A variety of access routes into the gastrointestinal tract and a range of feeding tube types are used for enteral feeding. This article is a practical guide and comes with a self-assessment enabling you to test your knowledge after reading it
Enteral tube feeding is provided in hospitals, patients’ homes and care homes. As there are a variety of feeding tubes available, nurses need to be aware of the different types of tube and how to look after them. This article offers a practical guide to the most commonly used enteral feeding tubes.
Citation: Best C (2019) Selection and management of commonly used enteral feeding tubes. Nursing Times [online]; 115: 3, 43-47.
Author: Carolyn Best is nutrition nurse specialist, Royal Hampshire County Hospital, Winchester.
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Do you know the difference between an NGT, PEG tube and BGT? Which type of tube is used for short-term enteral feeding? Long-term enteral feeding? Gastric feeding? Post-pyloric feeding? How are the different tubes held in place? How are they cared for? This article provides a practical guide to those that are most commonly used, both in hospital and in the community.
Enteral tube feeding is the administration of feed and/or fluid via a tube going into the gastrointestinal tract (parenteral nutrition uses the venous route). This feeding tube can also be used:
- To administer medication;
- For gastric aspiration;
- For gastric decompression.
If enteral tube feeding is likely to be needed only for a short time (less than four weeks), a feeding tube is usually inserted into the stomach through the nose (nasogastric tube, Fig 1); for longer periods gastrostomy feeding should to be considered (National Institute for Health and Care Excellence, 2006).
Serious complications after gastrostomy tube insertion are uncommon. However, in 2010, the National Patient Safety Agency (NPSA) issued a rapid response report following several patient deaths that occurred after gastrostomy insertion (Box 1).
Box 1. Complications after gastrostomy insertion
Between October 2003 and January 2010, the National Patient Safety Agency received 11 reports of deaths and 11 of severe harm describing delay in recognising and acting on signs of complications in the 72 hours after gastrostomy insertion. Pain on feeding and external leakage of gastric contents had not been recognised as ‘red-flag’ signs of peritoneal leakage of feed.
In a rapid response report, the agency asked all NHS organisations inserting gastrostomies to “mark patients notes with a high-visibility warning that if there is pain on feeding, prolonged or severe pain post procedure, or fresh bleeding, or external leakage of gastric contents”, staff need to:
- Stop feed/medication delivery immediately
- Obtain senior advice urgently
- Consider computed tomography scan, contrast study or surgical review
If enteral feed or medication cannot be administered into the stomach (for example, if there is delayed gastric emptying or pyloric obstruction), there is the option of post-pyloric feeding. In this procedure, enteral feed is administered into the small intestine – usually into the jejunum, more rarely into the duodenum. For short-term post-pyloric feeding, the nasal route can be used; for long-term post-pyloric feeding, a jejunostomy (surgical opening from the skin into the jejunum) may be considered. Alternatively, an existing gastrostomy can be used to insert a longer tube into the small intestine.
Gastrostomies and jejunostomies can be created, and their related tubes inserted:
- Endoscopically (using an endoscope);
- Radiologically (under X-ray guidance);
- Surgically under direct vision (open or laparoscopic).
Fig 2 shows access points and routes for enteral nutrition.
Source: Peter Lamb
Short-term gastric feeding
A nasogastric tube (NGT) is passed through the nostril along the nasopharynx and oesophagus into the stomach. Depending on the type (Table 1), NGTs are used for: gastric aspiration; gastric decompression; or administering enteral feed, fluid or medication. NGTs used for enteral feeding should be 6-12Fg (National Nurses Nutrition Group, 2016a). The smaller the gauge the higher the risk of blockage, while tubes over 12Fg are more likely to cause discomfort.
The NGT is secured externally at the nose or cheek by adhesive tape or a fixation device. The area should be checked daily for signs of pressure damage and to ensure the fixture device is intact (NICE, 2006).
Tube position should be checked in all patients:
- After insertion;
- At least once a day;
- After episodes of vomiting, retching or coughing;
- Whenever displacement is suspected;
- In the presence of any new and/or unexplained respiratory symptoms or reduction in oxygen saturation.
The NGT position should be checked using one of the following methods:
- Obtain, via the NGT, aspirate with a pH of ≤5.5 (NHS Improvement 2016; NPSA, 2005). The pH needs to be determined using pH indicator paper that is CE-marked for use with human aspirate (NHS Improvement 2016; NPSA, 2011);
- Inspect the tube on X-ray, using the four criteria outlined in Box 2.
