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Nutrition Support In Mechanical Ventilated
Patients
Pranithi Hongsprabhas MD.
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Swallowing function Oral phase
Preparation &movement of food from oral cavity to pharynx
Pharyngeal phase Soft palate rises to close nasal
cavity Vocal cords adducts Epiglottis tilts and shields larynx Respiration is temporarily
inhibited Pharynx contracts
esophageal phase upper esophageal sphincter
relaxes peristalsis
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The most dreaded complication of tube feedings is tracheobronchial
aspiration of gastric content
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Tube feeding associated aspiration
The most serious complication of ENClinically unimportant to respiratory
failure Clinically silent or cough, choking to
ARDS
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Aspiration categories
Oropharygeal bacteriaInert fluid, particulateAcidified gastric contents
Wynne JW et al. Ann Intern Med 1977, 87:486
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Prevalence and mortality
Prevalence Varies 70% in depressed
consciousness 22% in ICU 50-75% in ET
intubation 0-40 % EN
associated
Mortality62% in witness
aspiration40% with 1-lobe,
90% with 2 or more
Gastric aspiration:
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Risk factors for aspiration
Naso/oral enteral intubationTracheal intubationEnteral tube feedingIncreased age with physiologic
insultGastroparesisGastroesophageal reflux (GER)
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Risk factors for aspiration
Decreased level of consciousness (LOC)
Anesthesia Neurological disorderSeizureSupine position
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Impaired level of consciousness
StrokeHead injurySedationAnesthesia
Impaired ability to protect airway
Cough and gag LES GET
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Regurgitation and dysphagia
Increased risk of aspiration
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Cough and gag reflexes
Absence or presence of gag reflex: not influence the risk of aspiration
Cough reflex may or may not prevent aspiration
diminished cough or gag reflexes are not reliable indicators or aspiration risk
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Nasal or oral feeding tubes
Increased oropharyngeal secretions Impairment of laryngeal elevationDisruption of UES, LES Increased GER (75 vs. 35%)*,
aspiration
*Ibanez J. et al.JPEN 1992;16:419
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Gastric vs. small bowel feeding
Controversy Early study : SB feeding less aspiration Later study : not confirm
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ASPEN 2005
Acute brain injury Impaired gastric function: delayed GET Impaired LES: regurgitationPost pyloric feeding: more preferred
Jejunal feeding Better tolerate Less reflux
Gleghon E. et al. Neurologic diseases in: ASPEN manual 2005: -246255.
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Size of NG-NE tube
Children: Less GER in Fr8 vs Fr10-12
Adult No significant different in GER,
aspiration rate
Ferrer M. et al.Ann Int Med 19992;130:991
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Malposition of feeding tube
Faulty initial placementUpward dislocation
Increased risk when tube ports in or near esophagus
Need to confirm feeding tube position
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Enteral feeding schedule
Bolus vs. continuous feedingBolus: higher aspiration risk
Decreased LES intragastric pressure
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Intermittent vs. continuous
33.3%
16.67% 17.647%
5.89%
0
5
10
15
20
25
30
35
Ciocon study Kocan study
IntermittentContinuous
Asp
iratio
n ra
te (
%)
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Tracheal intubation /MV
Reduce upper airway defense Cough Desensitization of pharynx and larynx Laryngeal m atrophy
Esophageal compression Increase abdominal pressure: GER Sedation
increased risk after 48 hr. and 1%/day in MV
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Vomiting
Increased risk of aspiration Forceful entry of gastric content into
oropharynx Displacement of feeding tube
Sedation increases risk of vomiting
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Regurgitation and dysphagia
