Intensive and Critical Care Nursing (2004) 20, 330343

ORIGINAL ARTICLE

A review of the nursing care of enteral feeding

tubes in critically ill adults: part I
Teresa A. Williamsa,, Gavin D. Leslieb,1
a

Royal Perth Hospital, PO Box X2213, Perth, WA 6847, Australia

Centre for Nursing Evidence Based Practice, Education and Research, Royal Perth Hospital, PO Box
X2213, Perth, WA 6847, Australia

Accepted 9 August 2004

KEYWORDS
Enteral tube;
Feeding;
Intensive care

Summary Enteral tubes are frequently used in critically ill patients for feeding
and gastric decompression. Many of the nursing guidelines to facilitate the care
of patients with enteral tubes have not been based on current research, but on
ritual and opinion. Using a computerised literature search and an evidence-based
classication system as described by the Joanna Briggs Institute for Evidence Based
Nursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tube
management.
Several nursing practices related to enteral tube management are described. Evidence to support alternate methods of tube placement assessment other than abdominal X-ray was inconclusive. Enteral feeding should continue if gastric residual
volumes are not considered excessive, as feeding is often withheld unnecessarily.
Frequency of checking gastric residual volumes is largely opinion based and varies
considerably, but prokinetics that aid gastric emptying should be used if absorption
of feeds is problematic. Other recommendations include continuous rather than
intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspiration and diligent articial airway cuff management. Contamination of feeds can
be minimised by minimal, meticulous handling and the use of closed rather than
open systems. Generally, there was little high quality evidence to support practice recommendations leaving signicant scope for further research by nurses in the
management of patients with enteral tubes.
2004 Elsevier Ltd. All rights reserved.

Introduction
* Corresponding author. Tel.: +61 08 9224 2601;

fax: +61 08 9224 3196.

E-mail addresses: Teresa.Williams@health.wa.gov.au
(T.A. Williams), Gavin.Leslie@health.wa.gov.au (G.D. Leslie).
1 Tel.: +61 08 9224 8081; fax: +61 08 9224 1958.

Enteral tubes are frequently used in the critically ill patient for gastric decompression, delivery of medications and food substitutes. Although enteral feeding is benecial, as with most
healthcare interventions, there are risks and po-

0964-3397/$ see front matter 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2004.08.002

A review of the nursing care of enteral feeding tubes in critically ill adults
tential adverse events inherent with their clinical
application.
Nursing care of patients with enteral feeding
tubes has often been based on ritual and opinion
rather than current research (Booker et al., 2000;
Edwards and Metheny, 2000; Metheny, 1993). Best
practice is based on the highest levels of evidence
to facilitate the benets and minimise the harm associated with any therapy. The systematic and rigorous approach to the analysis and grading of research ndings in terms of level of evidence facilitates the development of specic guidelines, standards and recommendations to provide the best
possible care for every patient. In part I of this
two part paper, the current research ndings for
the nursing care of critically ill patients with enteral feeding tubes is reviewed. Nursing care of patients to prevent aspiration is described. In part 2
of this paper, nursing management and recommendations for implementing evidence-based protocols
for tube and feeding management are discussed.

Data sources and levels of evidence

Several methods were used to identify relevant articles for this review. A computerised literature
search of online databases MEDLINE (19662003),
EMBASE (19662003), CINAHL (19821996), and
the Cochrane Library (19922003) was conducted.
Searches were restricted to the English language,
adults and humans. Relevant abstracts were reviewed and identied articles assessed. The reference lists of all articles were examined for additional papers not previously identied. The evidence base applied in classifying literature was
adapted from the recommendations of The Joanna
Briggs Institute for Evidence Based Nursing and
Midwifery (The Joanna Briggs and Institute, 2002)
(Table 1).