Older methods of checking NGT position, such as observation of aspirate and auscultation, are now banned (NPSA, 2005).
Box 2. Checking position of naso- or orogastric tube on X-ray
One of the two recommended methods of checking the position of a nasogastric tube is to look at it on X-ray and check the following:
- Does the tube follow the path of the oesophagus and/or avoid the contours of the bronchi?
- Does it clearly bisect the carina of the bronchi?
- Does it cross the diaphragm in the midline?
- Is its tip clearly visible below the left hemi-diaphragm?
If the answer is “yes” to all four criteria, the tube is correctly positioned
An orogastric tube is passed through the mouth, throat and oesophagus, into the stomach. It is an alternative to an NGT when using the nasogastric route is not possible. Orogastric tubes are used primarily in neonates; they are usually avoided in all other patients due to the risk of being bitten or displaced by the tongue (NHS Improvement, 2016). Their position needs to be checked using the same methods as for NGTs.
Long-term gastric feeding
Percutaneous endoscopic gastrostomy
A percutaneous endoscopic gastrostomy (PEG) is created under endoscopic guidance. A PEG tube (Fig 3) is the long-term enteral gastric feeding tube of choice for patients with an uncompromised airway but accessible gastric region, who are able to undergo an endoscopic procedure. It can be used for administering enteral feed, fluid or medication, starting four hours after placement (NICE, 2006).
Daily care of a PEG tube consists of:
- Cleaning the stoma site (Box 3);
- Monitoring for signs of inflammation, infection, over-granulation and gastric leakage (NICE, 2006);
- Recording centimetre markers on the tube to ensure it is not migrating into the stomach (NICE, 2006); if markers fade with time it may be necessary to mark the tube with a pen;
- Flushing the tube once a day to keep it patent if it is not being used (Box 4).
A PEG tube also needs to be ‘advanced and rotated’ (Box 5) at least once a week (NICE, 2006), and up to once a day to reduce the risk of ‘buried bumper’. This happens when the piece securing the tube in the stomach (the bumper) becomes embedded in gastric mucosa once the gastrostomy tract has fully developed. The first advance and rotate is carried out 7-14 days after placement (Dowman et al, 2015). Frequencies and timings vary, depending on local policy.
A PEG tube requires replacement every two to three years.
Box 3. Cleaning the stoma site
- How the stoma site is cleaned will differ depending on local policy. Initially, cleansing may be done using sterile saline and gauze. Once the stoma site has healed, cleansing is likely to be undertaken with non-sterile equipment or using a shower
- After cleaning, the stoma site needs to be dried gently and the fixation plate or bolster repositioned (Box 5)
- Further management includes protecting the skin with a barrier film and leaving the site open to the air as much as possible
Source: Westaby et al (2010)
Box 4. Flushing a feeding tube
- Freshly run tap water/cooled boiled water/sterile water (as per local policy)
- 60ml enteral syringe
- Draw the required amount of water into the syringe, dispelling excess air
- If the tube has a clamp, close it
- Open the end of the tube and connect the syringe
- Open the clamp
- Gently insert the water
- Close the clamp
- Remove the syringe, refill it with water
- Repeat as needed to obtain the desired flushing volume
- Once completed, remove the syringe, close the tube cap and re-open the clam
Box 5. Advancing and rotating a feeding tube
- Gently push the tube 3-4cm into the abdomen until it moves freely
- Pull the tube back out of the abdomen until you feel resistance
- Secure the fixation plate or bolster at the abdomen
- There should be sufficient room between the skin and fixation device for the patient to take a deep breath comfortably when sitting upright
- The tip of the fixation plate or bolster should sit approximately 1cm from the skin so it does not restrict movement or cause local ischaemia
Source: Westaby et al (2010)
Radiologically inserted gastrostomy
A radiologically inserted gastrostomy (RIG) is placed under X-ray guidance. The type of tube used varies – a balloon gastrostomy tube (BGT, Fig 4) is the more common option. A RIG can be used:
- When a PEG is unsuitable – for example, in respiratory-compromised patients and in those with head and neck cancers, in whom seeding (potential spreading of cancer cells to adjacent tissues) may be a risk (Abd Rahim et al, 2014);
- When an endoscopic procedure is not technically possible – for example, in patients with pharyngeal stricture (Busch et al, 2016);
- When an attempt at PEG placement has been unsuccessful (Petrocelli et al, 2016) – for example, because the patient could not tolerate the procedure or because it was not possible to transilluminate through the abdomen. Transillumination refers to the ability to clearly see illumination from the tip of the endoscope in the patient’s stomach through the abdominal wall.
