154 severely disabled patients included, 59 (38%) were admitted in the Post-AGT period. Twenty-eight (30%) and 54 patients (92%) started gait training in the Pre-AGT and Post-AGT periods, respectively (p < 0.001). Significantly more patients recovered oral feeding in the Post-AGT than in the Pre-AGT periods (49% vs 19%, respectively; p < 0.001). After the introduction of AGT, the adjusted hazard ratio for the recovery of oral feeding was 4.0 (95% confidence interval, 1.9-8.3; p < 0.001).

CONCLUSION

After the introduction of AGT to patients, increased recovery of oral feeding was observed in this retrospective evaluation. AGT should be considered for patients with tube feeding to help them recover oral feeding even if patients were severely disabled and required full assistance during gait training.

Effectiveness of percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis

BACKGROUND

Weight loss and dysphagia are frequent features of amyotrophic lateral sclerosis (ALS) and influence prognosis. The aim of this study was to determine complications and outcomes in patients with percutaneous endoscopic gastrostomy (PEG) insertion in a high-volume center.

METHODS

A single center retrospective study on a prospectively collected cohort of 187 consecutive patients who have undergone PEG placement due to ALS was performed. Demographic and clinical parameters were analyzed.

RESULTS

There were 51.3% male; mean age at insertion was 65.7 years. Major complications occurred in 5 (2.7%) patients: 3 with local infections requiring intravenous antibiotic treatment, 1 patient with PEG dislocation required laparotomy and a new surgically introduced gastrostomy and 1 patient with buried-bumper syndrome. Improvement in Body Mass Index (BMI) and serum albumin levels were recorded in 37.3% and 51.9%, respectively. Mortality after 30 days, 6 months and 12 months was 5.3%, 38% and 64.3%, respectively. At the time of data collection, 78.9% of the patients had died. Mean survival after ALS diagnosis was 20.5 months.

CONCLUSIONS

PEG placement is as an effective, safe nutritional method with a low complication rate in patients with ALS, with or without non-invasive ventilation. The BMI and albumin levels stabilize after PEG placement, indicating benefits of early placement.

Ethics of providing clinically assisted nutrition and hydration: current issues

The provision of clinically assisted nutrition and hydration (CANH) often presents clinicians with ethical dilemmas. As the population grows there is increasing prevalence of patients with conditions such as stroke, dementia, advanced malignancy, cerebral palsy and eating disorders and a greater demand for CANH. It is important that healthcare professionals are familiar with the ethical and legal position for the provision of CANH. In addition, it is important to be aware of the clinical indications, relative contraindications and alternative means of supporting patients for whom CANH is not appropriate; this includes education and training for staff, patients, carers and relatives. The lack of high-quality evidence around clinical outcomes, particularly in the form of randomised clinical trials, and the challenges of accurate prognostication in patients who are approaching the end of life make decisions around the provision of CANH difficult for healthcare professionals.

Association between delivery methods for enteral nutrition and physical status among older adults

Background

The physical status of patients who received enteral nutrition is still unclear. We aimed to compare the physical functional status among older adult patients who underwent percutaneous endoscopic gastrostomy (PEG) and those with nasogastric feeding.

Methods

We conducted a retrospective cohort study in an acute care hospital from August 1, 2009 to March 31, 2015. We included older adult patients (age ≥ 65 years) who were administered PEG or nasogastric feeding during hospitalization and received enteral nutrition for ≥14 days. We excluded patients who were completely bedridden at the administration of enteral nutrition. The primary outcome was death or becoming bedridden at discharge. The incidence of being bedridden among the patients who survived and received enteral nutrition at discharge was also compared according to the enteral nutrition method used.

Results

Among the 181 patients who were administered enteral nutrition during hospitalization, 40 patients (22%) died and 66 patients (36%) were bedridden at discharge. The proportions of patients who fully resumed oral intake were 30% in the nasogastric group and 2.3% in the PEG group. The adjusted odds ratios comparing PEG feeding to nasogastric feeding were 0.38 (95% CI, 0.16–0.93) for death or being bedridden and 0.09 (95% CI, 0.02–0.40) for being bedridden among the patients who were receiving enteral nutrition at discharge.

