Methods for decreasing risk of aspiration pneumonia in critically ill patients

Oesophageal perforation by migrated Ryles tube

A 72-year woman with a history of multiple cerebrovascular accidents presented with severe epigastric pain. An oesophageal perforation by the tip of a Ryles tube, which had migrated into the mediastinum, was diagnosed by radiography. An attempt at pushing the nasogastric tube into the stomach resulted in increasing the rupture to about 6 cm in size. Replacement by a triple-lumen nasojejunal feeding tube and subsequent feeding with c.1,400 calories per day enabled the perforation to close without further intervention.

Effect of parenteral nutrition in oxygen escalation/de-escalation in SARS-CoV-2 infected patients who are pre-intubation: A multicenter, observational study

Background & aims

SARS-CoV-2 infection includes a variety of gastrointestinal manifestations along with the usual viral symptoms of malaise and myalgias. The objective of this study was to determine if intravenous parenteral nutrition (PN) affected the risk of intubation in SARS-CoV-2 patients who were dependent on non-invasive ventilation.

Methods

Retrospective, multicenter case-control study which analyzed oxygen requirements for 1974 adults with SARS-CoV-2, who were admitted to the local public hospital system between March 1 and May 17, 2020. Relevant baseline biomarkers were studied over 5 days. The main outcome was an escalation or de-escalation of oxygen requirements relative to the exposure of PN.

Results

111 patients received PN while on non-invasive ventilation. Patients who received PN had a significantly lower odds (p < 0.001) of oxygen escalation in comparison to their control group counterparts (OR = 0.804, 95% CI 0.720, 0.899) when matched for age, body mass index, Charlson comorbidity index, and gender.

Conclusion

Initiating PN in the setting of non-invasive ventilation of SARS-CoV-2 infected patients was significantly associated with a lower odds of oxygen escalation. PN does not independently exacerbate oxygen requirements in SARS-CoV-2 infected pre-intubated patients.

Risk Assessment of Intermittent and Continuous Nasogastric Enteral Feeding Methods in Adult Inpatients: A Meta-Analysis

Diarrhea and pneumonia are common and serious complications in hospitalized patients requiring nasogastric enteral feeding. Our study aimed to compare the risk of diarrhea and pneumonia between intermittent nasogastric enteral feeding (IEF) and continuous nasogastric enteral feeding (CEF). We systematically searched PubMed, Web of Science, and Cochrane for relevant articles published from August 9, 1992, to September 1, 2019. A total of 637 IEF and CEF patients were included in our meta-analysis. Odds ratios (ORs) with associated 95% confidence intervals (CIs) were calculated to estimate the effects of diarrhea and pneumonia. We showed that hospital patients that required IEF had an increased risk of diarrhea compared with CEF. In the subgroup analyses, similar conclusions were identified in the non-China group and small sample size group (size < 100). However, our results showed no significant differences in the China group or large sample size group (size ≥ 100). Furthermore, our analysis showed that no significant association was observed for the risk of pneumonia between IEF and CEF patients. For inpatients requiring nasogastric enteral feeding, CEF is a better method of enteral nutrition compared with IEF, of which patients experience a significantly increased risk of diarrhea.

Devising negative pressure within intercuff space reduces microaspiration

Background

Microaspiration past the tracheal tube cuffs causes ventilator-associated pneumonia. The objective of the current study was to evaluate whether creating negative pressure between the tracheal double cuffs could block the fluid passage past the tracheal tube cuffs.

Methods

A new negative pressure system was devised between the double cuffs through a suction hole in the intercuff space. Blue-dyed water was instilled above the cuff at negative suction pressures of − 54, − 68, − 82, − 95, − 109, − 122, and − 136 cmH₂O, and the volume leaked was measured in an underlying water trap after 10 min. Leakage tests were also performed during positive pressure ventilation, and using higher-viscosity materials. The actual negative pressures delivered at the hole of double cuffs were obtained by placing microcatheter tip between the intercuff space and the artificial trachea.

Results

No leakage occurred past the double cuff at − 136 cmH₂O suction pressure at all tracheal tube cuff pressures. The volume leaked decreased significantly as suction pressure increased. When connected to a mechanical ventilator, no leakage was found at − 54 cmH₂suction pressure. Volume of the higher-viscosity materials (dynamic viscosity of 63–108 cP <cP> and 370–430 cP) leaked was small compared to that of normal saline (0.9–1.1 cP). The pressures measured in the intercuff space corresponded to 3.8–5.9% of those applied.

Conclusions

A new prototype double cuff with negative pressure in the intercuff space completely prevented water leakage. The negative pressure transmitted to the tracheal inner wall was a small percentage of that applied.

Feeding young infants with their head in upright position reduces respiratory and ear morbidity

The influence of feeding position of the infant in the pathogenesis of ear and airway diseases has not been well established. We investigated the influence of instructing mothers to feed their 3-month old infants with their head in an upright position on ear and respiratory morbidity during a one-year follow-up. Mothers of 88 infants were instructed by trained nurses to feed their infants with their head in upright position (intervention group). The control group consisted of 75 mothers of infants of similar socioeconomic background who fed their infants without special instructions. Both groups were followed at Maternal-Child-Health clinics. Feeding position was evaluated at the beginning and the end of the twelve-month study, and parent reported morbidity data of both groups were evaluated at every 3-month's follow-up meeting. Infants from the intervention group were fed at a more upright head position. Parameters of parent reported morbidity evaluated as area under the curve were significantly lower in infants from the intervention group concerning ear diseases, respiratory diseases, prolonged fever episodes, need of bronchodilator inhalations and antibiotic courses compared to the control group. Instructing mothers to feed infants with their head in upright position was accompanied with less morbidity and treatment burden.

