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Issue Date: Veterinary Technician January 2005 (Vol 26, No 1)

The Ins and Outs of Feeding Tubes Ann Wortinger

For patients that cannot consume at least 85% of their calculated resting energy requirements by mouth, another route needs to be used. Many feeding tube and food choices are available that can be tailored to fit the individual patient and condition. Providing patients with nutritional support should not be an afterthought. Addressing the nutritional needs of hospitalized and critical care patients can dramatically improve their outcome and also allow them to return home sooner. SELECTING THE PROPER FEEDING TUBE There are a number of feeding tube options available. When selecting a feeding tube, the following factors should be taken into consideration:      

Patient’s condition Disease for which the patient is being treated Cost of administration Availability of intensive care facilities Preferred food type to be used Anticipated length of feeding assistance

When estimating the length of time the tube will need to be in place, the tube’s material should also be taken into consideration. The best feeding tubes for prolonged use are those made of polyurethane or silicone. For short-term feeding (less than 10 days), polyvinyl chloride (PVC; red rubber) tubes can be used. PVC tubes are not appropriate for long-term feeding because they tend to become stiff with prolonged use, which causes additional discomfort to the patient. Silicone is softer and more flexible than other tube materials and has a greater tendency to stretch and collapse. Polyurethane is stronger than silicone, allowing for thinner tube walls and a greater internal diameter, despite the same French gauge.a Both the silicone and polyurethane tubes do not disintegrate or become brittle in situ, providing a longer tube life. TYPES OF FEEDING TUBES Nasoesophageal or Nasogastric Tubes Nasoesophageal or nasogastric tubes are useful for providing short-term nutritional support (less than 10 days). The terminal end of nasoesophageal tubes is located in the esophagus, whereas the terminal end of nasogastric tubes is located in the stomach. Unless the stomach needs to be emptied of fluid or air, a nasogastric tube should not be used for feeding. When the tube passes through the cardiac sphincter of the stomach, it allows gastroesophageal reflux to occur. This can cause esophageal irritation severe enough to cause strictures as well as makes the animal very uncomfortable (similar to heartburn). They can be used in patients with a functional esophagus, stomach, and intestines. Nasoesophageal tubes are contraindicated in patients that are vomiting, comatose, or lacking a gag reflex.1,2 The primary advantages to using nasoesophageal tubes are their ease in placement, low cost, and the fact that general anesthesia is not needed for placement. Placement Supplies needed to place a nasoesophageal or nasogastric tube include the following:       

Lidocaine or ophthalmic drops 5- to 8-Fr tube with length sufficient to reach the distal esophagus Sterile lubricant Suture material or glue Luer slip catheter plug Elizabethan collar Piece of tape or marker

The length of tube to be inserted should be determined by measuring from the nasal planum along the side of the patient to the caudal margin of the last rib. This indicates the ideal tube placement; therefore, it is important to mark this area with either a piece of tape or a marker. After instilling a few drops of lidocaine into the patient’s nose, a sterile catheter of sufficient length (8-Fr x 42 inches in dogs weighing >15 kg; 5-Fr x 36 inches in dogs weighing <15 kg) should be advanced into the nose. The tube should be passed with the tip directed in a caudoventral, medial direction into the ventrolateral aspect of the external nares. The head should be held in a normal, static position. As soon as the tip of the catheter reaches the medial septum at the floor of the nasal cavity in dogs, the external nares should be pushed dorsally, opening the ventral meatus and ensuring passage of the tube into the oropharynx. Depending on the size of the cat, a 5- to 8-Fr tube can be used. In cats, the tube can be inserted initially in a ventromedial direction and continued directly into the oropharynx. The tube should be inserted until the tape tab or marked area is reached. To determine whether tube placement is correct, 3 to 15 ml of sterile water or saline can be injected through the tube and then the animal should be evaluated for coughing. Coughing indicates the tube is placed in the lungs and not the esophagus. Lateral radiographs may also be taken to confirm tube location. After confirmation of its position, the tube should be secured with either glue or sutures at the external nares and along the dorsal midline along the bridge of the nose. The tube should be directed over the patient’s head and secured with a bandage around the neck. The catheter plug should then be placed into the catheter. An Elizabethan collar can be used in most animals to prevent inadvertent removal of the tube.1–4 To place a nasogastric tube, the same procedure can be followed; however, the length of the tube should be measured from 3 to 4 inches past the last rib to allow extension through the cardiac sphincter into the stomach. Diet and Feeding Because of the small internal diameter of nasoesophageal and nasogastric tubes, only liquid enteral diets can be used. Patients can