Conclusions

Among older adult patients who were administered enteral nutrition, more than half of these patients died or became bedridden. PEG feeding could be associated with a lower risk of becoming bedridden or death in comparison with nasogastric feeding, although PEG feeding may be offered to the most mobile/ambulatory patients within clinical decision-making. Clinicians should carefully consider the administration and choice of enteral nutrition methods, when considering the prognosis of the patients.

Percutaneous Endoscopic Gastrostomy versus Nasogastric Tube Feeding: Oropharyngeal Dysphagia Increases Risk for Pneumonia Requiring Hospital Admission

Background: Aspiration pneumonia is the most common cause of death in patients with percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding. This study aimed to compare PEG versus NGT feeding regarding the risk of pneumonia, according to the severity of pooling secretions in the pharyngolaryngeal region. Methods: Patients were stratified by endoscopic observation of the pooling secretions in the pharyngolaryngeal region: control group (<25% pooling secretions filling the pyriform sinus), pharyngeal group (25–100% pooling secretions filling the pyriform sinus), and laryngeal group (pooling secretions entering the laryngeal vestibule). Demographic data, swallowing level scale score, and pneumonia requiring hospital admission were recorded. Results: Patients with NGT (n = 97) had a significantly higher incidence of pneumonia (episodes/person-years) than those patients with PEG (n = 130) in the pharyngeal group (3.6 ± 1.0 vs. 2.3 ± 2.1, P < 0.001) and the laryngeal group (3.8 ± 0.5 vs. 2.3 ± 2.2 vs, P < 0.001). The risk of pneumonia was significantly higher in patients with NGT than in patients with PEG (adjusted hazard ratio = 2.85, 95% CI: 1.46–4.98, P < 0.001). Cumulative proportion of pneumonia was significantly higher in patients with NGT than with PEG for patients when combining the two groups (pharyngeal + laryngeal groups) (P = 0.035). Conclusion: PEG is a better choice than NGT feeding due to the decrease in risk of pneumonia requiring hospital admission, particularly in patients with abnormal amounts of pooling secretions accumulation in the pyriform sinus or leak into the laryngeal vestibule.

Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding: a retrospective analysis on outcomes and complications

Background and study aims  Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are techniques used for long-term enteral feeding. Our primary aim was to analyze procedure-related and 30-day mortality and complications between PEG and PRG in relation to indications. Patients and methods  A single-center retrospective analysis was performed thath included all adult patients receiving initial PEG (January 2008 until April 2016) and PRG (January 2010 until April 2016). Outcomes were mortality (procedure-related, 30-day), complications (early (≤ 30 days) and late) and success rates. Results  A total of 760 procedures (469 PRG and 291 PEG) were analyzed. Most common indications were head and neck cancer (HNC), cerebrovascular accident (CVA) and amyotrophic lateral sclerosis (ALS). Success rates for placement were 91.2 % for PEG and 97.1 % for PRG ( P  = 0.001). Procedure-related mortality was 1.7 % in PEG and 0.4 % in PRG ( P  = 0.113). The 30-day mortality was 10.7 % in PEG and 5.1 % in PRG ( P  = 0.481 after multivariate logistic regression) CVA was associated with higher 30-day mortality, whereas ALS, higher body weight, and prophylactic placements in HNC were associated with lower rates. Tube-related complications were less frequent in PEG, both early (2.7 % vs. 26.4 %, P  ≤ 0.001) and late (8.6 % vs. 31.5 %, P  ≤ 0.001). The percentage of major complications and infections did not differ. Conclusions  With respect to procedure-related and 30-day mortality, PEG and PRG compare equally. PRG had a higher procedural success rate. Tube-related complications and pain are less frequent after PEG compared to PRG. The choice for either PEG or PRG therefore should primarily be based on local facilities and expertise.