Table 1
Level
Level
Level
Level
Level

331

Background
Nursing management of patients with enteral feeding tubes has a key role in ensuring the success
of enteral feeding (Marshall and West, 2004; Perry,
1997). Enteral feeding benets ICU patients by decreasing catabolic response to injury, maintaining
bowel mucosal integrity, decreasing translocation
of gut bacteria, improving wound healing and reducing septic complications (Bower et al., 1995;
Cerra et al., 1997; Galban et al., 2000; Hadeld
et al., 1995; Heyland et al., 1995; Heyland et
al., 1996; King and Kudsk, 1997; Lipman, 1998;
Moore et al., 1989; Romito, 1995; Sax, 1996). Although, some studies have demonstrated no clear
benet of enteral nutrition over parenteral nutrition (Braunschweig et al., 2001; Lipman, 1998), in
general, enteral feeding is accepted to be safer,
physiologically more compatible, associated with
better patient outcomes, and more economical
than parenteral nutrition, making it the preferred
and most popular route for nutrient administration
(Anonymous, 1994; ASPEN Board of Directors and
the Clinical Guidelines Task, 2002; Cerra et al.,
1997; Frost and Bihari, 1997; Reignier et al., 2002;
Sands, 1991). Enteral nutrition is recommended to
commence as soon as possible after initial patient
resuscitation (Alexander, 1999; Carr et al., 1996;
Cerra et al., 1997; Kompan et al., 1999; Lewis et
al., 2001; Taylor et al., 1999).
A wide variety of enteral tubes are commonly
used in ICU patients for the delivery of nutrition (Heyland et al., 1995). Tubes may be wide or
narrow-bore, gastric or intestinal. Typically they
are inserted nasally but oropharyngeal placement
may also be used. Wide bore tubes (e.g. 12 or
14 Fr) placed into the stomach are easy to insert
and aspirate but may be poorly tolerated because
of pharyngitis, otitis, trachealoesophageal erosion and oesophageal sphincter incompetence (Fry,
1985). Narrow-bore tubes inserted into the stomach

Levels of evidence.
Description

I
II
III.1
III.2

Level III.3
Level IV

Evidence obtained from a systematic review of all relevant randomized controlled trials
Evidence obtained from at least one properly designed randomized controlled trial
Evidence obtained from well-designed controlled trials, not randomized
Evidence obtained from comparative studies such as cohort studies, casecontrol studies
preferably from more than one centre or research group
Evidence obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments
Evidence from opinion of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees

Reproduced from: The Joanna Briggs and Institute (2002).

332

T.A. Williams, G.D. Leslie

or small intestine increase patient tolerance, reduce the risk of aspiration (Treloar and Stechmiller,
1984) and improve delivery of nutrition, but are difcult to aspirate, rupture, knot, block easily, and
tend to migrate unnoticed out of position (Marcuard
and Stegall, 1990; Powell et al., 1993; Treloar and
Stechmiller, 1984). Most patients commence feeding via a gastric tube (Preiser et al., 1999), which
is considered safe and efcient (Neumann and DeLegge, 2002), however, patients who develop gastric intolerance whilst being fed via this route may
be changed to an intestinal tube (Montejo et al.,
2002).

Complications of enteral tubes and feeding

Complications occur with enteral feeding (Cerra et
al., 1997) whatever type of tube is used (Table 2).
The incidence of complications varies considerably
and is largely unknown.
Pulmonary aspiration of oropharyngeal or gastric
contents is an important complication reported to
occur in 0.895% of critically ill patients (CataldiBetcher et al., 1983; Winterbauer et al., 1981), although the true incidence is unknown due to lack of
denition standardisation (Neumann and DeLegge,
2002) and silent aspiration. What is important is
whether the patient develops nosocomial pneumonia as a result of aspiration. Aspiration events are
often not accompanied by coughing or other signs of
Table 2

respiratory distress and may not be evident even to

skilled clinicians (Arrowsmith, 1993; Elpern, 1997;
Metheny et al., 1990). Critically ill patients with enteral tubes are at greater risk for aspiration because
of altered sensorium, sedative and narcotic medications, unstable physiological status and physical disruptions of the gastrointestinal tract (Booker
et al., 2000). The enteral tube bypasses the protective mechanisms of the oesophagus impinging
on the lower oesophageal sphincter increasing the
risk of gastro-oesophageal reux (Cook and Kollef,
1998; Ibanez et al., 1992; Orozco-Levi et al., 1995).
Oropharyngeal secretions have been found to be the
principal source of aspiration (Valles et al., 1995),
however, migration of bacteria along the tube from
the stomach to the upper airway may contaminate
oral secretions and increase the risk of pneumonia from aspiration (Anonymous, 1996; Ewig et al.,
1999; Inglis et al., 1993; Torres et al., 1992), although this process has been disputed (Bonten et
al., 1994; de Latorre et al., 1995). Despite frequent
suctioning, small volumes of pharyngeal secretions
may still be aspirated into the lower respiratory
tract increasing the risk of nosocomial pneumonia
(Finucane and Bynum, 1996). Risk factors associated with nosocomial pneumonia include organ system failure, method of airway management, age,
antibiotic exposure, level of consciousness and positioning of the patient (Kearns et al., 2000).
Intestinal feeding may be used for patients who
aspirate frequently or with a higher risk of gastric

Complications of enteral feeding in critically ill patients.