In a RIG, the gastrostomy tract is created via gastropexy and secured by skin fasteners or sutures on the abdomen. Gastropexy is a surgical procedure in which the stomach is sutured to the abdominal wall to provide a safe tract through which a gastrostomy tube is placed. The number of gastropexy fasteners or sutures varies from one to four (Lowe et al, 2012). The length of time for which gastropexy fasteners remain in place varies from 7-14 days (Lowe et al, 2012). If they are removed too soon, the formation of the tract could be compromised.
Once the gastrostomy tract has healed and fasteners have been removed, care of the RIG tube depends on the type of tube inserted during the procedure.
Balloon gastrostomy tube
A BGT is held in place in the abdomen by a water-filled balloon. It can be inserted radiologically or surgically or, if replacing a PEG through an established gastrostomy tract, percutaneously (NNNG, 2016b). BGTs can be used:
- When repeated endoscopic procedures are not an option or present a risk;
- As an interim measure before fitting a low-profile device (Fig 5);
- For the administration of a blended diet, as opposed to a pre-packaged sterile liquid feed;
- To avoid sedation and/or hospital intervention, as they can be placed percutaneously in the patient’s home by a trained health professional, a trained relative or even the patient themselves.
Care of a BGT requires:
- Daily stoma site cleaning (Box 3);
- Daily flushing (Box 4);
- Weekly advancing and rotating (Box 5);
- Weekly balloon checking (Box 6) (NICE, 2006) – the frequency of checks varies, depending on the manufacturer.
Box 6. Checking balloon in a balloon-held tube
To check the balloon, the water it contains must be removed, measured and replaced.
- Two Luer slip syringes (5-20ml, depending on balloon size)
- Sterile water or cooled, boiled water (depending on local policy)
- Ensure there is clear access to the gastrostomy tube
- Check the balloon port on the feeding tube for the volume of water required
- Draw up the required amount of water into one syringe
- Release the bolster and gently push the gastrostomy tube into the abdomen by approximately 2-3cm; to prevent the tube being expelled, ask the patient not to move quickly and, if possible, not to cough
- Use the other syringe to withdraw the water that is in the balloon through the balloon port; dispose of that syringe and immediately use the previously filled syringe to insert the required volume of water through the same port
- Remove the second syringe
- Gently pull the gastrostomy tube until you feel resistance
- Secure the bolster in its correct position (1cm from the abdominal wall)
- Record the volume of water removed and the amount inserted. If the level of water removed has decreased significantly in one week it may be an indication that the tube needs to be changed
Factors including gastric pH, frequency of tube use and fungal infection may affect the longevity of the balloon (NNNG, 2016b). BGTs need to be replaced every three to nine months depending on the manufacturer. Replacement can be undertaken in secondary or primary care (Ojo, 2011). If a BGT is to be changed in the community, the procedure should, where possible, be undertaken during office hours so support and advice is available if there are any problems (NNNG, 2016b).
The size of the balloon varies between devices. It is normal for the balloon to lose some water but the amount is individual to each person and the size of the BGT in situ. To monitor water loss, you will need to document how much water is removed from a balloon and how much is used to inflate it each time it is changed. Osmotic pressure may cause water to cross the balloon’s membrane and leak out, but a leak may also indicate balloon damage, in which case there is a risk of the tube falling out. If there is significant water loss or no water can be withdrawn, expert advice should be sought to consider replacing the tube.
Button gastrostomy tube with balloon
A button gastrostomy tube with balloon is a low-profile device – also called button low-profile gastrostomy tube (LPGT). This device is much shorter than the BGT so the tip of the tube sits against the abdomen. It is more discrete than the BGT, as there is no external length of tubing when it is not in use; an extension set is attached to administer nutrition or medication. Before insertion, the stoma tract needs to be measured so the correct size tube can be fitted. This type of feeding tube needs to be fitted to the individual to ensure correct fit (Lord, 2018); failure to do so will lead to an ill-fitting tube and increase the risk of leakage and stoma-site complications.
Button gastrostomy tubes with balloon are used when:
- A more discrete method of gastrostomy feeding is needed – for example, in children or young adults;
- There is a risk that a longer tube would become dislodged – for example, in children or physically active patients.