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be fed either through a syringe pump at a constant-rate infusion or using a bolus. If feeding through a syringe pump, the delivery equipment should be changed every 24 hours to help prevent bacterial growth within the system. Tube clogging is a common problem. A syringe pump may help decrease the incidence of clogs, as will flushing well before and after bolus feeding. If the tube becomes clogged, replacement may be necessary. Diluting the liquid diet with water may also help; however, this further decreases the caloric concentration of the diet, in turn increasing the volume necessary to meet the caloric needs. Potential Complications Complications from using nasoesophageal or nasogastric tubes include epistaxis, lack of tolerance of the procedure, and inadvertent removal of the tube by the patient. These tubes should not be used in vomiting patients or those with respiratory disease.1–4 Nasogastric tubes increase the risk of gastroesophageal reflux as well as the incidence of esophageal strictures. Removal When removing a nasoesophageal or nasogastric tube, the glue or sutures should be removed first, and then the tube can simply be pulled out. Pharyngostomy Tubes With the increased use of gastrostomy tubes, the indications for the use of pharyngostomy tubes are few and far between.1–4 The indications for pharyngostomy tubes are similar to those for nasoesophageal tubes, except pharyngostomy tube placement requires anesthesia. Although these tubes are still being used, they are not recommended because of the potential for severe complications and the fact that much better choices are available. Placement When placing a pharyngostomy tube, the following supplies are needed:     

Appropriately sized tube Forceps Scalpel blade Suture or tape Luer slip catheter plug

The patient should be anesthetized, intubated, and positioned in lateral recumbency. The area caudal to the mandible should be clipped and surgically prepared. A 14- to 18-Fr PVC tube should be measured before placement, as with a nasoesophageal tube, and then marked. The difference for the pharyngostomy tube is that the tube entrance should be caudal to the mandible. The patient’s mouth should be held open with a speculum, and the hyoid apparatus should be palpated with one finger. The tube exit site must be carefully planned to avoid interfering with the laryngeal opening and epiglottic movement. The tube should exit as far caudally and dorsally along the lateral pharyngeal wall as possible. The finger that is in the patient’s mouth should locate the hyoid apparatus and protrude from the pharyngeal wall laterally at the exit site. Forceps can also be used to locate the tube exit site. A skin incision of 1 cm should be made over the bulging pharyngeal wall; long, curved forceps should be used to bluntly tunnel caudally through the tissue from outside to inside. Blunt dissection can prevent injury to nearby nerves, the carotid artery, and the jugular vein. Forceps should be used to grasp one end of the feeding tube so it exits through the dissection site while the other end is passed down the esophagus. The tube should then be secured to the skin with tape and sutures. Finally, the catheter plug should be placed into the catheter.4 Diet and Feeding Because pharyngostomy tubes tend to have a larger diameter than nasoesophageal tubes, a gruel recovery diet can be used if the tube size is greater than 8-Fr. However, diets may still need to be thinned with water so that they can pass through the tube. Potential Complications When using a pharyngostomy tube, potential complications include airway obstruction, tube displacement, damage to the cervical nerves and blood vessels, and infection at the exit site. Improper placement caudal to the hyoid apparatus can result in airway obstruction or aspiration. These tubes should not be used in vomiting patients or those with respiratory disease.1–4

