Nasal bridles for securing nasoenteric tubes: a meta-analysis

Clinical Outcomes of Neonatal Intensive Care Unit Graduates with Bridled Nasogastric Feeding Tubes

OBJECTIVE

 The aim of this study was to describe clinical outcomes of bridled nasogastric tube (NGT) program implementation for infants requiring assisted home feeding (AHF) to discharge from the neonatal intensive care unit (NICU).

STUDY DESIGN

 This was a descriptive prospective analysis of a pilot cohort of infants after implementation of a bridled NGT AHF program to facilitate discharge from level III and IV NICUs from March 2019 to October 2020.

RESULTS

 Of 29 attempts in infants, 22 infants were discharged with bridled NGTs over 18 months. Bridle placement was unsuccessful in three patients, and four bridles were removed before discharge. Bridle use ranged from 7 to 125 days, with a median duration of 37 days. Dislodgement rate was 0.69 per 100 days. Seventeen infants (77%) achieved full oral feeds, while five (23%) discharged with bridled NGTs later converted to gastrostomy tubes.

CONCLUSION

 Implementation of a bridled NGT program is feasible for level III and IV NICUs to facilitate discharging infants who require feeding support to transition home.

KEY POINTS

· Bridled NGT use after NICU is typically 1 month.. · Infants have low bridle NGT dislodgement.. · Most bridled NGT NICU grads attain full oral feeds..

Nutrition considerations for patients with persistent critical illness: A narrative review

Critically ill patients experience high rates of malnutrition and significant muscle loss during their intensive care unit (ICU) admission, impacting recovery. Nutrition is likely to play an important role in mitigating the development and progression of malnutrition and muscle loss observed in ICU, yet definitive clinical trials of nutrition interventions in ICU have failed to show benefit. As improvements in the quality of medical care mean that sicker patients are able to survive the initial insult, combined with an aging and increasingly comorbid population, it is anticipated that ICU length of stay will continue to increase. This review aims to discuss nutrition considerations unique to critically ill patients who have persistent critical illness, defined as an ICU stay of >10 days. A discussion of nutrition concepts relevant to patients with persistent critical illness will include energy and protein metabolism, prescription, and delivery; monitoring of nutrition at the bedside; and the role of the healthcare team in optimizing nutrition support.

Safety and effectiveness of the nasal bridle securement device to retain feeding tubes in adult patients in the intensive care unit: An observational study

BACKGROUND

Nasal bridle securement devices were introduced to our adult intensive care unit (ICU) in October 2016 as an alternative for securing small-bore feeding tubes in patients at higher risk of inadvertent tube dislodgement.

METHOD

We assessed high-risk ICU patients from October 2014 to March 2019 to address three objectives. First, we prospectively monitored ICU patients with a nasal bridle for all types of adverse events. Second, we used propensity score methods to create a (1:1) matched historical comparison group (ie, tape group). We then compared the number of inadvertent tube dislodgements and the caloric intake between the tape and nasal bridle groups.

RESULTS

In the prospective group (n = 64), there were 20 adverse events, 12 of which were inadvertent tube dislodgements. Forty-eight participants in the nasal bridle group were matched with participants in the historical group. Thirty-five percent (17/48) of patients in the tape group had at least one inadvertent tube dislodgement; in the nasal bridle group, 48% (23/48) had at least one inadvertent tube dislodgement, although this only occurred in 7 of 48 (15%) patients after the nasal bridle had been inserted. The tape group achieved a lower median percentage of total caloric intake received (66.0%) compared with that of the nasal bridle group (86.1%; P = 0.017).

CONCLUSIONS

In the subpopulation of ICU patients with a small-bore feeding tube who demonstrate a higher risk of inadvertent tube dislodgement, use of the nasal bridle may be associated with a higher caloric intake, even though it does not completely prevent tube dislodgement.

Nasal Tube Securement: Randomized Controlled Trial in Pediatric Hospitalized Patients

PURPOSE

The aim of this study was to compare accidental dislodgement rates of nasal gastric tubes secured with standard methods or a nasal tube securement device in pediatric patients.

DESIGN

A randomized controlled trial was conducted.