Quality of Life in Adult Home Parenteral Nutrition Patients

BACKGROUND

Home parenteral nutrition (HPN) is life-sustaining therapy in some disease states. Patients, however, report alterations in physical, psychologic, and social function that negatively affect perceived quality of life (QOL). Many generic tools have been used to evaluate QOL during HPN, but there is no gold standard measurement. QOL improvement can only result from identifying and addressing patient-specific problems. The purpose of this study was to identify the tools used by others to measure QOL in adults receiving long-term HPN and to identify factors that affect QOL in this population.

METHODS

An electronic search of CINAHL, MEDLINE, and Health and Psychosocial Instruments databases was conducted to identify studies of HPN and QOL in adults.

RESULTS

Thirty-four publications on HPN and QOL were identified. Twenty-four studies of HPN and QOL were included in this review; 10 papers were review articles or editorials. QOL was worse in HPN patients compared with healthy populations. Impaired QOL was associated with decreased physical, psychologic, and social function. Depression, drug dependency, sleep disturbance, frequent urination, fear of therapy-related complications, and inability to eat negatively affected QOL.

CONCLUSIONS

Use of different QOL instruments, scales, and lifestyle domains limited comparison among studies. QOL is poor in patients receiving HPN and worse in the presence of depression and narcotic dependency. The technical aspects of HPN administration interfere with routine activities. It is difficult to determine whether HPN itself or the impact of the disease affected QOL. Development of an HPN-specific QOL tool may help in this differentiation.

A case of a ‘lost’ nasogastric tube

Objectives:

To present the case of a ‘lost’ nasogastric tube and to highlight the importance of imaging and/or chest X-ray after nasogastric tube insertion, especially in unreliable patients.

Case report:

A 50-year-old man, undergoing radiotherapy treatment for squamous cell carcinoma of the tongue base, was admitted for pain control and nasogastric tube feeding. This patient required multiple nasogastric tubes over a two-week period. The patient repeatedly denied pulling the nasogastric tube out and we were unable to establish the exact mode of nasogastric tube removal. On one such occasion another tube was inserted and a check X-ray showed two feeding tubes; the latest one was lying in the left main bronchus and the old nasogastric tube was observed in the oesophagus, with its upper end jutting above the hypopharynx. It was apparent that the patient had somehow cut the tube and swallowed it.

Conclusion:

This case not only illustrates the importance of flexible nasendoscopy and/or chest X-ray for checking the position of the nasogastric tube, but also highlights that some patients are not tolerant of nasogastric tubes. The use of nasogastric tubes should be avoided in these patients to prevent any self-inflicted injury.

Nasoenteric Tube Complications

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NETET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.

Can continuous pump feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled trial

BACKGROUND & AIMS

Continuous pump feeding is often used to reduce aspiration risk in older patients on tube feeding, but its effectiveness in preventing aspiration pneumonia is unproven. A randomized controlled trial was therefore performed to examine the effectiveness of continuous pump feeding in decreasing the incidence of pneumonia in tube-fed older hospital patients.

METHODS

One hundred and seventy eight elderly patients from three convalescence hospitals and one infirmary, on nasogastric tube feeding, were randomly assigned to have intermittent bolus (bolus) or continuous pump (pump) feeding for 4weeks. The primary outcome was the incidence of pneumonia. The secondary outcome was mortality.

RESULTS

Eighty five subjects were randomized into the pump group and 93 in the bolus group. The groups were comparable in age, nutritional and functional status, co-morbidities and history of pneumonia, except that there were more women in the pump group. Within 4weeks, 15 subjects (17.6%) in the pump group and 18 (19.4%) in the bolus group developed pneumonia. Seven subjects (8.2%) in pump group and 13 subjects (14.0%) in bolus group died. There was no significant difference in either pneumonia or death rates between the two groups.

CONCLUSION

Continuous pump feeding did not significantly affect the rates of pneumonia or mortality in tube-fed older hospital patients when compared with intermittent bolus feeding.

Clinical skills: assessing and treating shock: a nursing perspective

This article outlines the pathophysiology associated with hypovolaemic, cardiogenic and distributive shock, and discusses how each of these might present clinically in the patient. Nursing assessment of a patient in shock is explored, and the use of tools such as the pulse oximeter is examined. The evidence base for a variety of interprofessional interventions is analysed, including fluid therapies such as blood transfusion, the use of crystalloids and colloids, and drug therapies such as the use of inotropic and vasoactive agents. The nursing role in managing the patient in shock is considered throughout. The importance of recognizing the clinical presentation of shock is highlighted, with an emphasis on understanding the pathophysiology and potential systemic effects. Treatment is discussed and covers: providing optimal oxygen therapy, appropriate patient monitoring and location of care, using effective communication skills, assisting with activities of living, psychological support, and working collaboratively to maximize the overall quality of patient care delivered.