Complication

Study/results

Pulmonary aspiration

Cataldi-Betcher et al. (1983): 1%; Elpern et al. (1987): 77%

of ventilated patients; Esparza et al. (2001): 10% of
patients enterally fed; Metheny et al. (1986): 6% and 22%;
Mullan et al. (1992): 4%; Strong et al. (1992): 3140%;
Treloar and Stechmiller (1984): 0/30 (0%)
Eisenberg (1991); Metheny et al. (1990)

Other pulmonary complications (pulmonary haemorrhage, pneumothorax, pleural effusion, oesophageal perforation, pneumonitis)
Intolerance of feeding (such as high residual gastric
volumes, regurgitation, vomiting and diarrhoea)
Mechanical
Blocked feeding tubes
Inadvertant respiratory placement

Small bore tubes rupture, knot and block easily and

tend to migrate unnoticed out of position
Nonocclusive bowel necrosis

Adam and Batson (1997): 17% delivery interruption;

Cataldi-Betcher et al. (1983): 6.2%; Mentec et al. (2001):
upper digestive disorder 46%; McClave et al. (1999): 45%;
Montejo (1999): 63%
Adam and Batson (1997): 14% delivery interruption
Cataldi-Betcher et al. (1983): 3%; Pinilla et al. (2001): 7%
Aronchick et al. (1984): 4 cases in 3 months; Dorsey and
Cogordan (1985): 2 cases in 4 months; Harris and Huseby
(1989): 5.4%; Metheny et al. (1990): 10 cases in 2 years;
Valentine and Turner (1985): 0.3%
Marcuard and Stegall (1990); Powell et al. (1993); Treloar
and Stechmiller (1984)
Marvin et al. (2000): 0.3% in ICU trauma patients

A review of the nursing care of enteral feeding tubes in critically ill adults

Table 3

333

Studies assessing intestinal vs. gastric feeding.

Study

Design

Results

Davies et al. (2002) explored

whether nasojejunal feeding
improved tolerance of enteral
nutrition by reducing gastric
residual volumes
De Jonghe et al. (2001) assessed
the amount of nutrients required,
prescribed and delivered to critically ill patients

Randomised, prospective, clinical

study of 73 ICU patients

Demonstrated jejunal feeding

reduced gastric residual volumes
and tended to improve feeding
tolerance

Prospective cohort design in 51

consecutive patients who received
nutritional support either enterally
or intravenously for 2 days

Inadequate delivery of enteral

nutrition. Large volumes of
enterally fed nutrients wasted
because of inadequate timing in
stopping and restarting enteral
feeding
Clinical suspicion of aspiration was
insensitive and detected only 60%
of isotopically documented
aspirations. No difference in
aspiration rates between
gastrically and transpylorically fed
critically ill patients
Post pyloric feeding is associated
with a signicant reduction in
gastro-oesophageal regurgitation
and a trend toward less
microaspiration

Esparza et al. (2001) assessed the

difference in aspiration rates between gastrically and transpylorically fed patients in the ICU

Prospective study in 54 critically ill

patients

Heyland et al. (2001) determined

the extent to which postpyloric
feeding reduces gastroesophageal
regurgitation and pulmonary microaspiration in critically ill patients
Heyland et al. (2002) compared gastric with postpyloric feeding

Randomised trial with 33 patients

Kearns et al. (2000) investigated the

rate of ventilator acquired pneumonia and adequacy of nutrient
delivery of gastric vs. small intestine feeding

Prospective, randomised,
controlled trial. Medical ICU 44
endotracheally intubated,
mechanically ventilated patients

Kortbeek et al. (1999) evaluated

transpyloric feeds in ventilated
trauma patients

Randomised controlled trial of

duodenal vs. gastric feeds of 80
patients

McClave et al. (1999) evaluated factors that impact on the delivery of

enteral tube feeding

Prospective study 44 medical ICU

and coronary care units

Systematic review evaluated 10

randomised controlled trials

Patients who regurgitated were

much more likely to aspirate than
those who did not regurgitate.
Intestinal feeding more
advantageous. Gastro-oesophageal
regurgitation was reduced,
nutrient delivery increased, target
nutrition met in shorter time and
ventilator-associated pneumonia
reduced with intestinal feeding.
Small sample size threatens
internal validity. Use of surrogate
endpoint (>100 counts/min/g) may
not be clinically important
No clear difference in the
incidence of ventilator acquired
pneumonia in small intestine
compared with gastric enteral
nutrition. Small intestine feeding
received higher calorie and protein
intakes
Length of stay and ventilator days
were not signicantly different.
Transpyloric-duodenal feeds
signicantly reduced the time
required to achieve targeted
enteric nutrition
Half the patients received their
caloric requirements
underordering or frequent and
often inappropriate cessation of
feeding

334

T.A. Williams, G.D. Leslie

Table 3(Continued).
Study

Design

Results

Marik and Zaloga (2003) compared

gastric vs. post pyloric feeding

Systematic review and

meta-analysis of nine RCTs. Mixed
group of critically ill patients (n =
522), including medical,
neurosurgical, and trauma ICU
patients
Randomised, prospective study of
38 medical/surgical ICU patients

