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

Feeding tube safety: National guidance ignores the 'elephant in the room'

BackgroundNational guidance attempts to prevent tubes remaining undetected and being used when misplaced in the respiratory tract. The 'elephant in the room' is that this guidance detects misplacement too late to prevent most pneumothoraces and pneumonias.ObjectiveReview risks of undetected and detected respiratory or oesophageal tube misplacements and how 'in-procedure' methods of determining tube position might reduce them.MethodsTube misplacement risk was compared for different methods of checking tube position. Data were obtained from UK NHS England (NHSE), a literature search between 1986 and 12/07/2024 using CINAHL, Embase, Medline and Emcare and from a local database.ResultsPost-procedure pH or X-ray checks on tube position have failed to prevent a rising incidence of undetected respiratory misplacements (NEVER events) (0.013%). Worse, current checks cannot prevent the 0.52% of placements that lead to in-procedure pneumothorax, constituting 97% of lung complications. In addition, pH may fail to prevent aspiration risk from oesophageal misplacement. Conversely, pneumothorax-risk would be reduced to 0.021% by using a supplementary mid-procedure CO2 check or to 0.005% with expert guided tube placement (both p < 0.0001). Guided tube placement can additionally pre-empt oesophageal-related complications, but its safety is expert-dependent, with higher rates of undetected misplacement and pneumothorax in low-use Cortrak centres (0.10%) than expert centres (0%, p < 0.009).ConclusionThe high health burden from feeding tube-related complications could be almost eliminated if regulatory authorities recommended a mid-procedure CO2 check for respiratory placement or expert guided tube placement, alongside mandates for the necessary training.

Mitigating intubation stress, mucosa injury, and inflammatory response in nasogastric tube intubation via suppression of the NF-κB signaling pathway by engineering a hydration lubrication coating

Nasogastric tube (NGT) intubation is a common yet critical clinical procedure. However, complications arising from tube friction result in awful pain and morbidity. Here, we report a straightforward surface modification of slender NGT utilizing highly hydrated micelles that were composed of hyaluronic acid and Pluronic. The strong intermolecular hydrogen bonding facilitated the assembly of the micelles on NGT via a one-step dip coating process. The micelle coating conferred excellent hydrophilic, lubrication, anti-protein adhesive, and biocompatible properties. The in vivo efficacy of the micelle coating in alleviating catheterization irritation and mucosal injury was demonstrated using an NGT intubation model of rabbits. More importantly, compared to the paraffin oil coating (the current clinical means), the micelle coating possessed superior capability to reduce the inflammatory reaction caused by NGT intubation. The underlying mechanism was attributed to the suppression of the TLR4-IKBα-NF-κB inflammatory signaling pathway. This work provides a promising solution for developing lubricant medical coatings.

Carbon dioxide detection for diagnosis of inadvertent respiratory tract placement of enterogastric tubes in children

BACKGROUND

The insertion of an enterogastric tube (oral or nasal) (EGT) is the passage of a tube through the nose or mouth into the stomach. In a paediatric setting, EGTs are used within clinical practice for a variety of reasons including enteral feeding, decompression, post-gastrointestinal surgery, patient assessment, and drug and fluid administration. Confirmation of EGT placement is required immediately following insertion and thereafter prior to each use, including after the administration of enteral feed or medication. Although the majority of these tubes are inserted and used without incident, there is an established risk that the tube can be misplaced into the lungs or move out of the stomach. This misplacement can result in significant harm or mortality. As such, diagnostic tests are required to assess the placement of EGTs and to rule out the target condition of potential airway placement. Various methods are used to determine EGT position, including bedside assessment and observing for signs of respiratory distress. Air insufflated (blown) through the EGT in combination with epigastric auscultation (listening to the stomach with a stethoscope) for whooshing sounds has also been used. Although these tests are widely recognised, they are not officially recommended for use as standalone measures of EGT placement. Current American and UK guidelines recommend a combination of aspirate testing and radiological confirmation of EGT placement in infant, child, and adult populations. In adults, objective measures of pH of the aspirate may be used, with a pH reading between 1 and 5.5 considered a reliable method for excluding placement in the pulmonary tree. However, testing for acidity of aspirate obtained from the EGT does not accurately differentiate between bronchial and gastric secretions in paediatric practice. Additionally, there may be difficulty in obtaining aspirate from the EGT especially within a paediatric population due to the size of the EGT and the smaller volumes of gastric secretions produced. Radiography or direct visualisation are the only reliable methods of confirming EGT placement (valid at time of X-ray and point of insertion, respectively) in this population and are thus considered the reference standard. However, within the paediatric population, there is a known difficulty with obtaining radiographs that visualise the entire course of the EGT and a recognised risk in radiation exposure in the paediatric setting. The measurement of carbon dioxide (CO₂) in exhaled air is a recognised and mandatory standard of care for confirming and monitoring endotracheal tube or airway placement under general anaesthesia. The measurement of CO₂ can be achieved in one of two ways: capnography or colorimetric capnometry. Capnography is the measurement of inspired and expired CO₂ using the absorption of infrared light by CO₂ molecules to estimate CO₂ concentrations. These measurements are then displayed against time to give a continual graphical trace. Colorimetric capnometry involves the detection of CO₂ using an adapted form of pH filter paper impregnated with a dye that changes colour from purple to yellow in the presence of CO₂; however, this method does not provide a continual reading. The monitoring of CO₂ emanating from an EGT inadvertently passed into the airways would utilise this phenomenon in a reverse manner, confirming tracheobronchial placement rather than the intended stomach.