Increased risk of aspiration
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Cough and gag reflexes
Absence or presence of gag reflex: not influence the risk of aspiration
Cough reflex may or may not prevent aspiration
diminished cough or gag reflexes are not reliable indicators or aspiration risk
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Body position
Supine position: associated with more aspiration
Less aspiration with elevation of head of bed 30-45° during EN feeding
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Position and GER/aspiration
Aspiration: supine vs. semirecumbent MV patients* Semirecumbent decreases GER compare to supine#
*Torres A et al: Ann Int Med 1992;116:540-3
4154 cpm
954 cpm
68%
32%
0
10
20
30
40
50
60
70
Radioactive Culture
Supine
Semirecumbent
#Orozco-Levi et al. Am J Respi Crit Care 1995;152:1387
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Position and Pneumonia
0
5
10
15
20
25
Drakulovic et al Kollef et al
Supine Semirecumbent
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Recognizing patients at risk of AP
Decreased LOCTracheal intubationMVNG, NEMajor abdominal and thoracic
trauma/surgeryDMAdvance age
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Gastric residual volume (GRV)
HistoryUnderlying rationale Inherent flaws in the rationale Inherent flaws in the practiceClinical pattern of GRVEvidence of correlation of GRV with
ENEvidence of GRV and aspiratiom
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Gastric residual volume (GRV)
GRV >150-200 ml Fluid in stomach:
3000/d ~125ml/hr
50 ml???? Use less GRV: receive
nutrient lessGRV and risk of
aspiration: controversy
GI Secretion (ml)
Saliva 1000
Gastric 2000
Pancreatic 2000
Bile 1000
Small bowel 1000
Reach colon 600-1500
The Washington Manual of Surgery. Chapter14
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Clinical pattern of GRV
GRV>100 GRV>150 GRV>200
Normal volunteers
40% (11%) 15% (2.4%) 0% (0%)
Critically ill NG
50% (27.4%)
50% (13.1%)
30% (4.3%)
Critically ill PEG
25% (2.5%) 0% (0%) 0% (0%)
McClave SA, et al. JPEN 1992;16:99
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Correlation of GRV with ETF
Change in ETF rate change in GRVGRV increases at the initial but
decreases as feeds continueBolus generate more GRVGRV obtained from NG>gastrostomy
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GRV and aspiration: Pro
GRV>500, 2
consecutive GRV150-500, or
vomiting, 43%
without intolerace,
24%
0%
10%
20%
30%
40%
50%
Mentec H. Critical Care Med 2001;29:1955-61.
P=0.01
GRV<100 ml, 33.4
>2 GRV>=150ml,
46.6
>2GRV>=200ml, 44.2
0
10
20
30
40
50
Evidence of aspiration (gastric pepsin)Metheney NA. JPEN2005;29:S10.
P=0.020
P=0.018
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Incidence of regurgitation by range of GRV
GRV 0-50
GRV 51-100
GRV101-150
GRV151-200
GRV201-299
GRV300-399
GRV400+
P-value
Regurgit-tion
28.7%
(439)
41.0%
(39)
29.4%
(17)
35.7%
(14)
33.3%
(9)
40.0%
(5)
37.5%
(8)
0.134
Aspiration 22.8%
(501
23.7%
(38)
26.7%
(15)
20.0%
(10)
0.0%
(10)
40.0%
(5)
25.0%
(8)
0.412
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GRV and aspiration: Cons
Paracetamol absorption test (GET): no difference in GRV McClave 2005: found no difference in aspiration (using
yellow dye) in GRV<150 ml vs.>150 ml, and >400 ml
GRV 0-50
GRV 51-100
GRV101-150
GRV151-200
GRV201-299
GRV300-399
GRV400+
P-value
Regurgit-tion
28.7%
(439)
41.0%
(39)
29.4%
(17)
35.7%
(14)
33.3%
(9)
40.0%
(5)
37.5%
(8)
0.134
Aspiration 22.8%
(501
23.7%
(38)
26.7%
(15)
20.0%
(10)
0.0%
(10)
40.0%
(5)
25.0%
(8)
0.412
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GRV and aspiration: Cons
Lukan JK. AJCN 2002;75:417S
35%
27.80%21.6%
22.6%
0
5
10
15
20
25
30
35
Regurgitation Aspiration
GRV> 200 mlGRV 400 ml
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Prevention
Head of bed elevation 30-45°Verify tube placementGastric aspirate: GRVEvaluate GI intolerance
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GI intolerance
Abdominal discomfortBowel movementAbdominal distentionBowel soundGRVTrend to increased GRV Trend to
increased GRVRadiography
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Conclusion
Identify the risk patientsPrevention
Verify tube placement position Position: head of bed elevation Avoid bolus feeding