Removal The tube may be simply pulled out after the sutures are removed. The exit hole should be allowed to heal by second intention. A light bandage may be applied for the first 12 hours. Esophagostomy Tubes Esophagostomy tubes are not recommended for patients that are vomiting or those with respiratory disease. Placement The following supplies are needed when placing an esophagostomy tube:

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Large Kelly-Murphy or Carmalt forceps Appropriately sized tube Tape or suture material Luer slip catheter plug

Esophagostomy tube placement requires the patient to be anesthetized, intubated, and placed in lateral recumbency. The entire lateral cervical region from ventral midline to near dorsal midline should be clipped and surgically prepared. The tube should be measured beforehand, as with a nasoesophageal tube, except the exit should be in the mid to caudal esophagus. Depending on the technique used and the size of the patient, a catheter ranging in size from 8- to 14-Fr in cats and 8- to 24-Fr in dogs may be used.

One technique uses large, curved Kelly-Murphy or Carmalt forceps inserted into the proximal cervical esophagus. The tip of the forceps should be turned laterally, and pressure should be applied in an outward direction, causing a bulge in the cervical tissue so the instrument tip can be seen and palpated externally. A small skin incision, just large enough to accommodate the feeding tube, should be made over the tip of the forceps. In small dogs and cats, the tip of the forceps should be forced bluntly through the esophagus. In larger dogs, a deeper incision should be made to allow passage of the tip of the forceps through the esophagus. The distal tip of the tube should be grasped with the forceps, pulled into the esophagus and out through the mouth, then turned around and redirected into the esophagus. The tube should be secured with tape and sutures. A light bandage should be wrapped around the neck with triple antibiotic ointment applied at the tube site. The catheter plug should then be placed into the catheter.1–4 Tube placement systems are also available. Diet and Feeding The large bore of these catheters allows for feeding of a gruel recovery diet, sometimes without dilution with water. These catheters are also easy for clients to use and maintain, as long as vomiting is not a problem. Potential Complications Complications include tube displacement caused by vomiting or removal by the patient, skin infection around the exit site, and the patient biting off the tube end after vomiting. Removal The tube may be simply pulled out after the sutures are removed. The exit hole should be allowed to heal by second intention. A light bandage may be applied for the first 12 hours. Gastrostomy Tubes Gastrostomy tube placement is the technique of choice for long-term enteral support. These tubes can be placed endoscopically, blindly, or surgically. All three techniques require general anesthesia. Endoscopic placement allows for visualization of the esophagus and stomach as well as biopsy collection from the stomach and proximal duodenum and foreign body removal. Blind biopsy allows placement of a gastrostomy tube without investing in an endoscopic unit. Surgical placement is useful during exploratory surgery or when the scope cannot be passed through the esophagus because of trauma or esophageal strictures. Placement The following supplies are needed for placement of a gastrostomy tube:       

Endoscope Endoscopic grabbers 20- to 24-Fr Pezzer’s catheter 14-gauge needle or catheterOne to two lengths of #2 suture material approximately 3-ft long Catheter guide Sterile lubricant Luer slip catheter plug For percutaneous endoscopic gastrotomy (PEG) tube placement, the patient should be anesthetized and placed in right lateral recumbency. The right flank should be clipped and surgically prepared from 1 to 2 inches above the last caudal rib to 2 to 3 inches beyond the last caudal rib. The area should be 4 to 6 inches in diameter. A 20- to 24-Fr Pezzer’s catheter should be used for placement; these are available individually or in kits. The endoscope should be advanced into the stomach and used to insufflate air into it. This helps to ensure that the spleen or omentum does not become entrapped between the stomach and body wall. An assistant should digitally palpate the external body wall approximately 1 to 2 cm behind the ninth rib. Because the palpation can be seen internally, this method can be used to confirm correct placement of the feeding tube. When the site is confirmed, a 14-gauge needle or catheter should be introduced into the stomach through the body wall. A length of #2 suture should be threaded through the needle into the stomach and grasped with endoscopic grabbers. The string and scope should be removed from the stomach. The assistant must maintain a hold on his or her end of the suture and make sure that it does not get pulled through as the scope is removed. The person placing the tube should then slide the catheter guide onto the suture and use it to secure the Pezzer’s catheter (it helps to bevel the end of the Pezzer’s catheter to make it fit into the catheter guide). A 14-gauge needle should be used to push the suture material through the Pezzer’s catheter. The suture should then be threaded through the needle, the needle should be removed, and the suture secured. The suture material, catheter guide, and Pezzer’s catheter should be pulled taunt, and the sterile lubricant should be liberally applied to the feeding tube. The catheter guide with the Pezzer’s catheter attached should be pulled back through the body wall using firm and steady pressure. It may be necessary to

