VOL: 101, ISSUE: 35, PAGE NO: 26
Jane Williams, PhD, MSc, RGN, is consultant nurse in stroke care, East Hampshire, Fareham and Gosport PCTs
Enteral feeding is an essential form of life support for a large group of patients and has been a nutritional management option for many years. Feeding patients by a tube placed in the gastrointestinal tract began as early as 1598.
The first incident of tube feeding directly into the stomach was reported by Hunter in 1793 (Clevenger and Rodriguez, 1995). These early tubes were made of leather. The use of rubber, then the advent of various man-made materials such as polyvinyl, silicone and polyurethane have led to the production of tubes that are better tolerated and associated with fewer complications (Clevenger and Rodriguez, 1995).
Nasogastric tube placement is usually the responsibility of the nurse (Colagiovanni, 1999). The procedure is purported to be simple (Ciocon et al, 1988) and while this may be true for patients who are able to assist the passage of the tube by swallowing, in patients with dysphagia, correct placement can be much more difficult (McWey et al, 1988).
An increase in the use of nasogastric tubes in hospital and community settings has been reported in the British Artificial Nutrition Survey (Elia, 2001), with the largest single diagnostic group being reported as patients who have had strokes.
Passing the nasogastric tube can be an unpleasant experience for the patient, particularly if it induces coughing or retching. In patients who have impaired swallowing and protective reflexes the fine bore tube may be misplaced into the respiratory tract.
The procedure for checking nasogastric tubes has been the subject of a recent safety alert from the National Patient Safety Agency (2005). It is a timely reminder that the process of placing and managing nasogastric tubes requires considerable skill and competence in order to minimise the risks to the patient. This includes minimising the number of intubations each patient has to tolerate and ensuring misplacement and displacement do not occur.
Fixing the tube
Working in the field of stroke care, nurses in all settings are responsible for considerable numbers of patients in whom enteral feeding has been instigated. The results of the FOOD Trial (2005) have been published and support early nasogastric feeding yet delaying percutaneous endoscopic gastrostomy (PEG) placement until it is clear that the patient will require longer-term feeding.
Fixing nasogastric tubes in place often causes problems and particular patients who are restless or cognitively impaired may displace the tube frequently (Ciocon et al, 1988). This problem becomes more complex and ethically sensitive if the patient is not thought to be suitable for PEG placement yet requires alternative feeding. While inadvertent removal can be a particular problem with such patients it occurs widely, for various reasons, and not just with uncooperative patients.
The disadvantages of nasogastric feeding have been well documented, with the inability to ascertain correct placement, blockage and subsequent failure to complete prescribed feeding all high on the list of problems. Recurring problems create cumulative nutritional deficits.
There have been many alternatives produced for securing nasogastric tubes. Most are unsightly and involve adhesive fixing systems or, in the past, suturing. A new system has been produced, called the nasal loop, clinically presented in a small study by Anderson et al (2004).
The nasal bridle
The nasal bridle (The AMT product leaflet, 2005) is a tape that is passed internally, up and over the nasal septum by means of a placement catheter and retrieval probe. The catheter and probe are inserted into opposite nostrils and magnets situated at the tips connect the two together.
The guide wire from the catheter is removed and the tape that is attached to the catheter is pulled through until a length of tape is visible from each nostril. The catheter is cut free leaving the tape in place.
The tape and nasogastric tube are secured together (as close to the nose as possible) into a retaining clip. Once this clip is shut it cannot be opened. Excess tape is then trimmed. If the patient inadvertently pulls at the tube the resistance and sensation felt discourages the patient from pulling further.
As a consultant nurse in stroke care I am regularly involved with difficult feeding situations. I had been introduced to the nasal bridle system a few weeks earlier. My immediate impression was that it looked rather difficult to apply - especially in those patients who had experienced strokes - but that it might be a reasonable choice when it was utilised in theatre with surgical patients. I was unclear about its feasibility in my clinical practice.
However, after one particular patient was referred to me for advice (Box 1) I discussed the system with the senior nutrition nurse specialist and we agreed it was a viable option.
I met with the patient’s family and described the option of trying this new fixing system, explaining that it had not been used in the area before. They were keen to try as their mother was not receiving adequate nutrition and they felt PEG placement was too high risk at that stage.
Two people are required to pass the bridle. Our first attempt demonstrated that it was a fiddly but relatively simple procedure. We followed the manufacturer’s instructions and correctly placed the bridle first time. The patient was not distressed at any time during the procedure.
Following the placement of the bridle, nasogastric feeding then progressed straightforwardly. The patient did not make any further attempts to pull at the tube and over the next three weeks received an adequate dietary intake through the tube and overall made significant progress.
At this juncture her condition was stable but the dysphagia had not improved. PEG placement was therefore deemed appropriate and as her condition had improved, risks of the procedure had diminished. Placement was organised and undertaken successfully without complications. The patient was then accepted for transfer to an inpatient rehabilitation ward, where she continued to make gradual progress.
Implications for practice
Following this success the bridle system has been used on several other occasions in the trust. Its use has stimulated local discussion. As a new piece of equipment and a new intervention, the bridle is only being made available for placement by the nutrition nurse specialists and myself, and each use is being evaluated to gauge benefits and potential for harm.
It is clear that for some patients this method of fixation would not be appropriate. It is particularly contraindicated in those with such severe impairments, restlessness and agitation that they would continue to pull the tube, even when trauma was caused, for example possibly patients with a head injury or advanced dementia.
Like any other clinical decision, options have to be considered and made in the light of full information, discussion with families, and consultation as far as possible with patients. With increasing experience and evaluation of each use, a clearer picture will be established of the contribution of this equipment in nutritional support of enteral tube-fed patients.
This article has been double-blind peer-reviewed.
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