METHODS

Participants ( n = 43) were randomized into standard securement or nasal tube securement device using block randomization to control for age and diagnosis. Surveys were collected from staff and caregivers on device ease of use and satisfaction.

RESULTS

There were a similar number of tube dislodgements for patients in the nasal tube securement device group ( n = 6) and the standard practice group ( n = 7). The median hospital length of stay was higher for the standard practice group (13 days vs. 9 days).

CONCLUSION

Use of the nasal tube securement device did not significantly decrease the rate of tube dislodgements compared with standard practice.

CLINICAL RELEVANCE TO REHABILITATION NURSING

The study provides information for pediatric rehabilitation nurses in choosing securement options for nasal gastric tubes.

Nasogastric Bridles are Associated with Improved Tube-Related Outcomes in Children

OBJECTIVE

To compare tube-related outcomes in children with standard tape versus nasal bridle securement of nasogastric tubes (NGTs).

STUDY DESIGN

Single-center, retrospective, correlational study of outcomes from the time of NGT placement until full oral feeds or durable-tube placement. Outcomes of interest included NGT dislodgements, length of stay, emergency department (ED) encounters, radiographic exposures, and adverse skin outcomes. Negative binomial regression and logistic regression were used to analyze differences between groups.

RESULTS

582 children had NGTs secured traditionally [43% female; age at therapy initiation 2.6 months (SD 8.1)] and 173 received nasal bridles [55.5% female; age at therapy initiation 8.4 months (SD 11.8)]. Children with bridled NGTs were 16.67 times less likely to experience ≥1 dislodgement (OR=0.06, 95% CI 0.04, 0.09); 2.5 times less likely to have one more ED visit (OR=0.4, 95% CI 0.19, 0.82), and 4.76 times less likely to require one more radiographic exposure (OR=0.21, 95% CI 0.14, 0.33) than their non-bridled NGT counterparts (all p values <0.02). The mean initial hospital length of stay was 28 and 54 days in the bridled and standard care group respectively (p<0.001). Overall, 62.4% children with bridled NGTs and 77.1% children with unbridled NGTs progressed to full oral feedings and required no further therapy (p<0.001). Adverse skin outcomes were rare in both groups.

CONCLUSION

Children with bridled NGTs experienced fewer dislodgements, days in the hospital, ED encounters, and radiographic exposures than children with traditionally secured NGTs. The majority of children in both groups progressed to full oral feedings. This article is protected by copyright. All rights reserved.

Reining in Nasogastric Tubes: Implementation of a Pediatric Bridle Program

Nasogastric tubes (NG) used for enteral nutrition support of medically complex children (MCC) are often inadvertently removed, risking frequent replacements. Bridles have been shown to provide a safe securement method for NGs in adult patients, but are not widely used in pediatrics. Furthermore, nutritional management of MCC is often fragmented. We established a pediatric NG bridle program to bridge the gap amongst disciplines and improve patient outcomes. In January 2018, a multidisciplinary work group involving nurses, physicians, clinical dietitians, advanced practice providers, and speech-language pathologists was established to develop criteria for patient referral and policies, procedures, and order sets for nutritional management of MCC children with bridled NG tubes. Formal teaching sessions engaged clinicians and administrators to participate in building a successful program. Relevant outcomes of interest are tracked continuously for process performance improvement measures and are reviewed quarterly by the core work group. Patient enrollment began in May 2018 and to date, 244 patients have been enrolled. Adhering to strict enrollment criteria, competency modules and review of patient status provided a solid core for the program and process review. Successful implementation of an NG Bridle program was achieved. Outcomes of interest continue to be monitored for process improvement. Balancing measures are also being tracked for potential downstream effects.

