Intrapulmonary Feeding Tube Placements While Using an Electromagnetic Placement Device: A Review (2019-2021).

BACKGROUND: Intrapulmonary placements of feeding tubes inserted with use of an electromagnetic placement device (EMPD) continue to occur. OBJECTIVE: To describe circumstances and outcomes associated with intrapulmonary feeding tube placements during use of an EMPD. METHODS: A retrospective review of reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database of intrapulmonary feeding tube placements during use of an EMPD from 2019 through 2021. Complications, outcomes, operator training, interference from anatomical variations and medical devices, and the use and accuracy of radiographs in identifying pulmonary placements were recorded. RESULTS: Sixty-two cases of intrapulmonary tube placement were identified; 10 were associated with a fatal outcome. Pneumothorax occurred in 35 cases and feedings were delivered into the lung in 11 cases. User error was cited in 6 cases and was implicit in most others. Little information was provided about operator training. Four intrapulmonary placements were associated with anatomical variations and 1 with a left ventricular assist device. Radiographic follow-up was described in 28 cases and correctly identified 23 of the intrapulmonary placements. CONCLUSIONS: User error was a significant factor, which highlights the need for empirical data to clarify the amount of training needed to safely credential EMPD operators. Clearer information is needed about anatomical variations that may contraindicate use of an EMPD, as well as medical devices that may interfere with an EMPD. Use of follow-up radiographs, interpreted by qualified personnel, is supported to increase the probability of identifying intrapulmonary tube placements.

CE: Monitoring Adult Patients for Intolerance to Gastric Tube Feedings.

ABSTRACT: Gastric tube feeding is a common and valuable intervention for patients in a variety of care settings. While tube feeding can save the lives of patients for whom oral feeding isn't possible, intolerance to tube feeding is a potential complication. This article discusses risk factors for feeding intolerance; the assessment of signs and symptoms of feeding intolerance; the various means of assessing gastric emptying, including the practice of monitoring gastric residual volume (GRV); the controversy surrounding GRV monitoring in assessing feeding tolerance; and the special considerations for monitoring feeding tolerance in acutely and critically ill adults with coronavirus disease 2019. The author, a nurse researcher with extensive experience in the area of enteral feeding, briefly summarizes recommendations and guidelines for enteral feeding published by national and international health care organizations between 2015 and 2020, and offers her perspective on best nursing practices for monitoring food tolerance in adults.

Factors affecting STEMI performance in six hospitals within one healthcare system.

BACKGROUND: How quickly percutaneous coronary intervention is performed in patients with ST-elevation myocardial infarction (STEMI) is a quality measure, reported as door-to-balloon (D2B) time. OBJECTIVES: To explore factors affecting STEMI performance in six hospitals in one healthcare system. METHODS: This was a retrospective chart review of clinical features and D2B times. Predictors for D2B times were identified using multivariate linear regression. RESULTS: The median D2B time for all six hospitals was 63 minutes and all hospitals surpassed the minimal recommended percentage of patients achieving D2B time ≤90 minutes (87.8%vs75%,p<0.001). Patient confounders adversely affect D2B times (+21.5 minutes, p<0.001). Field ECG/activation with emergency department (ED) transport (-22.0 minutes) or direct cardiac catheterization laboratory (CCL) transport (-27.3 minutes) was superior to ED ECG/activation (p<0.001). CONCLUSION: Field ECG/STEMI activation significantly shortened D2B time. To improve D2B time, hospital and Emergency Medical Service collaboration should be advocated to increase field activation and direct patient transportation to CCL.

Salt Toxicity: A Systematic Review and Case Reports.