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use a scalpel blade to enlarge the hole in the body wall to allow passage of the tube assembly. It is important to maintain firm and steady pressure throughout the entire passage of the feeding tube from the mouth through the body wall. Once the tube is through the body wall, the mushroom tip should be pulled firmly against the stomach wall, which in most animals can be felt from the outside. An external tube assembly should be made to prevent the tube from migrating back into the stomach; it is important to leave a little extra room (about 1 inch) between the body wall and the external tube assembly to allow tube movement and weight gain. The Luer plug should then be placed into the catheter.1â&#x20AC;&#x201C;4 For animals requiring long-term management, the initial Pezzerâ&#x20AC;&#x2122;s catheter can be replaced with either low-profile silicone tubes or with Foley-type gastrostomy tubes. Both types of tubes can be placed through the external stoma site without an endoscope. Sedation or anesthesia may be necessary based on the individual patient. Blind percutaneous gastrostomy tube placement involves basically the same technique as endoscopic placement; however, a large plastic or steel tube should be used instead of the endoscope and a firm wire used instead of the suture material. Both procedures also use the same type of catheter. Surgical placement has been largely superseded by endoscopic placement because of the ease and speed of placement, lower cost, and decreased morbidity. A surgical approach may be indicated in obese animals, those with esophageal disease, or those that are already scheduled for a laparotomy. To place a surgical gastrostomy tube, a larger incision is needed in the stomach. The exit location is sometimes hard to locate because of the position on the surgical table. Surgical placement involves placing purse string sutures around the catheter to secure it as well as attaching the stomach to the body wall. Diet and Feeding A minimum of 12 hours is needed for a temporary stoma to form before feeding can begin; the feeding tube should be left in place for a minimum of 7 to 10 days to allow a permanent stoma to form before removal. The initial tubes placed can be left in long-term (1 to 6 months) without replacement. If longterm use is required, the tubes can then be replaced with another PEG tube, low-profile silicone tube, or Foley-type feeding tube. The stoma can be used for the rest of the patientâ&#x20AC;&#x2122;s life. These tubes are well tolerated by the patient, produce minimal discomfort, allow feeding of either gruel recovery diets or commercial foods that have been ground up in a blender, and can be easily managed by owners at home.2 Patients are able to eat normally with gastrostomy tubes in place, and the tubes can easily be used to provide nutritional supplement until the patient can eat on its own. These feeding tubes can also be used to deliver drugs to patients that are difficult to medicate and require long-term medications. Potential Complications Complications associated with PEG tubes include those seen from tube placement, such as splenic laceration, gastric hemorrhage, and pneumoperitoneum. Delayed complications, such as vomiting, aspiration pneumonia, in-advertent tube removal, tube migration, and peritonitis or stoma infection, can also occur.1 The major disadvantage of gastrostomy tubes is the need for general anesthesia during placement and the risk of peritonitis.2 Reported complications from using blind percutaneous gastrostomy tubes are the same as for PEG tubes; however, the risk of splenic, stomach, or omental laceration is greater. Using the blind technique is contraindicated in patients that are grossly obese because palpation of the end of the tube is difficult and because of the risk of esophageal disease. Removal If the tube has been in place 16 weeks or less, it may be simply removed. This is best accomplished by placing the patient in right lateral recumbency. The tube should be grasped with the right hand close to the body wall and with the left hand holding the animal. The tube should be pulled firmly and consistently to the right in an upward motion. Some force may be required for this. It is also helpful to ensure the patient has been fasted and that a towel is placed over the tube site to catch any stomach contents, especially if the patient has not been fasted prior to removal. If the tube has been in place longer than 16 weeks, the incidence of tube breakage is much higher. The retained parts may need to be endoscopically retrieved, depending on where the breakage occurred. Most large patients can easily pass retained parts, but smaller patients may need to have them retrieved. The exit hole should be allowed to heal by second intention. A light bandage may be applied for the first 12 hours. Jejunostomy Tubes A jejunostomy feeding tube is indicated when the upper gastrointestinal tract must be rested or when pancreatic stimulation must be decreased. Placement The following supplies are needed for placement of a jejunostomy tube:   