Feeding and nutrition in children with medical complexity

Providing adequate and appropriate nutrition to children with medical complexity (CMC) is often a challenging task. These patients are a diverse group whose varying nutritional needs must be carefully assessed and monitored. Optimal feeding and nutrition strategies in CMC require an individual approach and may include oral, enteral (gastric or jejunal), or parenteral provision of nutrients. Complications of enteral feeding, including those associated with medical devices such as feeding tubes, are common, and provider familiarity with some of the more common complaints is helpful. We provide here a summary of different feeding approaches, with exploration of the rationale for each, as well as discussion of common complications and some practical troubleshooting tips.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Nasogastric/nasoenteric catheter in the adult ICU: best practices implementation project

BACKGROUND

Good-quality nursing care is usually associated with decreased risk of harms or adverse events and improved nutritional status in patients. It is important to prevent an increased risk of infection, mortality, and hospital costs in patients, along with a rework for the nursing team.

OBJECTIVE

To implement best evidence-based practices in the management of the nasogastric catheter in patients admitted to adult clinical intensive care.

METHOD

The methodology used for this study was based on that of the Joanna Briggs Institute, using the audit and feedback tools JBI Practice Application of Clinical Evidence System and Getting Research into Practice. A base audit was performed, which screened for the education of the nursing team aimed at the knowledge of the best practices, approaching the barriers related to nonadherence to the best practices and a follow-up audit.

RESULTS

The results of the base and follow-up audit showed positive variation in the percentage of adherence to the best practices proposed after the education of the nursing team. The implemented criteria that showed the greatest impact in practice (P < 0.001) were related to insertion and checking of the catheter and maintenance of the device with adequate lavage technique.

CONCLUSION

The results obtained from adherence to the best practices contributed to the enhancement of care related to catheter insertion, its maintenance, and withdrawal. Changes were made to the local care protocol, with care being taken to measure the exteriorized portion and to increase the frequency of catheter lavage. It is necessary to invest in the record in the chart of the care related to the management of the catheter to confirm the care provided and to assist in the clinical audit process. The results obtained can also be compared with the nutritional indicators.

Nasal Bridles for Securing Nasoenteric Feeding Tubes: A Review of Clinical Effectiveness and Potential Complications

Nasal bridle is a feeding tube retaining device that is now increasingly used worldwide. While common complications tend to be minor, it is important to remain vigilant for newer adverse events. We hereby delineate the case of an elderly female who required nasoenteric feeding tube following simultaneous liver-kidney transplantation. Nasal bridle placement was warranted owing to her significant frailty and poor mentation. Due to her extreme agitation during the procedure, bridle insertion could not be completed. Upon removal of the probe, unprompted detachment of the magnetic tip was noted. Radiological workup revealed the dislodged magnet in the sphenoid sinus. Subsequently, she underwent an uneventful endoscopic sinus surgery, resulting in successful retrieval of the magnet. This paper highlights the spontaneous magnet avulsion from a bridling system and serves the purpose of community awareness regarding this unusual procedural complication. Additionally, we aim to evaluate the efficacy of the nasal bridle, further accentuating its advantages and possible complications.

Efficacy of commercial nasal bridle use in reducing feeding tube dislodgements in pediatric patients following double stage laryngotracheoplasty

INTRODUCTION

Maintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements.

METHODS

Medical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements.

RESULTS

A total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group.

CONCLUSION

The commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

Endoscopic retrieval of magnetic foreign body ingestions with a nasal bridle: description of a novel technique (with video)

BACKGROUND AND AIMS

Accidental and intentional foreign body ingestions are common and frequently require endoscopic intervention. Sharp metallic objects pose a risk of perforation to the entire GI tract and are often difficult to visualize among food and other matter in the stomach.

METHODS

Three patients with histories of multiple ingestions are considered. Metallic foreign bodies can be easily removed using a nasal bridle. A snare and magnetic catheter are used as endoscopic tools to extract various metallic items.

RESULTS

The bridle technique was used in 68 endoscopies in 3 patients who presented numerous times for foreign body ingestions. The technique was successful in 66 of the 68 procedures, with no adverse events.

CONCLUSIONS

The bridle technique is an easy and effective way to remove metallic foreign bodies and has many advantages over traditional, mechanical modes of foreign body retrieval.

Observation of inadvertent tube loss in ICU: effect of nasal bridles

Background:

safe placement and securement of feeding tubes are essential to establishing early enteral nutrition. Nasogastric or nasojejunal feeding tubes are often inadvertently removed, and using a nasal bridle can reduce the number of tube replacements required.