Home Enteral Nutrition in Singapore's Long-Term Care Homes-Incidence, Prevalence, Cost, and Staffing

Introduction: Data on home enteral nutrition (HEN) in long-term care facilities (LTCF) in Singapore is scarce. This study aims to determine the prevalence and incidence of chewing/swallowing impairment and HEN, and the manpower and costs related. Methods: A validated cross-sectional survey was sent to all 69 LTCFs in Singapore in May 2019. Local costs (S$) for manpower and feeds were used to tabulate the cost of HEN. Results: Nine LTCFs (13.0%) responded, with a combined 1879 beds and 240 residents on HEN. An incidence rate (IR) of 15.7 per 1000 people-years (PY) and a point prevalence (PP) of 136.6 per 1000 residents were determined for HEN, and an IR of 433.0 per 1000 PY, with PP of 385.6 per 1000 residents for chewing/swallowing impairment. Only 2.5% of residents had a percutaneous endoscopic gastrostomy (PEG). The mean length of residence in LTCF was 45.9 ± 12.3 months. More than half of the residents received nasogastric tube feeding (NGT) for ≥36 months. Median monthly HEN cost per resident was S$799.47 (interquartile range (IQR): 692.11, 940.30). Nursing costs for feeding contributed to 63% of total HEN costs. Conclusions: The high usage and length of time on NGT feeding warrants exploration and education of PEG usage. A national HEN database may improve the care of LTCF residents.

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Background

The long-term outcomes of artificial nutrition in older people with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is one of the major methods of artificial nutrition. Enteral feeding is indicated for patients with a functional gastrointestinal tract. However, total parenteral nutrition (TPN) is often inappropriately chosen for artificial nutrition in Japan, even in patients with a functional gastrointestinal tract, as PEG has recently been viewed as an unnecessary life-prolonging treatment in Japan. This study aimed to compare the long-term outcomes between PEG and TPN.

Methods

This single-center retrospective cohort study investigated long-term outcomes in older patients with dysphagia who received PEG or TPN between January 2014 and January 2017. The primary outcome was survival time. Secondary outcomes were oral intake recovery, discharge to home, and the incidence of severe pneumonia and sepsis. We performed 1-to-1 propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox regression analysis were used to compare the survival time between groups.

Results

We identified 253 patients who received PEG (n = 180) or TPN (n = 73). Older patients, those with lower nutritional states, and severe dementia were more likely to receive TPN. Propensity score matching created 55 pairs. Survival time was significantly longer in the PEG group (median, 317 vs 195 days; P = 0.017). The hazard ratio for PEG relative to TPN was 0.60 (95% confidence interval: 0.39–0.92; P = 0.019). There were no significant differences between the groups in oral intake recovery and discharge to home. The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 25.5%, P = 0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 30.9%, P = 0.018).

Conclusions

PEG was associated with a significantly longer survival time, a higher incidence of severe pneumonia, and a lower incidence of sepsis compared with TPN.

Benefit of Reducing Body Weight Loss with A Nutritional Support Pathway in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

This retrospective, historically controlled investigative study examined the benefit of a nutritional support pathway that included nutritional education before the start of conditioning and emphasized oral nutrition in response to nutrition-related adverse events in patients undergoing hematopoietic stem cell transplantation (HSCT).

MATERIAL AND METHODS

Participants were patients undergoing allogeneic HSCT; 46 were in the control group (i.e., did not follow our nutritional pathway) and 36 were in the group that underwent nutritional intervention (enhanced nutrition group). We compared the following parameters between groups from the day before the start of conditioning to the day after completion of parenteral nutrition (PN): percent loss of body weight (%LBW), percent loss of skeletal muscle mass (%LSMM), and estimated basal energy expenditure (EBEE) sufficiency rate. The relationship between each parameter and %LBW was also examined. We also compared nutritional indices, gastrointestinal graft versus host disease (GvHD) grade, oral energy intake, and %LBW between groups.

RESULTS

There was a relationship between %LBW, %LSMM, and EBEE sufficiency rate in both groups. Compared with the control group, the enhanced nutrition group had significantly improved energy intake amount, EBEE sufficiency rate, PN duration, and oral energy intake over time. The enhanced nutrition group also had increased oral energy intake, no difference in gastrointestinal GvHD grade, and improved %LBW compared with the control group.

CONCLUSIONS

Use of our nutritional support pathway in patients undergoing HSCT may be beneficial for %LBW and gastrointestinal GvHD grade, enabling early enhanced nutritional intervention after HSCT.

