Nutritional support for adults with swallowing difficulties

Background

A number of conditions compromise the transport of food along the digestive tract. Patients with swallowing disturbances can develop low nutritional status, which affects their recovery from illness, surgery, and injury. Conditions associated with swallowing disorders include stroke, neurological diseases, dementia, cancers of the head and neck, amyotrophic lateral sclerosis, physical obstruction, and dysphagia from stroke. Nasogastric tube feeding is a time proven technique to provide nutritional support; the tube can be inserted by a nurse. Percutaneous endoscopy gastrostomy (PEG) involves a feeding tube inserted directly into the stomach through the abdomen and is particularly useful when enteral nutrition is needed for a length of time.

Review question

Prolonged use of a nasal tube can lead to adverse events such as damage to the nose and larynx, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia (which can result from inhalation of stomach contents leading to lower respiratory tract infection and pneumonia).

Study characteristics

We obtained updated evidence for this review from 11 randomised controlled studies comparing a nasogastric tube with PEG in a total of 735 patients. Seven studies measured treatment failure i.e. feeding interruption, blocking or leakage of the feeding tube in 408 patients randomised to either a nasal gastric tube or PEG.

Key results

The studies showed a higher probability of treatment failure with a nasal gastric tube. The number of deaths was no different with the two methods; nor was the overall occurrence of adverse events. Participants with PEGs may have a better quality of life.

Quality of the evidence

Possible limitations of this review include the small number of participants in the majority of studies, explained by the high cost of PEG and requirements for endoscopy in its use, the operational challenges to accomplish a clinical trial in this area and the different length of follow-up of the patients in the studies (from less than four weeks to six months). There were clinical differences between the trials, with the participants having different baseline diseases and different techniques used to insert the PEG. The findings of the present review of the literature should be interpreted with caution, given that there were methodological issues with most of the included studies which increase the risk of bias in the trial. This systematic review of the literature is valuable in analysing 11 studies, with a sample size of 735 patients. Nevertheless, further randomised clinical trials that adopt a rigorous method are warranted.

Authors' conclusions: 

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.

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Background: 

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

Objectives: 

To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

Search strategy: 

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

Selection criteria: 

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

Data collection and analysis: 

We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

Main results: 

We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). The push subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).

There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).

For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

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