No demonstrated clinical benet

from post-pyloric vs. gastric tube
feeding. Incidences of pneumonia,
ICU LOS, and mortality were
similar between groups

Montecalvo et al. (1992) compared

nutritional status, gastric colonisation, and rates of nosocomial
pneumonia of gastric tube vs. jejunal tube feeding
Montejo et al. (2002) compared
the incidence of enteral nutritionrelated gastrointestinal complications, the efcacy of diet administration, and the incidence of nosocomial pneumonia in patients fed
in the stomach or in the jejunum
Neumann and DeLegge (2002) compared the outcomes of ICU patients fed through a nasogastric
vs. a nasal-small-bowel tube
Spain et al. (1995) evaluated the
rate of transpyloric migration, the
efcacy of adjunctive measures to
promote passage, and the effect
on pulmonary complications
Strong et al. (1992) assessed postpylorus delivery of enteral feeding
being safer than intragastric delivery

Prospective, randomised
multicentre study. ICUs in 11
teaching hospitals

Prospective study, 60 patients

randomised to receive gastric or
small-bowel tube feedings
Retrospective study of 74 patients

Retrospective study of 33 patients

motility dysfunction (Kirby et al., 1995). Whether

intestinal tubes decrease the rate of aspiration remains controversial (Table 3). Comparing aspiration rates between transpyloric and gastric feeding, some investigators have found no difference
in aspiration rates (Esparza et al., 2001; Kearns
et al., 2000; Neumann and DeLegge, 2002; Spain
et al., 1995; Strong et al., 1992) whilst other investigators have found decreased aspiration rates
which did not reach statistical signicant (Heyland
et al., 2001; Montecalvo et al., 1992). No difference was observed in the rate of nosocomial pneumonia (Kortbeek et al., 1999; Marik and Zaloga,
2003; Montejo et al., 2002) in the ICU length of
stay or mortality in patients fed gastrically versus
postpylorically (Marik and Zaloga, 2003), although
gastrointestinal complications were observed more
frequently in patients with gastric tubes (mainly
larger residual gastric volumes) (Montejo et al.,
2002).

Clinical nosocomial pneumonia in

two (10.5%) patients with gastric
tubes, none in the jejunal tube
group. Signicantly higher
proportion of nutrition and lower
rate of pneumonia in jejunal tube
fed patients
Gastrointestinal complications less
frequent in jejunal tube fed
patients. Accepted gastric residual
volumes of 300 ml in the intestinal
tube group
No increase in aspiration or other
adverse outcomes in gastric
feeding compared with
small-bowel feeding in the ICU
Failed to demonstrate any
advantages in nutrition from
intestinal tubes
Failed to demonstrate any
advantages in nutrition from
intestinal tubes

Rare complications include mesenteric ischaemia, with abdominal pain, distension, increased nasogastric drainage or intestinal ileus
seen with jejunal tubes (Lawlor et al., 1998; Rai
et al., 1996; Schunn and Daly, 1995; Smith-Choban
and Max, 1988) and small bowel necrosis, which
has been associated with a high mortality (Munshi
et al., 2000).
Enteral feeding is often delayed or ceased because of gastrointestinal intolerance (such as high
residual gastric volumes, regurgitation, vomiting
and diarrhoea) and for stoppage for procedures
(Adam and Batson, 1997; Heyland et al., 1995; Heyland et al., 2003). Many critically ill patients have
impaired gastric motility, often caused by medications such as opioids or catecholamines, hyperglycaemia, increased intracranial pressure, decreased
gastric blood ow or the response to stress and
pain (Montejo, 1999; Reignier et al., 2002). Stopping feeds because of the risk of gastrointestinal

A review of the nursing care of enteral feeding tubes in critically ill adults
complications may lead to underfeeding or loss of
other benets afforded by early enteral feeding.
Placement of intestinal tubes may be difcult and
time consuming, due to the technical expertise
and equipment that is required which may in turn
further delay feeding (Maykel and Bistrian, 2002).
Feeding via an intestinal tube has been reported
to provide a higher caloric intake than the gastric
route (Kearns et al., 2000; Kortbeek et al., 1999;
Montecalvo et al., 1992; Montejo et al., 2002), although other investigators report no nutritional advantages (Spain et al., 1995; Strong et al., 1992).
Other reasons for not meeting nutritional needs include fasting, procedures, stafng shortages, unavailability of feeds/equipment, low priorities for
feeding, variations in feed prescriptions (Adam and
Batson, 1997; Briggs, 1996; De Jonghe et al., 2001;
Marshall and West, 2004; McClave et al., 1999;
Spain et al., 1999) and blockages in feeding tubes
(Pinilla et al., 2001). Despite the risks and uncertainty of the best route of administration for enteral feeds, diligent tube maintenance is clearly a
nursing responsibility essential to the administration of enteral feeding.