Aim:

to review current nasal bridle practices on one intensive care unit. Over a 3-month period, nasal bridle use was recorded to measure unintentional tube loss and tube duration (the time a tube remained in situ).

Method:

an observational service evaluation.

Findings:

109 patients were recruited; 205 tubes were passed and 77 bridles were inserted, with 42% (n=46) of the bridles placed on day 1. Tubes secured with tape were more likely to be dislodged than tubes secured with a bridle, P=0.0001. Duration of tubes remaining in situ was significantly longer in patients who had a bridle fitted on day 1, P=0.0001 compared with tubes secured with tape.

Conclusion:

securing a tube with a nasal bridle from day 1 is independently associated with reduced tube loss, increased duration of tube use, and likelihood that the tube would reach redundancy when it was no longer required.

The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019

OBJECTIVES

Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety.

METHODS

A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors.

RESULTS

A total of 33 recommendations were voted on using the nominal voting technique.

CONCLUSIONS

JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.

Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach?

Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

Unplanned Removal of Medical Devices in Critical Care Units in North West England Between 2011 and 2016

BACKGROUND

The unplanned removal of medical devices poses a risk of harm to critically ill patients.

OBJECTIVE

To determine rates, causes, and consequences of unplanned medical device removal, as well as factors mitigating harm to patients, in critical care units in the United Kingdom by reviewing patient safety incident reports.

METHODS

Incidents of unplanned medical device removal in critical care units in North West England between 2011 and 2016 were retrospectively reviewed and classified. The incidents were classified by type of device displaced, staff and patient factors, causes and consequences of removal, and staff actions following removal. Displacement rates were calculated per 1000 patient days per unit.

RESULTS

A total of 34 705 incident reports were reviewed, of which 1090 described unplanned device removal. The median rate of device removal was 0.7 (interquartile range, 0.4-2.2) per 1000 patient days per unit. Devices displaced most commonly included nasogastric tubes (317), central catheters (245), tracheostomy tubes (174), and endotracheal tubes (140). A total of 11 cardiac arrests were reported (8 associated with airway devices and 3 with central catheters). Factors contributing to displacement included initial placement (188), patient factors (563), and manual handling (238). Manual handling was cited in 49% of central catheter incidents and only 9% of nasogastric tube incidents. Patients' organic confusion was a factor in 16% of endotracheal tube and 80% of nasogastric tube removals.

CONCLUSIONS

Unplanned device removal may cause patient harm and is often preventable. The causes and consequences depend on the type of device removed.

Care time and quality indicators in Intensive Care Units

OBJECTIVE

To verify the correlation between nursing care time and care quality indicators.

METHOD

Observational, correlational study, developed in 11 Intensive Care Units. The population comprised records of the number of nursing professionals, the number of patients with at least one of the Oro/Nasogastroenteral Probe (GEPRO), Endotracheal Tube (COT) and Central Venous Catheter (CVC) therapeutic devices and the occurrences related to the losses of these artifacts.

RESULTS

The time corresponded to 18.86 hours (Hospital A), 21 hours (Hospital B) and 19.50 hours (Hospital C); the Unplanned Outflow Incidence of GEPRO indicator presented a mean of 2.19/100 patients/day; Unplanned Extubation of COT Incidence, 0.42/100 patients/day; and CVC Loss Incidence, 0.22/100 patients/day. There was no statistically significant correlation between time and indicators analyzed.

CONCLUSION

This research may support methodological decisions for future investigations that seek the impact of human resources on the care quality and patient safety.

Enteral Access Devices: Types, Function, Care, and Challenges

Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient

The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.

Avulsed Nasoenteric Bridle System Magnet as an Intranasal Foreign Body

Nasoenteric tubes provide short-term nutrition support to patients unable to take an adequate oral diet. Bridling systems may be used to secure tubes to guard against displacement. We present the first case of an avulsed magnet from a bridling system to raise awareness of this potential complication. The primary methods of securing a nasogastric tube are reviewed, and comparative assessment of the 3 main systems is presented. Diagnosis and management of nasal foreign bodies relevant to this case are reviewed and prevention/safety considerations discussed.