Everyone needs food for survival, but sometimes due to illness a person is unable to eat normally. This can be due to difficulty swallowing, reduced appetite or due to surgery that interferes with the eating process. Enteral tube feeding should be used in such cases. For this treatment, a special food mixture is used that contains carbohydrates, proteins, fat, minerals and vitamins. This food is given through a tube and delivered into the stomach or small bowel. The feeding tube can be used in people of all ages. Infants, adults, and children may receive this feeding tube. As long as it is needed this feeding tube can be used. If the person is able to eat normally again, the tube feeding is stopped and in such cases the tube feeding is used short-term.
If a patient finds it difficult to eat and the GI tract is functioning, this natural means of feeding is used. For instance, a patient who had a stroke has difficulty swallowing, over a period of time the swallowing will become normal. In other cases there is a chance that the food mixture will be swallowed into the lungs leading to complications. In such cases, tube feeding inserted through the nose will be used. The tube can also be inserted through a puncture made in the stomach.
A study has shown that common nursing practices associated with enteral feeding may lead to underfeeding.
Types of enteral feeding
To recover from any illness adequate nutrition is needed by patients. The nutritional requirement is high in patients who are critically ill and if not received, they can become malnourished. Research findings have shown that for patient outcome, early feeding is very important. A daily review of the patients nutritional needs should be done as soon as tube feeding has started. Usually, feeding through the gastrointestinal tract is the best way. Patients are fed through a feeding tube since they are unable to swallow food because of the breathing tube. To help the patient recover, a specially designed solution is provided which will contain most of the nutrients. Most of the feeding tubes are first inserted into the nose and then further advanced into the stomach. These are given as steady infusion by first mixing them in a sterile bag and this is fed for 24 hours per day. To deliver the mixture a pump is used which is similar to an intravenous pump.
The gastrointestinal tract may not work properly if a person is critically ill. The food may regurgitate into the lungs leading to aspiration which is a serious complication. Also, the patient’s nutritional needs will not be met if the food enters into the bowel. The risk of aspiration is reduced when in the small bowel feeding tubes are inserted. When through the nose or through the mouth the feeding tube is inserted and manipulated in such a way that from the stomach and into the bowel the mixture is encouraged to pass.
Through a small puncture made in the abdominal wall the feeding tube can be inserted in case the tube does not advance into the small bowel. This type of tube is known as a percutaneous feeding tube. Gastric tubes are those that are used in the stomach. The contents are emptied towards the right side and then into the small bowel. A duodenal tube is the one that ends in the duodenum. A jejuna tube is the one that ends into the jejunum. A nasal tube is inserted through the nose. A nasogastric tube is the one that is inserted through the nose into the stomach. Oral tubes are those that are inserted through the mouth. Through the mouth if the stomach tube is inserted then it is known as orogastric tube. Through the mouth the tube is inserted and it ends into the jejunum then it is known as orojejunal tube. If through a puncture a tube is inserted and it ends in the stomach then it is known as gastrostomy. If it ends in jejunum then it is known as jejunostomy.
To drain the stomach contents, larger tubes are inserted into the stomach, this is known as gastric drainage. By doing this vomiting associated with aspiration can be prevented and comfort can be provided to the patient. To help keep the stomach empty this drainage can be connected to low suction. By using the gastric tube, the stomach can be kept empty while the food can be delivered below the stomach by using a small bowel feeding tube.
Endoscopic procedures have been used to insert the enteral feeding tube in patients who previously needed open procedures.
- Nasoenteric feeding tube - when the level of nutritional support expected is short-term or when more intrusive procedure becomes inadvisable due to the physical condition of the patient then these tubes are used. The tube is made to reach the stomach by inserting it through nasal cavity and then down the back of the throat and oesophagus. This kind of enteral feeding is also known as nasogastric feeding. If instead of the stomach the tube is advanced into the jejunum, then it is known as naso-jejuna tube. Before administering water, food or any drugs through the tube, first the position of the tube is checked. Since there is a potential that the internal end of the tube may get displaced. Gastric positioning is indicated when the pH is less than 5.5 and the position of the tube is in the small bowel if the pH is between 6-8. By various methods the food can be administered:
- Bolus - several times a day through syringe the food is administered for a period of 15-20 minutes.
- Intermittent gravity drip - several times a day a set volume is administered for a period of 30-60 minutes.
- Continuous - by using an enteral feeding pump a solution is administered for a period of 8-24 hours at a prescribed rate.