Reducing the risk of aspiration

Residual gastric volumes
Nurses frequently assess gastro-intestinal function
by checking gastric residual volumes, listening for
bowel sounds and observing for abdominal distension in an attempt to reduce the risk and severity
of aspiration (Beattie et al., 1996; Eisenberg, 1994;
Jolliet et al., 1998; Kirby et al., 1995). The presence
of bowel sounds to conrm gastrointestinal function
is questionable (Anonymous, 1994). High residual
volumes may indicate delayed gastric emptying, intolerance to enteral feeding and increase the risk of
regurgitation and aspiration (McClave et al., 1992;
Metheny, 1993). Many conditions decrease gastric
motility, including drugs such as opioids, surgery,
trauma, shock and respiratory failure (Bosscha et
al., 1998; Dive et al., 1994; Tarling et al., 1997).
The measuring of gastric residual volume by aspiration with a syringe is a popular approach, although this has not been validated (Chapman et al.,
2000). Using a mobile gamma camera, scintigraphy,
is noninvasive, well tolerated, and may not interfere with nursing care (Horowitz and Dent, 1991),
however, its use in ICU is impractical (Chapman et
al., 2000). Methods that may be used in the future
include continuous monitoring of oesophageal tone,
electrogastrograms and tonometry (Alston, 2001).

335

Wide variation exists in the literature as to what

constitutes an excessive gastric residual volume.
The value that is considered to be acceptable or
excessive (Table 4 ) has not been established by controlled trials and is often based on opinion (McClave
et al., 1992; Metheny, 1993; Pinilla et al., 2001).
Measuring residual gastric volumes is an imprecise
method of determining gastric emptying and upper digestive functioning (Alston, 2001; Chapman
et al., 2000), with the volume of salivary and gastric secretions often not taken into account. In addition, gastric residual volume and the presence of
bowel sounds may not correlate with gastric emptying (Goldhill et al., 1997). Having high residual
gastric volumes does not always imply gastric stasis (Jooste et al., 1999) suggesting the rationale for
using gastric residual volumes is awed (Burd and
Lentz, 2001; McClave and Snider, 2002). The current practice of stopping enteral feeding if gastric
residual volumes are less than 400500 ml is not
physiologically or clinically appropriate (Lin and Van
Citters, 1997). Decreasing the designated threshold
of gastric residual volume at which feeds should
be withheld does not decrease the risk of aspiration (Lukan et al., 2002; McClave and Snider, 2002;
Pinilla et al., 2001; Powell et al., 1993).
Despite few randomised controlled trials being
conducted regarding the management of gastric
residual volumes (Booker et al., 2000), current research supports continuation of feeding if possible (Davies et al., 2002; Jolliet et al., 1998; McClave and Snider, 2002; Mentec et al., 2001). Elevated residual volumes should alert clinicians to
potential problems, but a single high gastric residual volume should not result in automatic cessation of feeding. Feeding should continue whilst
the patient is closely monitored (McClave et al.,
1992). Cessation of enteral feeding due to high
residual volumes is a frequent avoidable action
contributing to inadequate caloric intake (Spain
et al., 1999). It has been recommended that only
patients demonstrating overt regurgitation, vomiting or aspiration should have their feeds abruptly
ceased (McClave and Snider, 2002). If gastric aspirates exceed 500 ml, then it has been recommended
that feeds should be withheld and the patient reassessed (McClave et al., 2002). Gastric aspirates of
500 ml or less should be returned. If the aspirate is
200500 ml, careful bedside assessment using a decision algorithm to manage enteral nutrition delivery is recommended (McClave et al., 2002). Feeding
should continue whilst reducing the rate of feeding
and administering prokinetics considered (Mentec
et al., 2001). Further studies are needed to determine the amount of gastric residual volume that is
excessive.

336

Table 4

T.A. Williams, G.D. Leslie

Studies investigating gastric residual volumes.

Study

Design

Comments

Burd and Lentz (2001) estimated

gastric volume

Mathematical model

Evaluation of gastric residual volume is

an unreliable method to monitor feeding
intolerance
25% of patients with high gastric residual
volumes (greater than 150 ml or more
than twice the hourly nutritional
administration rate) had normal
paracetamol absorption tests for gastric
empting
Accepted gastric residual volumes of
250 ml more than the amount delivered
since the previous gastric aspiration
before ceasing feeding. Complications
were rare and they had a much higher
rate of tolerated enteral nutrition when
compared to other studies
Large variation in gastric emptying was
observed. The volume of gastric aspirate
and the presence of bowel sounds did not
correlate with gastric emptying