INTRODUCTION: Salt toxicity is a rare form of hypernatremia that typically occurs after a single massive ingestion of salt over a short period of time (minutes/hours). It is a dangerous imbalance capable of causing significant neurological injury; quick recognition of salt toxicity is crucial to allow treatment before permanent brain injury occurs. The purpose of this review is to assist emergency nurses in gaining knowledge on the causes, pathophysiology, symptoms, and treatment of salt toxicity. METHODS: A systematic search for case reports of hypernatremia due to salt toxicity was conducted in the PubMed and Scopus electronic databases. The search terms used were salt, sodium, hypernatremia, toxicity, poisoning, case reports, case series, and cases. The following were the inclusion criteria: publication dates between January 1, 2000, and September 30, 2019; evidence of an acute large oral or gastric tube ingestion of salt over a short period of time (minutes/hours); admission for treatment within hours of the event; laboratory verification of hypernatremia; and full-text article available electronically in English. The following were the exclusion criteria: an unclear history, high salt consumption over a period of days, high sodium intake via the intravenous route, and breast feeding. RESULTS: Only 15 cases met the inclusion criteria for the review. Patients described in the case reports ranged in age from 5 days to 73 years. Forty percent of the patients were children less than 15 years old. Of the 14 cases with known outcomes, 50% were fatal. The most frequent causes of salt toxicity were salt water emetics, intentional administration of large quantities of salt to a child by a caregiver, and suicide attempts. Among the other causes were unintentional salt overload in infant formula, an exorcism ritual, and a college prank. DISCUSSION: Findings from this review of 15 case reports in which a large salt load was ingested over a short period of time suggest that salt toxicity is a rare condition associated with high mortality. In addition, salt toxicity can occur in patients of all ages for a variety of reasons; the most frequently identified reasons in this review were use of salt water as an emetic and child abuse by the intentional administration of a high salt load by a caregiver. For patients whose massive exposure to salt is recent (such as minutes to hours), rapidly reducing the serum sodium concentration may prevent irreversible neurological injury.

A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes.

The purpose of this review was to (1) identify areas of agreement and disagreement in guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tube and (2) summarize factors that affect choices made by clinicians regarding which method(s) to use in specific situations. Systematic searches were conducted in the PubMed, Scopus, and CINAHL Plus databases using a combination of keywords and data-specific subject headings. Searches were limited to guidelines/recommendations from national level specialty groups and governmental sources published in the English language between January 1, 2015 and September 20, 2018. Fourteen guidelines that described methods to distinguish between gastric and pulmonary placement of nasogastric tubes were identified from a variety of geographic locations. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation.

Incidence of Sinusitis Associated With Endotracheal and Nasogastric Tubes: NIS Database.

BACKGROUND: Endotracheal and nasogastric tubes are recognized risk factors for nosocomial sinusitis. The extent to which these tubes affect the overall incidence of nosocomial sinusitis in acute care hospitals is unknown. OBJECTIVE: To use data for 2008 through 2013 from the Nationwide Inpatient Sample database to compare the incidence of sinusitis in patients with nasogastric tubes with that in patients with an endotracheal tube alone or with both an endotracheal tube and a nasogastric tube. METHODS: Patients' data with any of the following International Classification of Disease, Ninth Revision, Clinical Modification codes were abstracted from the database: (1) 96.6, enteral infusion of concentrated nutritional substances; (2) 96.07, insertion of other (naso-)gastric tube; or (3) 96.04, insertion of an endotracheal tube. Sinusitis was defined by the appropriate codes. Weighted and unweighted frequencies and weighted percentages were calculated, categorical comparisons were made by χ2 test, and logistic regression was used to examine odds of sinusitis development by tube type. RESULTS: Of 1 141 632 included cases, most (68.57%) had an endotracheal tube only, 23.02% had a nasogastric tube only, and 8.41% had both types of tubes. Sinusitis was present in 0.15% of the sample. Compared with patients with only a nasogastric tube, the risk for sinusitis was 41% greater in patients with an endotracheal tube and 200% greater in patients with both tubes. CONCLUSION: Despite the low incidence of sinusitis, a significant association exists between sinusitis and the presence of an endotracheal tube, especially when a nasogastric tube is also present.

Testing Placement of Gastric Feeding Tubes in Infants.