Compared to the NG feeders the flow rate of the food mixture is lower in the case of the continuous feeders.
- Gastrostomy feeding - when enteral feeding has occurred for more than eight weeks and the tube can be inserted into the patient, then enterostomy tubes are used. Sometimes this method is known as a button gastrostomy or percutaneous endoscopic gastrostomy. Through various methods the food can be administered such as bolus, intermittent gravity drip or continuous. If using radiological methods, if the tube is inserted, then it is known as a radiologically inserted gastrostomy.
- Jejunostomy feeding - the tube is advanced into the jejunum.
- Gastrostomy with jejuna adapter - by replacing the existing gastrostomy with a transgastric jejuna feeding tube, this method can be adopted. There is no need of doing a second surgical procedure or performing a jejunostomy. Through the abdominal wall into the stomach, the tube enters into the stomach wall, and is held by a fixation device. The tube is advanced into the jejunum. This is also known as a percutaneous endoscopic gastrostomy. This type can be administered by bolus, intermittent gravity drip or continuous.
Enteral feeding is not always tolerated by the patient, the patient may need to be fed through a special intravenous formula. This is known as total parenteral nutrition.
Enteral versus parenteral feeding
The normal way of eating encompasses enteral feeding. With this method, the food is delivered through the digestive tract. This system relies on the mouth, esophagus, stomach and the intestine. Enteral nutrition is what we do daily which is feeding through the mouth. Another option for enteral feeding is parenteral feeding, which is delivering the nutrients through a vein. When nutrition or food is delivered without involving the digestive system, then it is parenteral nutrition.
What is enteral and parenteral feeding?
The method of consuming food through the gastrointestinal tract is known as enteral nutrition. By using a feeding tube, a normal diet can be provided or through liquid supplements. The delivery of calories and nutrients into a vein is known as parenteral feeding. This is an intravenous solution with simple sugar or carbohydrates calories or all nutrients such as electrolytes, protein or fat. Conditions such as bowel obstruction, Crohn's disease, short bowel syndrome, ulcerative colitis or other GI disorders call for the use of enteral and parenteral feeding. Even though enteral feeding is always preferred, in some patients due to medical issues, it may not be safe to use the GI tract. The current level of functioning of the gastrointestinal tract may not help to meet their nutritional requirements. In such cases, the person can remain healthy, and maintain their well-being through nutrients provided by parenteral feeding.
There are some complications associated with enteral feeding, such as constipation, food may enter the lungs, diarrhea, absorption of nutrients may be improper, vomiting, nausea, abnormalities of electrolyte, dehydration, vitamin deficiency, mineral deficiency, high blood sugar, and liver proteins may decrease. There are complications associated with nasoenteral tubes too, such as acute sinus infection, irritation of the throat or nose, and larynx or oesophagus may get ulcerated. Complications similarly exist with a gastrostomy as well as a jejunostomy. Clogging can take place in the feeding tubes that are inserted through the skin of abdominal wall or they may get displaced or the wound may get infected. When it comes to long-term enteral feeding, one should reduce complications by practicing preventive measures.
In case of parenteral feeding infection, clogging and breakage are the most common complications associated with catheter placement. Irrespective of types of catheter it is recommended to follow a strict infection control protocol such as aseptic site and hand washing, for redness or inflammation the catheter site appearance is monitored. By flushing the catheter one can prevent aspiration of blood sample, catheter occlusion and inability to infuse solution. One should replace the catheter or repair it when it is cracked, leaked or broken. Between the exit site and the break, the catheter is clamped so that air or blood does not enter or leak. Another potential complication is thrombosis.
Can it be done at home?
One can do enteral nutrition at home. The provider or dietitian will prescribe how the formula should be given for food, what should be the strength, how to deliver and how quickly to eat. Gravity controlled and pump assisted methods are two delivery methods. According to one study, when enteral feeding is done at home, there are many added advantages.
To successfully manage parenteral feeding at home, a team of clinicians are required. As a short-term therapy or long-term therapy parenteral feeding can be done at home. Education on how to use the parenteral feeding will be provided on how to operate the infusion pump, how to take care of catheter, how to set up the device and maintain the intake and output records, how to disconnect the procedure, review any metabolic complications, and keep contact numbers if any problem arises. To provide continuous care the team in the hospital and at home if required will decide on readmission. When parenteral feeding is done at home, cost is less but about the efficiency more studies needs to be done.
According to studies, enteral feeding is considered to be much safer than parenteral feeding.