Prospective study of 32 critically

Cohen et al. (2000) assessed the
ill patients
effect of continuing enteral
nutrition in patients with an
elevated gastric residual volume
but normal gastric emptying by
the paracetamol absorption test
Davies et al. (2002) compared
Prospective study
nasojejunal to nasogastric
feeding in critically ill patients

Goldhill et al. (1997) investigated

the absorption of cisapride, and
its effect on gastric emptying
and the usefulness of clinical
signs of gastric emptying
Jolliet et al. (1998) assessed a
simple approach to optimise
enteral nutrition modalities
with practical application.
Jooste et al. (1999) assessed the
effect of metoclopramide on
gastric motility in critically ill
patients
Lin and Van Citters (1997) tested
hypothesis that gastric residual
volume increases with slower
gastric emptying and faster
formula delivery but reaches a
plateau volume
McClave et al. (1992) investigated
the gastric residual volume that
indicates intolerance or
inadequate gastric emptying

McClave and Snider (2002)

summarised results from studies
that evaluated the practice,
interpretation, and impact on
patient outcome from use of
gastric residual volume

RCT involving 27 patients

Literature review by the working

group on nutrition and metabolism
of the European Society for
Intensive Care Medicine
Prospective, controlled,
single-blind cross-over trial in 10
patients
Computer simulation modelling

Assessed 20 healthy normal

volunteers, 8 stable patients with
gastrostomy tubes and 10
critically ill patients prospectively
for 8 h while receiving enteral
nutrition

Systematic review

Rrate of feeding should be decreased if

gastric residual volumes were greater
than 300 ml
High residual gastric volume did not
always imply gastric stasis.
Metoclopramide effective prokinetic
agent
Practice of stopping enteral feeding if
gastric residual volumes were less than
400500 ml not physiologically or
clinically appropriate
Wide range of residual volumes (even up
to 400 ml) were seen with no obvious
intolerance such as regurgitation.
Residual volumes were higher with higher
feeding rates. Should be wary when
residual volumes exceed 200 ml. Small
sample size and narrow sampling time
frame (6 h following fasting for 2 h)
threaten the internal validity of this
study. Rate of feeding may not be
appropriate for patients who have been
fasting
Use of gastric residual volumes as a
marker of impending clinical
deterioration is limited by the fact that
the timing of increases in GRV is
unpredictable and high GRVs do not
correlate independently to adverse
outcome. Practice of GRV may in fact
impede delivery of ETF by promoting
inappropriate cessation and reducing
potential infusion time

A review of the nursing care of enteral feeding tubes in critically ill adults

337

Table 4 (Continued.)
Study

Design

Comments

Mentec et al. (2001) investigated

the frequency of and risk
factors for increased gastric
residual volume and upper
digestive intolerance (dened
as vomiting or increased gastric
residual volumes) and their
complications

Prospective observational study in

153 patients receiving nasogastric
tube feeding. Aspirate was
returned to the patient unless it
exceeded 500 ml

Spain et al. (1999) determined

whether the use of an infusion
protocol could improve the
delivery of enteral tube feeding
in ICU
Tarling et al. (1997) described the
range and factors that may
affect gastric emptying in the
critically ill patient using a
paracetamol absorption test

Prospective study, 31 patients in

the protocol group with 44
patients in the control group

High residual gastric volumes were

frequent, occurred early and more
frequent in patients receiving
catecholamines or sedation. High residual
gastric volumes were an early marker of
upper digestive intolerance, which was
associated with a higher incidence of
nosocomial pneumonia, longer stays in
the intensive care unit and a higher ICU
mortality rate. Rather than discontinue
feeding, the investigators recommended
more aggressive use of prokinetics
Cessation of enteral feeding due to high
residual volumes was a frequent
avoidable problem contributing to
inadequate caloric intake

Validation study of 27 ICU patients Observed a wide range of volumes in

gastric emptying. Over 50% of patients in
a validation sample had normal gastric
residual volumes despite abnormal
paracetamol absorption tests for gastric
emptying

Enhancing gastric motility by the use of prokinetic agents, with differing pharmacological properties, have been supported by randomised trials
(Boivin and Levy, 2001; Booth et al., 2002; Chapman et al., 2000; Heyland et al., 1996; Jooste et
al., 1999; MacLaren et al., 2000; Spapen et al.,
1995; Yavagal et al., 2000). Metoclopramide is a
selective dopamine-2 receptor antagonist that enhances cholinergic induced peristaltic contractility of the upper gastrointestinal tract (MacLaren et
al., 2000). Cisapride acts by selectively enhancing
cholinergic motor activity throughout the gastrointestinal tract (MacLaren et al., 2000). Eythromycin
enhances motilin release from the duodenal enterochromafn cells (MacLaren et al., 2000). A systematic review of promotility drugs concluded that
prokinetics are effective in promoting gastric emptying in ICU patients (Booth et al., 2002; MacLaren
et al., 2000). Introducing prokinetic agents early
has been suggested when the pre feeding residual
volume exceeds 20 ml or during feeding if residual volumes exceed 100 ml, (Mentec et al., 2001).
Mandatory use of prokinetics reduces the incidence
of enteral feeding intolerance (Pinilla et al., 2001).
Whether these drugs improve the amount of nutrition patients receive is not proven (Pinilla et al.,
2001). There are concerns regarding their safety
and lack of effect on clinical outcomes such as survival (Booth et al., 2002).