Complications Associated with Enteral Nutrition: CAFANE Study

Objectives: To determine the association between home enteral nutrition (HEN) administration modality and its complications in patients. Methods: This is a prospective multicenter longitudinal study including 15 Spanish hospitals, from April 2015 to March 2017. A 4-month follow-up period was conducted for each patient by home visit. The study subjects were adult patients who began their nutrient intake by tube feeding, known as HEN, during the recruitment period. The variables studied included the type and modality of HEN administration and its related complications, such as vomiting, regurgitation, constipation, diarrhea, and abdominal distention. Mechanical complications and bronchoaspiration were also evaluated. Descriptive variables were used for fitting. Results: The study consisted of 306 patients; 4 were lost due to death. Specific HEN modalities protected against constipation (odds ratio (OR) = 0.4) and regurgitation (OR = 0.4). The use of a nasogastric tube (NGT) resulted in a lower risk of diarrhea compared to percutaneous endoscopic gastrostomy (PEG) (OR = 0.4) but resulted in a higher risk of tube obstruction (OR = 7.4). The use of intermittent gravity versus bolus feeding was a protection factor against vomiting (OR = 0.4), regurgitation (OR = 0.3), constipation (OR = 0.3), diarrhea (OR = 0.4) and abdominal distension (OR = 0.4). The increase in the number of doses was a risk factor for the incidence of regurgitation (OR = 1.3). Conclusions: Gastrointestinal complications were the most frequent problems, but an adequate choice of the formula, route, feeding modality, number of doses, administration time, and dose volume can reduce the risk of these complications.

SEOM clinical guidelines on nutrition in cancer patients (2018)

Nutritional deficiency is a common medical problem that affects 15-40% of cancer patients. It negatively impacts their quality of life and can compromise treatment completion. Oncological therapies, such as surgery, radiation therapy, and drug therapies are improving survival rates. However, all these treatments can play a role in the development of malnutrition and/or metabolic alterations in cancer patients, induced by the tumor or by its treatment. Nutritional assessment of cancer patients is necessary at the time of diagnosis and throughout treatment, so as to detect nutritional deficiencies. The Patient-Generated Subjective Global Assessment method is the most widely used tool that also evaluates nutritional requirements. In this guideline, we will review the indications of nutritional interventions as well as artificial nutrition in general and according to the type of treatment (radiotherapy, surgery, or systemic therapy), or palliative care. Likewise, pharmacological agents and pharmaconutrients will be reviewed in addition to the role of regular physical activity.

[Percutaneous endoscopic gastrostomy]

Percutaneous endoscopic gastrostomy (PEG) was developed in 1980. Since that time this method has become preferable for long-term enteral nutrition. PEG is an effective and relatively safe procedure for enteral nutrition of patients with impaired enteral feeding. However, complications and mortality are also observed. Indications, contraindications and potential complications of PEG are reviewed in the article.

Feeding Difficulties and Orofacial Myofunctional Disorder in Patients with Hepatic Glycogen Storage Diseases

Hepatic glycogen storage diseases (GSDs) are inborn errors of metabolism whose dietary treatment involves uncooked cornstarch administration and restriction of simple carbohydrate intake. The prevalence of feeding difficulties (FDs) and orofacial myofunctional disorders (OMDs) in these patients is unknown.

OBJECTIVE

To ascertain the prevalence of FDs and OMDs in GSD.

METHODS

This was a cross-sectional, prospective study of 36 patients (19 males; median age, 12.0 years; range, 8.0-18.7 years) with confirmed diagnoses of GSD (type Ia = 22; Ib = 8; III = 2; IXa = 3; IXc = 1). All patients were being treated by medical geneticists and dietitians. Evaluation included a questionnaire for evaluation of feeding behavior, the orofacial myofunctional evaluation (AMIOFE), olfactory and taste performance (Sniffin' Sticks and Taste Strips tests), and facial anthropometry.

RESULTS

Nine (25%) patients had decreased olfactory perception, and four (11%) had decreased taste perception for all flavours. Eight patients (22.2%) had decreased perception for sour taste. Twenty-six patients (72.2%) had FD, and 18 (50%) had OMD. OMD was significantly associated with FD, tube feeding, selective intake, preference for fluid and semisolid foods, and mealtime stress (p < 0.05). Thirteen patients (36.1%) exhibited mouth or oronasal breathing, which was significantly associated with selective intake (p = 0.011) and not eating together with the rest of the family (p = 0.041). Lower swallowing and chewing scores were associated with FD and with specific issues related to eating behavior (p < 0.05).

CONCLUSION

There is a high prevalence of FDs and OMDs in patients with GSD. Eating behavior, decreased taste and smell perception, and orofacial myofunctional issues are associated with GSD.