Ultrasonography-guided post-pyloric feeding tube insertion in medical intensive care unit patients

A multifaceted comparative analysis of image and video technologies in gastrointestinal endoscope and their clinical applications

This paper presents a comprehensive exploration of endoscopic technologies in clinical applications across seven tables, each focusing on a unique facet of the medical field. The discourse begins with a detailed analysis of pediatric endoscopes, highlighting their diagnostic capabilities in various conditions. It then delves into the specifications and applications of globally recognized capsule endoscopy devices. Additionally, the paper incorporates an analysis of advanced imaging techniques, such as Narrow Band Imaging (NBI), Flexible Spectral Imaging Color Enhancement (FICE), and i-scan, which are increasingly being integrated into ultrathin gastrointestinal (GI) endoscopes. Factors like technological capabilities, light source, camera technology, and computational constraints are evaluated to understand their compatibility with these advanced imaging techniques, each offering unique advantages and challenges in clinical settings. NBI, for instance, is lauded for its user-friendly, real-time enhanced imaging capabilities, making it effective for early detection of conditions like colorectal cancer and Barrett's esophagus. Conversely, FICE and i-scan offer high customizability and are compatible with a broader range of endoscope models. The paper further delves into innovative advances in movement control for Nasojejunal (NJ) feeding tube endoscopy, elucidating the potential of AI and other novel strategies. A review of the technologies and methodologies enhancing endoscopic procedure control and diagnostic precision follows, emphasizing image and video technologies in pediatric endoscopy, capsule endoscopes, ultrathin endoscopes, and their clinical applications. Finally, a comparative analysis of leading real-time video monitoring endoscopes in clinical practices underscores the continuous advancements in the field of endoscopy, ensuring improved diagnostics and precision in surgical procedures. Collectively, the comparative analysis presented in this paper highlights the remarkable diversity and continuous evolution of endoscopic technologies, underlining their crucial role in diagnosing and treating an array of medical conditions, thereby fostering advancements in patient care and clinical outcomes.

Nasogastric tube insertion length measurement and tip verification in adults: a narrative review

Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.

Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk

Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods. During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres. Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak's package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.

Stomach position evaluated using computed tomography is related to successful post-pyloric enteral feeding tube placement in critically ill patients: a retrospective observational study

BACKGROUND

Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement.

METHODS

Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion.

RESULTS

Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91).

CONCLUSIONS

Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.

A Two-Stage Bedside Intubation Method to Improve Success Rate of Post-pyloric Placement of Spiral Nasoenteric Tubes in Critically Ill Patients: A Multi-Center, Prospective Study

Backgrounds

Prokinetic agents could improve the success rate of post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs), and bedside blind technique might apply as a rescue therapy subsequent to spontaneous transpyloric migration failure. The objective of this study was to investigated the validity and safety of these two bedside intubation methods as a sequential procedure for post-pyloric placement of spiral NETs in critically ill patients.

Methods

The multicenter, prospective study was conducted in intensive care units of four tertiary hospitals (June 2020 to January 2021). Eligible patients received self-propelled spiral NET placements, promoted by prokinetic agents (Stage 1). An abdominal X-ray performed 24 h post-intubation confirmed the position of the tube tip. Patients with a failed transpyloric migration entered Stage 2, where beside blind intubation was conducted (reconfirmed by X-ray). The primary end point was the overall success rate of post-pyloric placement.

Results

The overall success rate of post-pyloric placement of the spiral NET was 91.1% (73.4% in the third portion of the duodenum [D3] or beyond). The total adverse event rate was 21.0%, without any serious adverse events. In Stage 1, 55.6% of participants achieved transpyloric migration, of these, 44.4% migrated to D3 or beyond. The median time from decision to intubate to the initiation of enteral nutrition (EN) was 25 h. In Stage 2, 83.0% of patients had successful post-pyloric intubation (67.9% in D3 or beyond). The median time from decision to EN initiation after the two-stage process was 36 h.

Conclusions

Prokinetic agents-assisted self-propelled intubation and remedial bedside blind technique as a sequential procedure for post-pyloric placement of spiral NETs were effective and safe, and this two-stage process did not affect the implementation of early EN in critically ill patients.

Trial Registration

Chinese Clinical Trial Registry, ChiCTR1900026381. Registered on 6 October 2019.

Integrated real-time imaging system, 'IRIS', Kangaroo feeding tube: a guide to placement and image interpretation

Background

Lung complications occur in 0.5% of the millions of blind tube placements. This represents a major health burden. Use of a Kangaroo feeding tubes with an ‘integrated real-time imaging system’ (‘IRIS’ tube) may pre-empt such complications. We aimed to produce a preliminary operator guide to IRIS tube placement and interpretation of position.

Methods

In a single centre, IRIS tubes were prospectively placed in intensive care unit patients. Characteristics of tube placement and visualised anatomy were recorded in each organ to produce a guide.

Results

Of 45 patients having one tube placement, 3 were aborted due to refusal (n=1) or inability to enter the oesophagus (n=2). Of 43 tubes placed beyond 30 cm, 12 (28%) initially entered the respiratory tract but all were withdrawn before reaching the main carina. We identified anatomical markers for the nasal or oral cavity (97.8%), respiratory tract (100%), oesophagus (97.6%), stomach (100%) and intestine (100%). Organ differentiation was possible in 100%: trachea-oesophagus, oesophagus-stomach and stomach-intestine. Gastric tube position was confirmed by aspiration of fluid with a pH <4.0 and/ or X-ray. Trauma was avoided in 13.6% by identifying that the tube remained in the nasal lumen in the presence of a base of skull fracture (n=3) and in the stomach in the presence of recently bleeding polyps or mucosa (n=3). A systematic guide was produced from records of tube placement and interpretation of anatomical images.

Conclusion

By permitting real-time confirmation of tube position, direct vision may reduce risk of lung complications. The preliminary operator guide requires validation in larger studies.