BACKGROUND: Inadvertent positioning of a nasogastric tube in the lung can cause serious complications, so identifying methods to detect improperly inserted tubes is imperative. OBJECTIVES: To compare the sensitivity, specificity, and negative and positive predictive values of 4 pH cut points (< 4.0, < 4.5, < 5.0, and < 5.5) in differentiating gastric and tracheal aspirates under various treatment conditions and to explore the utility of a pepsin assay for distinguishing between gastric and tracheal aspirates. METHODS: Gastric and tracheal aspirates were collected from critically ill infants undergoing mechanical ventilation who had nasogastric or orogastric feeding tubes. Aspirates were tested with colorimetric pH indicators and a rapid pepsin assay. Information about treatment conditions was obtained from medical records. RESULTS: Two hundred twelve gastric aspirates and 60 tracheal aspirates were collected from 212 patients. Sensitivity was highest and specificity was lowest at the gastric aspirate pH cut point of less than 5.5. Positive predictive values were 100% at all pH cut points less than 5.0. Negative predictive values were higher at the pH cut point of less than 5.0 than at cut points less than 4.5. A higher percentage of pepsin-positive readings was found in gastric aspirates (88.3%) than in tracheal aspirates (5.4%). CONCLUSION: For a desired positive predictive value of 100%, a pH cut point of less than 5.0 provides the best negative predictive values, regardless of gastric acid inhibitor administration and feeding status. The pepsin assay is promising as an additional marker to distinguish gastric from tracheal aspirates.

Effect of pH Test-Strip Characteristics on Accuracy of Readings.

BACKGROUND: Little is known about characteristics of colorimetric pH test strips that are most likely to be associated with accurate interpretations in clinical situations. OBJECTIVES: To compare the accuracy of 4 pH test strips with varying characteristics (ie, multiple vs single colorimetric squares per calibration, and differing calibration units [1.0 vs 0.5]). METHODS: A convenience sample of 100 upper-level nursing students with normal color vision was recruited to evaluate the accuracy of the test strips. Six buffer solutions (pH range, 3.0 to 6.0) were used during the testing procedure. Each of the 100 participants performed 20 pH tests in random order, providing a total of 2000 readings. The sensitivity and specificity of each test strip was computed. In addition, the degree to which the test strips under- or overestimated the pH values was analyzed using descriptive statistics. RESULTS: Our criterion for correct readings was an exact match with the pH buffer solution being evaluated. Although none of the test strips evaluated in our study was 100% accurate at all of the measured pH values, those with multiple squares per pH calibration were clearly superior overall to those with a single test square. CONCLUSIONS: Test strips with multiple squares per calibration were associated with greater overall accuracy than test strips with a single square per calibration. However, because variable degrees of error were observed in all of the test strips, use of a pH meter is recommended when precise readings are crucial.

Update on Effectiveness of an Electromagnetic Feeding Tube-Placement Device in Detecting Respiratory Placements.

BACKGROUND: Radiography is the accepted gold standard for testing feeding tube placement; however, an electromagnetic tube-placement device (ETPD) is sometimes used in lieu of radiography for this purpose. High success rates have been reported when the device was used by well-trained individuals. However, authors previously described 20 cases that occurred between 2007 and 2012 in which clinicians voluntarily reported inability to detect inadvertent tube insertions in the respiratory tract while using an ETPD. OBJECTIVE: To describe case reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database between 2013 and 2015 regarding inadvertent respiratory placement of feeding tubes by operators using an ETPD. METHODS: The MAUDE database was searched for cases dated from January 1, 2013, through December 31, 2015, along with selected brand names. A total of 34 cases (25 after removal of duplicates) were located in which a feeding tube was inserted into the respiratory tract during insertions assisted by an ETPD. RESULTS: Sites of the malpositioned tubes included the right lung (n = 13), left lung (n = 6), unspecified lung (n = 4), and bronchus (n = 2). A pneumothorax occurred in 17 of the 25 misplacements; feedings were administered in 6 cases. CONCLUSIONS: Many case reports involved clinicians failing to recognize tube misplacements in the respiratory tract while using an ETPD. These reports provide evidence that not all clinicians can use the device effectively to detect malpositioned tubes. Thus, one must continue to question the wisdom of eliminating radiographic confirmation of tube position before starting feedings.

Administering Polyethylene Glycol Electrolyte Solution Via a Nasogastric Tube: Pulmonary Complications.