Care is the same as for BGTs.
Capsule gastrostomy tube
A capsule gastrostomy tube, also known as a Monarch tube, is inserted percutaneously and held in place internally by a silicone bolster. It provides an alternative in case of intolerance to balloon-held devices.
A capsule gastrostomy tube requires less-frequent changes than a BGT (usually every nine months) and can be changed without sedation in the patient’s home by a trained health professional, relative or the patient themself. Care is as for BGTs, without the weekly checks of the balloon.
Short-term post-pyloric feeding
A nasojejunal (NJ) tube (Fig 6) is passed through the nostril, nasopharynx, oesophagus and stomach into the jejunum. NJ tubes are used for short-term enteral feeding when gastric feeding is not possible. Like an NGT, an NJ tube is secured externally at the nose or cheek by adhesive tape or a fixation device.
As there is no fluid pool in the jejunum, pH testing cannot be used to check the position of an NJ tube. NICE (2006) recommends checking centimetre markers at the nose daily for signs of tube movement to ensure it does not migrate into the stomach.
Long-term post-pyloric feeding
Percutaneous endoscopic gastrojejunostomy (PEGJ) tube
The jejunal extension tube is introduced through an existing PEG tube and secured to the PEG tube externally. It is used when post-pyloric administration of nutrition or medication is required due to a patient’s intolerance of gastric feeding caused by gastroparesis or delayed gastric emptying. The gastric port can be used for gastric decompression while feeding is provided jejunally.
A PEGJ tube (Fig 7) should be advanced at least once a week like a PEG tube but should not be rotated – as this may result in displacement or twisting of the jejunal tube. You will need to be careful not to accidentally remove any connectors at the distal end of the PEGJ tube. Although bulky, all connectors are necessary for PEGJ tube stability, as this is the only point at which the jejunal extension is secured. Disconnecting the connectors may result in the jejunal extension becoming displaced inside the tube and migrating through the small bowel.
Balloon jejunal feeding tube
A balloon jejunal feeding tube is inserted percutaneously after a tract has been created surgically or radiologically into the small bowel and a BGT inserted as primary placement.
A balloon jejunal feeding tube needs to be inserted at least 6cm into the existing tract to minimise fluid leakage. These tubes can be placed without sedation or anaesthesia at the patient’s bedside. The balloon should be checked on weekly. Balloon size is likely to be smaller than a gastrostomy placed in the stomach as the jejunum cannot accommodate a large balloon.
Surgically placed jejunostomy tube
A surgically placed jejunostomy tube is inserted into the small intestine during a surgical procedure. It is an alternative to a PEGJ for patients who need post-pyloric feeding but cannot tolerate a PEGJ, or in whom PEGJ tube insertion is not possible. It may be used for patients with complex gastric or small-intestine pathology, who may have had repeated surgery.
Care differs depending on the type of jejunostomy tube used. Surgically inserted jejunostomy tubes are often smaller-bore tubes compared with gastrostomy tubes, so preventing blockages is essential as replacing the tube may require another surgical intervention.
Some jejunostomy tubes are secured internally with a cuff and silicone wings, so they can only be removed after the Dacron cuff has been separated from the surrounding tissue. Other jejunostomy tubes are only secured externally at the stoma site, either with sutures or dressings (Lord, 2018). To check the tube has not been displaced, the patients should be monitored for signs such as increased vomiting and gastric pain.
Either registered or non-registered nursing staff may be involved in caring for patients with enteral feeding tubes. The level of involvement may depend on the environment in which the person is being cared for and the knowledge, skills and level of competency of the individual staff member. Both registered and non-registered staff are likely to be involved in the day-to-day care of tubes. In areas where it is more common to find patients fed by enteral tubes, non-registered nursing staff may be involved in checking and cleaning the site. Registered nurses are likely to be responsible for balloon checks, advancing tubes and monitoring to minimise risk of complications. Tube changes and repairs will be the responsibility of clinical nutrition specialist health professionals.
- Enteral tube feeding is the administration of feed and/or fluid via a tube into the gastrointestinal tract
- A gastrostomy is the surgical creation of an opening (stoma) in the abdomen leading to the stomach
- A range of different feeding tubes are available and nurses need to know how to care for them
- Feeding tubes need regular care and checks to avoid infection, leakage or migration
- Pain on feeding and external leakage of gastric contents are ‘red-flag’ signs of severe complication
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