OBJECTIVES

To determine the diagnostic accuracy of capnometry and capnography for detecting respiratory EGT placement in children compared to the reference standard.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and Medion database on 4 September 2023. There were no limits on language or publication status.

SELECTION CRITERIA

We included studies that compared the diagnostic accuracy of CO₂ detection (assessed by either capnometry or capnography) for EGT placement in the respiratory tract with the reference standard, and those that evaluated the diagnostic accuracy of CO₂ detection for differentiating between respiratory and gastrointestinal tube placement, in children. We included both prospective and retrospective cross-sectional studies. We included diagnostic case-control studies where patients acted as their own controls whereby the same EGT and end placement was tested both via index and reference test concurrently.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed methodological quality using QUADAS-2. There were no disagreements. Where data were available, we reported test accuracy as sensitivity and specificity. Calculation of both sensitivity and specificity with a 95% confidence interval (CI) was only possible for one study. We calculated specificity with a 95% CI for all included studies. Due to the low number of included studies, we were not able to perform meta-analysis or conduct our planned investigations of heterogeneity.

MAIN RESULTS

We identified three studies for inclusion in the review, all of which provided data on test accuracy of capnography or capnometry against the radiological test standard. Across the three studies, there were a total of 121 participants and 139 EGT insertions with low event data for false-positive (n = 6 insertions) and true-positive (n = 3 insertions) scenarios. No event data were available for false-negative scenarios. Overall, the body of evidence has a low risk of bias, although further clarity regarding patient enrolment (whether consecutive or random) and details about the conduct of the index and reference tests would have enhanced the overall quality of the evidence base included in the review.

AUTHORS' CONCLUSIONS

There is currently not enough evidence to suggest that CO₂ detection for inadvertent respiratory tract placement of EGTs in children should be added to current checking procedures. Future studies should aim for larger samples across a range of ages and evaluate different types of CO₂ monitoring (capnography and capnometry), using a range of EGT sizes in participants who are both spontaneously breathing or who require mechanical ventilation with or without impairments of conscious level.

Application of Gastric Tube Decompression for Rapid Tip Positioning in Bedside Blind Insertion of Nasoenteric Tubes

Objective

This study aims to examine the efficacy of gastric tube decompression in rapid tip positioning during bedside blind insertion of nasoenteric tubes.

Methods

Between August 2023 and July 2024, patients who were critically ill in the emergency intensive care unit of a tertiary hospital in Beijing who required nasoenteric tube placement were enrolled in this study. Gastric tube decompression was used to facilitate the tip positioning of nasoenteric tubes inserted blindly (without direct visualization), at the bedside. The accuracy of this method was verified by comparing the results to the "gold standard" of abdominal X-ray imaging. Consistent results indicated successful positioning. Additionally, the number of positioning attempts, time taken, and associated adverse events were recorded as outcome indicators.

Results

A total of 55 patients who were critically ill were included in the study, achieving a positioning conformity rate of 98.18% (54/55). The first-time positioning conformity rate was 94.55% (52/55). The median time for positioning attempts was 21 minutes (18, 28 minutes). The sensitivity was recorded at 100%, and no related adverse events were reported.

Conclusion

Gastric tube decompression can rapidly and accurately determine the position of the nasoenteric tube tip, providing a safe and convenient method with a high accuracy rate. This technique enhances the safety of long-term nasoenteric tube placement in patients who are critically ill and enhances the efficiency of blind nasoenteric tube insertion.

Qualitative study on the ability of neurological nurses to manage patients with indwelling gastrointestinal canal

Aim and objectives

This study aims to assess the proficiency of nurses in the neurology department in managing patients with indwelling gastrointestinal canal.