BACKGROUND: Patients sometimes require insertion of a nasogastric tube for the administration of a large volume of a polyethylene glycol electrolyte solution. If the tube is malpositioned, the risk for direct instillation of the solution into the lung increases. The risk for aspiration also increases if the infusion rate exceeds gastrointestinal tolerance. PURPOSE: To review published cases of patients' experiencing adverse pulmonary events after administration of polyethylene glycol electrolyte solution via a nasogastric tube and to offer suggestions to prevent these outcomes. METHODS: A search of the literature from 1993 through 2014 was performed by using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases. RESULTS: In the 12 case reports located, none of the patients had radiographs to verify tube location before infusion of polyethylene glycol electrolyte solution. After symptoms developed in 3 children (ages 8-11 years), radiographs showed their tubes incorrectly positioned in the bronchus, lung, or esophagus; ports of a fourth child's tube were in the oropharynx. The remaining 8 patients (ages 5-86 years) never had radiographs to determine tube placement. Pulmonary complications from the infusions of polyethylene glycol electrolyte solution contributed to the death of 5 of the patients. CONCLUSION: Relatively simple maneuvers to reduce the likelihood of adverse pulmonary events following the administration of large volumes of polyethylene glycol electrolyte solution via a nasogastric tube are well worth the cost and effort to protect patients from potential serious injury.

The pH of Feeding Tube Aspirates From Critically Ill Infants.

BACKGROUND: The extent to which gastric acid inhibitors and feedings affect gastric pH in infants is unclear. OBJECTIVES: To compare pH values of gastric aspirates from infants according to use or no use of gastric acid inhibitors and feedings. METHODS: Colorimetric pH tests were used to measure the pH of aspirates from feeding tubes in 54 critically ill infants; 29 of the gastric aspirates were from infants who did not receive acid inhibitors or feedings, 13 were from infants who received acid inhibitors but no feedings, 3 were from infants who received feedings but no acid inhibitors, and 5 were from infants who received both acid inhibitors and feedings. The remaining 4 feeding tubes were in nongastric sites. RESULTS: Individual pH readings of 5.5 or less were found in 97% of the gastric aspirates from infants with no recent feedings or acid inhibitors, 77% of the gastric aspirates from infants who received acid inhibitors, and 67% of the gastric aspirates from infants with recent feedings. Among 2 esophageal aspirates and 2 duodenal aspirates, 1 of each type had a pH less than 5.5. A pH cut point of 5.5 or less did not rule out esophageal or duodenal placement. CONCLUSIONS: The pH of gastric aspirates from critically ill infants is often 5.5 or less, regardless of the use of acid inhibitors, feedings, or both. Most likely a cut point of 5.5 or less would rule out respiratory placement because tracheal pH is typically 6.0 or higher.

Gastric reflux: association with aspiration and oral secretion pH as marker of reflux: a descriptive correlational study.

BACKGROUND: Gastric reflux leading to pulmonary aspiration is a frequent event in mechanically ventilated, gastric-fed patients, which can lead to ventilator-associated complications and pneumonia. OBJECTIVES: The objectives of this study were to determine the association between gastric reflux and aspiration using the presence of pepsin in oral or tracheal secretions as a marker of reflux or aspiration and to determine the association between the pH (range, 0-14) and the presence of pepsin in oral secretions. METHODS: A descriptive correlational study was conducted in mechanically ventilated surgical or medical patients receiving gastric tube feedings. Oral secretions were suctioned hourly and tracheal secretions every 2 to 3 hours for 12-hour periods over 1 to 2 days in 15 patients. RESULTS: There were 142 paired samples of oral tracheal secretions. A majority of samples (60%) had the same results, with 32% both pepsin-positive and 27% both pepsin-negative. The range of pH measurements was 4 to 8, with a mean of 6.3 ± 0.05. Ninety oral specimens had a pH of 4 to 6. Forty-seven of the oral specimens with pH measures between 4 and 6 (52%) were pepsin-positive. The correlation of pH percent pepsin-positive oral secretions was not significant. CONCLUSION: Aspiration events were more frequent than reflux events. Measurement of actual pepsin concentration to detect new reflux and aspiration events is recommended in future studies. Bedside pH measures of oral secretions are not a valid marker of gastric reflux.

Head-of-bed elevation and early outcomes of gastric reflux, aspiration and pressure ulcers: a feasibility study.