The frequency of checking gastric residual volumes varies from 2 to 24 hourly (Arrowsmith,
1993; Bowers, 1996; Cataldi-Betcher et al., 1983;
Goodwin, 1996), and is opinion based. Aspiration
regimes include 4 hourly on the rst day of feeding and then 8 hourly (Fellows et al., 2000); 3 to 4
hourly when feeding was commenced then checking
daily once full volume and tolerance is established
(Goodwin, 1996; Jolliet et al., 1998; Kleibeuker and
Boersma-van Ek, 1991); and 4 to 12 hourly (Edwards
and Metheny, 2000; Metheny, 1993; Payne-James,
1992). The risk of aspiration during continuous nasogastric tube feeding has been reported as greatest during the rst few hours of administration
(Kleibeuker and Boersma-van Ek, 1991). It may be
necessary to monitor residuals more closely during
the early phase of feeding, and then less frequently
once feeding is established. In patients with established feeding and where volume of aspirate is not
a problem, consideration may be given to less frequent aspirations (Fellows et al., 2000). Although
there are no established guidelines indicating how
often enteral tubes should be aspirated, most institutions follow some type of protocol although compliance issues have been identied (Breach and Saldanha, 1988; Sands, 1991).
Discarding gastric aspirate may result in loss of
gastric uid and electrolytes (Cataldi-Betcher et
al., 1983) but reduces the potential for contami-

338

Table 5

T.A. Williams, G.D. Leslie

Studies investigating return of gastric aspirates.

Study

Design

Comments

Booker et al. (2000) studied the

effects of discarding vs. returning
gastric residual volumes on body
weight, electrolyte levels, and
complications associated with
tube feeding

Randomised controlled trial, 35

patients but only 18 sets of useable
data obtained

McClave and Snider (2002)

summarised results from studies
that evaluated the practice,
interpretation, and impact on
patient outcome from use of
gastric residual volume

Systematic review

No signicant differences between

the discard group or return group.
Both groups had substantial
numbers of complications,
including feeding delays due to
high gastric residual volumes (7 in
the discard group and 8 in the
return group). Although electrolyte
levels did not differ signicantly
between the 2 groups, potassium
levels tended to be lower in the
discard group. Small sample size,
many data being collected
retrospectively and the effect of
uid intake and output not being
measured that may have inuenced
electrolyte status threatened
internal validity
Recommended that aspirates be
returned

nation during the aspiration process and clogging

of enteral tubes when aspirate is returned. A RCT
found no signicant differences in outcomes between the discard group or return group (Booker et
al., 2000), although potassium levels tended to be
lower in the discard group (Table 5). Small sample
size, many data being collected retrospectively and
the effect of uid intake and output that may have
inuenced electrolyte status not being measured,
threatened study internal validity.

Patient positioning during enteral feeding

Continuous feeding increases the risk of aspiration as the oesophageal sphincter remains open,
therefore, nursing the patient at a minimum of
3045 elevation has been recommended to reduce this risk (Table 6) (Arrowsmith, 1993; Bowers, 1996; Drakulovic et al., 1999; Elpern, 1997;
Ibanez et al., 1992; Kirby et al., 1995; Kollef, 1993;
Orozco-Levi et al., 1995; Potts et al., 1993; The
Joanna Briggs and Institute, 2002; Torres et al.,
1992; Treloar and Stechmiller, 1984). Some investigators believe that elevating the head of the bed
does not prevent aspiration (Elpern et al., 1987),
however, the semi-recumbent position may reduce
the risk. Because the head up position is difcult to achieve at all times, aspiration may occur

during those times when a patient has to lie at

(Metheny, 1993).

Management of articial airways

Patients with articial airways are at risk of aspiration. Decreased elevation of the larynx, obstruction
by the cuff of the articial airway, decreased sensation of the larynx, reduced reexes due to chronic
airway diversion and uncoordinated laryngeal closure due to chronic upper airway bypass have been
noted with the use of articial airways (Goodwin,
1996). Tracheostomy tube cuffs do not prevent aspiration, even when properly inated (Elpern et
al., 1987; Koeman et al., 2001). Whilst trial based
evidence is lacking, a cuff pressure maintained at
2025 cmH2 O and regular oropharyngeal suctioning
to the back of the mouth in intubated patients has
been well supported by expert opinion to minimise
the risk of aspiration (Elpern, 1997).