5- to 8-Fr PVC tubing Suture material Luer slip catheter plug

Jejunostomy tubes can be placed either surgically or threaded through a gastrostomy tube for transpyloric placement. Standard gastrojejunostomy tubes designed for humans are unreliable in dogs because of frequent reflux of the jejunal portion of the tube back into the stomach. Investigation is ongoing involving endoscopic placement of transpyloric jejunostomy tubes through PEG tubes. These tubes are being used in universities and larger referral practices; however, many problems are still being encountered during placement. Diet and Feeding Because of the small diameter of these tubes and their location, liquid enteral diets are recommended. The jejunum has minimal storage capacity compared with the stomach; therefore, constant-rate infusion using a syringe pump is the preferred method of delivery. Potential Complications Common complications include osmotic diarrhea and vomiting. It is recommended that the jejunal tube be left in place for 7 to 10 days to allow adhesions to form around the tube site and prevent leakage back into the abdomen.2,3 Completely changing the delivery equipment every 24 hours can help prevent bacterial growth within the system. Clogging is a common problem; a syringe pump may help to decrease the incidence of clogs, as will flushing well every 4 hours. Removal

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The tube may be simply pulled out after the sutures are removed. The exit hole should be allowed to heal by second intention. A light bandage may be applied for the first 12 hours. conclusion While force-feeding can be used to provide necessary nutrition, this is usually too stressful for the patient, not to mention stressful for the owner. This method is seldom able to deliver the volume of nutrients necessary to meet the patient’s needs. The use of feeding tubes — for both in-hospital and at-home care — allows the veterinary staff to provide nutritional support in a nonstressful way. There is a tube that can work for every patient to treat every disease. References 1. Marks SL: Enteral and parenteral nutritional support, in Ettinger SJ, Feldman EC (eds): Textbook of Veterinary Internal Medicine, vol 1, ed 5. Philadelphia, WB Saunders, 2000, pp 275–282. 2. Guilford WG: Nutritional management of gastrointestinal diseases, in Guilford WG, Center SA, Strombeck DR, et al (eds): Strombeck’s Small Animal Gastroenterology, ed 3. Philadelphia, WB Saunders, 1996, pp 889–910. 3. Willard M: The GI system, in Nelson RW, Couto CG (eds): Essentials of Small Animal Internal Medicine. St. Louis, Mosby, 1992, pp 305–309. 4. Assisted feeding techniques, in Hand MS, Thatcher CD, Remillard RL, Roudebush P (eds): Small Animal Clinical Nutrition, ed 4. Topeka, KS, Mark Morris Institute, 2000, pp 1145–1153. aThe

French gauge unit measures the outer lumen diameter of a tube and is approximately equivalent to 0.33 mm in diameter.1

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