BACKGROUND: Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º. OBJECTIVES: To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation. METHODS: A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and Kendall τ correlations were conducted. RESULTS: Fifteen patients were enrolled; 11 completed both days. Patients were maintained at 30º (mean, 30º) for 96% of minutes and at 45º (mean, 39º) for 77% of minutes. No patients showed signs of pressure ulcers. A total of 188 oral secretions were obtained, 82 (44%) were pepsin-positive; 174 tracheal secretions were obtained, 108 (62%) were pepsin-positive. The median percentage of pepsin-positive oral secretions was not significantly higher (P = .11) at 30º elevation (54%) than at 45º elevation (20%). The median percentage of pepsin-positive tracheal secretions was not significantly higher (P = .37) at 30º elevation (71%) than 45º elevation (67%). Deeper sedation correlated with increased reflux (P = .03). CONCLUSIONS: HOB elevation greater than 30º is feasible and preferred to 30º for reducing oral secretion volume, reflux, and aspiration without pressure ulcer development in gastric-fed patients receiving mechanical ventilation. More deeply sedated patients may benefit from higher HOB elevations.

Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement.

BACKGROUND: Use of technology capable of electromagnetically tracking advancement of a feeding tube on a monitoring screen during insertion may enable detection of deviation of the tube from the midline as it advances through the chest, possibly indicating entry of the tube into the right or left main bronchus. PURPOSES: To describe (1) published peer-reviewed studies that report on the detection of malpositioned tubes inserted by an electromagnetic tube placement device, and (2) events reported to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database regarding use of such a device. METHODS: An Ovid MEDLINE search was conducted to locate peer-reviewed studies published between 2007 and 2012 that referred to use of an electromagnetic tube placement device to detect inadvertent respiratory placements of feeding tubes. In addition, an online search of the MAUDE database was conducted for the years 2007 through 2012. RESULTS: The Ovid MEDLINE search yielded 6 studies that referred to respiratory placements; no cases of pneumothorax were reported. The MAUDE database search yielded 21 adverse events associated with use of an electromagnetic tube placement device (including 17 cases of pneumothorax and 2 deaths). As the MAUDE database relies on voluntary reports, this number should not be construed as the incidence of malpositioned tubes during this period. CONCLUSIONS: The ability of clinicians to place feeding tubes correctly by using an electromagnetic tube placement device varies. Thus, it is reasonable to question the wisdom of eliminating radiographic confirmation of tube position before starting feedings.

A review of published case reports of inadvertent pulmonary placement of nasogastric tubes in children.

PROBLEM: Little is known about the incidence of inadvertent pulmonary placement of nasogastric tubes during blind insertions in children. PURPOSE: The purpose of this paper was to conduct a review of published case reports over the past two decades. METHODS: An OVID Medline search was conducted of articles published from 1993 through 2012. RESULTS: Fifteen published case reports were located; four patients died as a result of their malpositioned tubes. The auscultatory bedside method failed to detect the malpositioned tubes in all seven cases in which it was used. CONCLUSIONS: The incidence of inadvertent pulmonary placement of nasogastric tubes is relatively low but can lead to serious and even lethal results in children. The auscultatory method to predict tube location is unreliable.

A pilot study of pepsin in tracheal and oral secretions.

BACKGROUND: Because reflux of gastric juice into the oropharynx must precede its aspiration into the lungs, it is reasonable to hypothesize that the detection of pepsin (the major gastric enzyme in gastric juice) in oral secretions may provide a relatively noninvasive method of predicting risk for aspiration. OBJECTIVE: To describe the incidence of pepsin in oral and tracheal secretions collected concurrently from a sample of 50 gastric-fed patients undergoing mechanical ventilation. METHODS: An exploratory descriptive design with a convenience sample from 4 medical and surgical intensive care units. An oral secretion and a tracheal secretion were collected concurrently from each patient (yielding a sample of 50 oral and 50 tracheal secretions). The tracheal secretions were obtained via the inline suction system with an attached sputum trap; oral secretions were obtained via a Yankauer suction tip with an attached sputum trap. All specimens were assayed for pepsin by the Western blot method. RESULTS: Oral secretions from 10 patients (20%) and tracheal secretions from 2 patients (4%) were pepsin-positive. Both patients with pepsin-positive tracheal secretions also had pepsin-positive oral secretions. Pepsin was not found in the tracheal secretions from the remaining 8 patients with pepsin-positive oral secretions. CONCLUSIONS: Although reflux of gastric juice into the oropharynx must precede its aspiration into the lungs, individual reflux events do not necessarily lead to aspiration. Thus, it is reasonable that we found pepsin 5 times more often in oral secretions than in tracheal secretions.

Head-of-bed elevation in critically ill patients: a review.

Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions are needed.