Mouth care
The risk for aspiration pneumonia is decreased by
up to 60% in patients receiving aggressive oral hygiene/decontamination (Koeman et al., 2001; Terpenning et al., 2001; Yoneyama et al., 2002). Pa-

A review of the nursing care of enteral feeding tubes in critically ill adults

Table 6

339

Studies evaluating patient position in patients receiving enteral nutrition.

Study

Results

Drakulovic et al. (1999)

The frequency of suspected and microbiologically conrmed pneumonia was

signicantly less in patients randomised to the semi-recumbent position
The upright position was used 80% of the time in 31 intubated patients and an
aspiration rate of 27% was observed
Randomised controlled trials demonstrated greater gastro-oesophageal reux
in patients with orotracheal intubation and naso gastric tube. Semirecumbency
does not prevent GER, but there is less incidence than in the supine position
Three times increased risk of nosocomial pneumonia during the rst 24 h of
mechanical ventilation in cohort of patients nursed supine
Prospective, randomised crossover design studies observed that the supine
body position had a higher rate of pulmonary aspiration but clinically
signicant aspiration was not observed. Higher radioactive counts of
technetium sulphur colloid, instilled into the stomach, in endobronchial
secretions in patients nursed supine
Patients with clinically signicant aspiration were fed supine 98% of the time,
patients who did not aspirate being fed supine only 21% of the time
Prospective, randomised crossover design studies observed that the supine
body position had a higher rate of pulmonary aspiration but clinically
signicant aspiration was not observed. Higher radioactive counts of
technetium sulphur colloid, instilled into the stomach, in endobronchial
secretions in patients nursed supine
Zero incidence of aspiration when the head of the bed was elevated by 3045

Elpern et al. (1987)

Ibanez et al. (1992)
Kollef (1993)
Orozco-Levi et al. (1995)

Potts et al. (1993)

Torres et al. (1992)

Treloar and Stechmiller (1984)

tients should receive regular mouth care (McClave

et al., 2002) but antiseptic solutions should be used
in preference to antimicrobials to decrease the possibility of antimicrobial resistance (DeRiso et al.,
1996).

Continuous versus intermittent feeding

Continuous feeding delivered via a peristaltic pump
is considered to reduce the risk of aspiration be-

Table 7

cause of the assured constant delivery volume and

smaller volumes in the stomach at any one time
(Ciocon et al., 1992; Kocan and Hickisch, 1986;
Steevens et al., 2002). Intermittent feeding supposedly allows pH to restore itself between boluses
of food thus minimising gastric colonisation. However, critically ill patients have higher than normal
pH (Metheny et al., 1997). Studies evaluating intermittent feeding have design and methodological
aws. Although no signicant differences have been
found between continuous and intermittent feeding

Continuous vs. intermittent feeding.

Study

Design

Comments

McKinlay et al. (2001) compared the

effect of recent changes in system
design on the levels and incidence
of bacterial contamination in enteral tube feeds
McKinlay et al. (1995) compared the
levels and types of microorganisms present in residual nutrient
containers and giving sets
Spilker et al. (1996) evaluated
the effect of intermittent enteral
feeding on gastric pH and gastric
microbial growth in mechanically
ventilated patients

Randomised study of 34
neurological ICU patients

No differences in bowel activity,

evidence of aspiration or meeting
caloric targets were found

Randomised study of 18 trauma

patients

Continuous feeding facilitated

nutrient delivery with less
gastrointestinal complications

13 patients converted from

continuous to intermittent feeding

No signicant differences were

found between the 2 groups

340
(Elpern, 1997; McKinlay et al., 2001; Spilker et al.,
1996) (Table 7) continuous feeding has been recommended (McClave et al., 2002; Metheny et al.,
2002) on the basis it facilitates nutrient delivery
with less gastrointestinal complications (McKinlay
et al., 1995).

Conclusion
When patients are unable to feed normally, the
use of enteral tubes for nutrition delivery provide the best alternative mode of sustenance. However, their use is not without risk. Of all complications from enteral feeding tubes, pulmonary aspiration represents one of the most frequent and
problematic issues. Nursing measures to minimise
this risk include regular checking of gastric residual volumes, continuous rather than intermittent
feeding, semi-recumbent positioning to reduce the
risk of airway aspiration, good oral hygiene practices and diligent articial airway cuff management. Frequency of checking gastric residual volumes is largely opinion based and varies considerably, but prokinetics that aid gastric emptying
should be used if absorption of feeds is problematic. In part two of this paper, other nursing management issues are discussed and recommendations
for enteral tube placement, care and maintenance
are described.

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