Background

Many critically ill patients in neurology departments require the placement of nasoenteric tubes to provide enteral nutrition. However, in clinical practice, there exists considerable variability in nurses' competencies regarding the management of patients with nasoenteric tubes. A thorough understanding of the challenges nurses face throughout the entire process of nasoenteric tube care and the development of targeted improvement measures are crucial for delivering enhanced patient care and facilitating patient recovery.

Design

A qualitative interview study.

Methods

From August to October 2023, 11 neurological nurses were recruited offline in three hospitals for semi-structured and in-depth interviews. The data analysis uses the KJ method to summarize and classify the themes from the semi-structured interview results, and then organize the themes into a coherent visual and logical path. The COREQ list is used.

Results

The researchers conducted semi-structured interviews with 11 neurology nurses from three hospitals using a purposive sampling method, of which 64% of the participants were female and 36% were male; the average age was 38.27 ± 7.85 years; 27% from the Department of Neurology, 73% from the Department of Neurosurgery; junior professional titles accounted for 18%, intermediate professional titles accounted for 64%, senior professional titles accounted for 18%; 27% of the subjects were head nurses and 73% were nurses. The study identified 5 themes: (1) Preparation and evaluation before intubation; (2) Enhancement of intubation success rates; (3) Prevention of complications; (4) Management of complications and emergencies; (5) The acquisition of relevant knowledge and experience. In clinical practice, the bedside blind insertion technique is random and has not yet formed a unified standard, and the specific operation details and techniques need to be further improved.

Conclusion

Disparities exist in the nursing capabilities of neurology nurses due to variations in their knowledge and experience regarding gastrointestinal canal management.

An improved biologically transparent illumination system that increases the accuracy of detecting the correct position of a nasogastric tube in the stomach

The aim of this study was to determine whether an improved biologically transparent illumination system results in more reliable detection of the correct position of the nasogastric tube in surgical patients. In total, 102 patients undergoing general surgery were included in this prospective observational study. After general anesthesia, all patients were inserted a nasogastric tube equipped with an improved biologically transparent illumination catheter. Identification of biologically transparent light in the epigastric area indicated successful insertion of the nasogastric tube into the stomach. The position of the tube was confirmed by X-ray examination, and its findings were compared with those of the biologically transparent illumination system. We observed biologically transparent light in epigastric area in 87 of the 102 patients. X-ray examination revealed that the nasogastric tube was placed in the stomach in all of these 87 patients. Light was not observed in the remaining 15 patients; the tube position was confirmed in the stomach in 11 of these patients but not in the other 4 by X-ray examination. Illumination had a sensitivity of 88.8% and a specificity of 100%. Our results suggest that this improved biologically transparent illumination system increased the accuracy of detecting the correct position of a nasogastric tube in the stomach. X-ray examination is required to check the position of the nasogastric tube in patients when biologically transparent illumination light is negative.

Validation of image interpretation for direct vision-guided feeding tube placement

BACKGROUND

Unguided (blind) tube placement commonly results in lung (1.6%) and oesophageal (5%) misplacement, which can lead to pneumothorax, aspiration pneumonia, death, feeding delays, and increased cost. Use of real-time direct vision may reduce risk. We validated the accuracy of a guide to train new operators in the use of direct vision-guided tube placement.

METHODS

Using direct vision, operators matched anatomy viewed to anatomical markers in a preliminary operator guide. We examined how accurately the guide predicted tube position, specifically whether respiratory and gastrointestinal placement could be differentiated.

RESULTS

A total of 100 patients each had one tube placement. Placement was aborted in 6% because of inability to enter or move beyond the oesophagus. In 15 of 20 placements in which the glottic opening was identified, the tube was maneuvered to avoid entry into the respiratory tract. Of 96 tubes that reached the oesophagus, 17 had entered the trachea; all were withdrawn pre-carina. One or more specific characteristics identified each organ, differentiating the trachea-oesophagus (P < 0.0001), oesophagus-stomach, and stomach-intestine in 100%. End-of-procedure tube position was ascertained by pH ≤4.0 (gastric) of aspirated fluid and/or x-ray (gastric or intestinal). In patients with a trauma risk (13%), it was avoided by identification that the tube remained within the nasal, oesophageal, or gastric lumen.

CONCLUSION

Operators successfully matched anatomy seen by direct vision to images and descriptions of anatomy in the "operator guide." This validated that the operator guide accurately facilitates interpretation of tube position and enabled avoidance of lung trauma and oesophageal misplacement.

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.