An externally validated guide to anatomical interpretation using a direct-vision ('IRIS') feeding tube.

BACKGROUND & AIMS: Most of the 11.5 million feeding tubes placed annually in Europe and the USA are placed 'blind'. This carries a 1.6% risk that these tubes will enter the lung and 0.5% cause pneumothorax or pneumonia regardless of whether misplacement is identified prior to feeding. Tube placement by direct vision may reduce the risk of respiratory or oesophageal misplacement. This study externally validated whether an 'operator guide' would enable novice operators to differentiate the respiratory and alimentary tracts. METHODS: One IRIS tube was placed in each of 40 patients. Novice operators interpreted anatomical position using the built-in tube camera. Interpretation was checked from recorded images by consultant gastroenterologists and end-of-procedure checks using pH or X-ray checked by Radiologists and a consultant intensivist. RESULTS: The 40 patients were a median of 68y (IQR: 56-75), 70% male, mostly medical (65%), conscious (67.5%) and 70% had no artificial airway. Three tubes were removed due to failed placement. In the remaining 37 placements, novice operators identified the airway in 17 (45.9%) and airway + respiratory tract in 19 (51.4%), but redirected all these tubes into the oesophagus. By using direct vision to reduce the proportion of tubes near the airway or in respiratory tract from 0.514 to 0, operator discrimination between the respiratory and alimentary tracts was highly significant (0.514 vs 0: p < 0.0001, power >99.9% when significance = 0.05). In addition, organ boundaries (respiratory tract vs oesophagus, oesophagus vs stomach, stomach vs intestine) were identified in 100%. CONCLUSIONS: Novice operators, trained using the guide, identified all respiratory misplacements and accurately interpreted IRIS tube position. Guide-based training could enable widespread use of direct vision as a means to prevent tube-related complications.

Validation of image interpretation for direct vision-guided feeding tube placement.

BACKGROUND: Unguided (blind) tube placement commonly results in lung (1.6%) and oesophageal (5%) misplacement, which can lead to pneumothorax, aspiration pneumonia, death, feeding delays, and increased cost. Use of real-time direct vision may reduce risk. We validated the accuracy of a guide to train new operators in the use of direct vision-guided tube placement. METHODS: Using direct vision, operators matched anatomy viewed to anatomical markers in a preliminary operator guide. We examined how accurately the guide predicted tube position, specifically whether respiratory and gastrointestinal placement could be differentiated. RESULTS: A total of 100 patients each had one tube placement. Placement was aborted in 6% because of inability to enter or move beyond the oesophagus. In 15 of 20 placements in which the glottic opening was identified, the tube was maneuvered to avoid entry into the respiratory tract. Of 96 tubes that reached the oesophagus, 17 had entered the trachea; all were withdrawn pre-carina. One or more specific characteristics identified each organ, differentiating the trachea-oesophagus (P < 0.0001), oesophagus-stomach, and stomach-intestine in 100%. End-of-procedure tube position was ascertained by pH ≤4.0 (gastric) of aspirated fluid and/or x-ray (gastric or intestinal). In patients with a trauma risk (13%), it was avoided by identification that the tube remained within the nasal, oesophageal, or gastric lumen. CONCLUSION: Operators successfully matched anatomy seen by direct vision to images and descriptions of anatomy in the "operator guide." This validated that the operator guide accurately facilitates interpretation of tube position and enabled avoidance of lung trauma and oesophageal misplacement.