Post-pyloric versus gastric tube feeding for critically ill adult patients

Review question.

We reviewed the evidence on benefits and complications of passing a feeding tube into the small bowel instead of placing it in the stomach to feed critically ill adults admitted to the intensive care unit (ICU).

Background

Providing early nutritional support for participants in the ICU is very important. Nutrition is supplied in a special liquid form, which is delivered through a tube placed in the mouth or nose of the person and extended into the stomach (gastric), or the tube may be advanced more distally to reach the small bowel (duodenum or jejunum), in which case it is called a post-pyloric feeding tube. We wanted to learn about the safety and potential benefits associated with post-pyloric feeding, as well as potential complications.

Study characteristics

We searched the databases until October 2013 and identified 14 studies (randomized controlled trials) with a total of 1109 participants. We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review. We investigated the benefits of post-pyloric tube feeding for reducing the rate of pneumonia, decreasing the number of days that a person needs to be dependent on a breathing machine, increasing the percentage of nutrients that can be provided to the participant and reducing the number of deaths. We also investigated potential complications that may occur during insertion of the tube, such as bleeding from the gastrointestinal tract, and complications arising during maintenance of the tube, such as the need to replace the tube.

Key results

We found that post-pyloric feeding appeared to reduce the rate of pneumonia and increase the amount of nutrition delivered to the patient. Its use did not result in fewer days that a person needed to be dependent on a breathing machine nor in fewer deaths. The target amount of feeding for a person fed with a post-pyloric tube was reached without delay. Insertion of a post-pyloric feeding tube appears safe and did not increase the likelihood of complications.

Quality of the evidence

We found evidence of moderate quality for the outcomes of rate of pneumonia, duration of dependency on a breathing machine and rate of death, mainly because identified studies were poorly conducted. With regard to the total quantity of nutrients that can be delivered to patients and complications related to insertion and maintenance of the tube, the quality of evidence was assessed as low. Evidence for the time required to reach the target amount of feeding was very low in that results were not similar across studies and study design issues hindered assessment.

We recommend that a post-pyloric feeding tube should be used routinely for all ICU patients, when this approach is feasible.

Authors' conclusions: 

We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.

Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.

We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.

Read the full abstract...
Background: 

Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed.

Objectives: 

To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding.

Search strategy: 

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review.

Selection criteria: 

Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults.

Data collection and analysis: 

We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data.

Main results: 

We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).

Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.

Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials.

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