Literature Review for Safe Feeding Tube Placement Techniques
Author/year
Citation
LOE
Bourgault, A. & Halm,
M. (2009). Feeding
tube placement in
adults: Safe
verification method
for blindly inserted
tubes. American
Journal of Critical
Care, 18, 73-76.
5
Boyer, N., McCarthy,
M., & Mount, C.
(2014). Analysis of an
electromagnetic tube
placement device
versus a selfadvancing nasal
jejuna device for
post-pyloric feeding
tube placement.
Journal of Hospital
Medicine, 9(1), 23-28.
6
Study Aim/
Purpose
Synthesize
current
evidence on
the accuracy
of methods to
verify initial
placement of
blindly
inserted
feeding tubes
Compare the
Tiger 2 tube
and the
Cortrack
Enteral Access
System to
determine
which system
most
efficiently
achieved postpyloric
placement on
initial
insertion.
Population
Studied/Sampl
e Size/Criteria/
Power
12 pertinent
studies were
included in this
review
All patients on
a mixed
medicalsurgical ICU
who had either
type of feeding
tube placed.
145 small
bowel feeding
tubes: 71 T2T
and 74 C-EAS
Methods
Primary Outcome
Measures and Results
Author Conclusions
My Comments
Search included
MEDLINE, CINAHL and
hand searching
bibliographies. All types
of evidence (nonexperimental/
experimental,
systematic reviews)
were included
7 studies evaluated
pH, 3 used
capnography/capnom
etery, 3 used
auscultation, 2
measured bilirubin, 1
measured enzyme
levels, and 1 used
visual inspection
Retrospective chart
review. Patients who
received small bowel
feeding tubes were
identified via electronic
medical record;
confirmation of the
tube placement was
made by examining the
medical record.
Radiographs, radiologic
reports and archived
real-time tracings were
compared. Tubes were
considered successfully
placed if the first
confirmation film after
completion noted the
tip in post-pyloric
position.
Successful postpyloric placement was
achieved on the first
attempts in 62% of
the T2T and 43% of
the C-EAS. There were
no endotracheal
insertions or other
complications noted
during the study
period.
Radiology remains the only reliable
method to verify initial placement of
blindly inserted feeding tubes. According
to research and expert opinion secondary
confirmation via pH or carbon dioxide
testing must be performed regularly.
A secondary confirmation strategy such
as carbon dioxide testing could aid in
placement as well as detect inadvertent
airway placement before lung damage
occurs. However, radiology confirmation
should not be eliminated.
There is a statistically significant
difference favoring T2T over C-EAS. “One
reason for this difference may be that CEAS relies on user familiarity and
dexterity with electromagnetic guidance
system…The T2T system is more
simplistic in that no further training
beyond basic feeding tube insertion is
required.” However, one advantage to
the C-EAS is direct visualization of tube
placement.
Both systems allow for post-pyloric
placement, reducing the risk for
aspiration. The Cortrack system allows
direct visualization (reducing risk for
placement in the lung) but has a
significant learning curve unlike the Tiger
2 tube. The T2T tube by itself offers no
protection from accidental lung
placement.
Burns, S., Carpenter,
R., Blevins, C., Bragg,
S., Marshall, M.,
Browne, L., Perkins,
M., Bagby, R.,
Blackstone, K., &
Truwit, J. (2006).
Detection of
inadvertent airway
intubation during
gastric tube insertion:
Capnography versus
a colorimetric carbon
dioxide detector.
American Journal of
Critical Care, 15, 188195.
6
Compare
standard
capnography
with a
colorimetric
carbon
dioxide
detector to
determine
variables that
affect
accurate
placement of
gastric tubes
Convenience
sample of 195
gastric tubes
insertions in
130 adults in a
MICU
Part 1: feeding tube
placed 3 cm through
top of ET tube in 5
patients receiving
mechanical ventilation
to see if the
colorimetric device
would indicate the
presence of CO2.
Part 2: 195 consecutive
insertions of gastric
tubes were monitored
by using the unit’s
standard procedure
(capnography) while
also monitoring with a
colorimetric device. All
tubes that did not
register a change in
CO2 were injected with
a bolus of air to ensure
patency then sensing
devices were
reattached to test for
presence of CO2. If CO2
was detected the
insertion was
considered a failure
and tube was removed.
If none was detected,
successful placement
was ensured according
to standard hospital
policy (gastric contents,
x-ray).
Part 1: CO2 was
detected via the
capnography and
colorimetric device in
all 5 patients.
Part 2: CO2 was
detected (within
seconds) with the
colorimetric device in
all insertions in which
CO2 was detected
with capnography.
CO2 was detected in
27% of the insertions
and the mean
distance the tubes
were inserted before
CO2 was detected was
30 cm. Four nonfailure/non-verified
insertions occurred in
2 pts. All other
placements that did
not detect CO2 were
successful.
X-rays may be misinterpreted by bedside
staff, teaching how to use a colorimetric
device is easy and less expensive.
However, this procedure should not
replace final confirmatory x-ray (gold
standard).
Some training is required to ensure ports
are not occluded which would result in a
false-negative. Administering a 30 ml
bolus of air is essential. The colorimetric
device is inaccurate if it becomes wet.
This article indicated that this procedure
could be a simple method of improving
safety by preventing potential airway or
lung intubation with gastric tubes.
Chau, J., Thompson,
D., Fernandez, R.,
Griffiths, R., & Lo, H.
(2009). Methods for
determining the
correct nasogastric
tube placement after
insertion: a metaanalysis. JBI Library of
Systematic Reviews,
7(16), 679-760.
Howes, DW., Shelley,
ES, & Pickett, W.
(2005). Colorimetric
carbon dioxide
detector to
determine accidental
tracheal feeding tube
placement. Canadian
Journal of Anesthesia,
52(4), 428-432.
1
6
Present best
available
evidence
related to
methods used
to determine
the correct
placement of
nasogastric
tubes.
Determine
accuracy of
colorimetric
CO2 detection
compared to
standard twostep x-ray
confirmation
26 trials were
included in this
meta-analysis
93 gastric tube
placements on
adult patients
in a 21-bed
medical –
surgical ICU
A systematic review
was conducted and
eligibility and
methodological quality
was assessed by two
independent reviewers.
Data was extracted
using a data extraction
form. Data collected
included purpose of the
study, sample,
measurements used,
index test results and
reference standards.
Phase 1: briefly
inserted NG tube with
colorimetric CO2
detector in ET tubes of
10 ICU pts to evaluate
if device would detect
CO2. Phase 2: 93
feeding tube
placements were
confirmed with the
colorimetric device as
well as standard two
step x-ray
-Significant cost and
time savings using
CO2 detectors.
-High sensitivity and
specificity in detecting
airway intubation and
high agreement with
standard x-ray
-CO2 detectors cannot
replace final
confirmatory x-ray
since they can’t
determine final tip
location.
-Bedside ultrasound
examination is reliable
and sensitive but
requires extensive
training.
-Magnetic detection
to determine feeding
tube location showed
high sensitivity, but
practicality and ease
of use must be
considered in the
clinical setting.
Phase 1: Colorimetric
device correctly
identified CO2 in all
10 patients. Phase 2:
Colorimetric device
was 98% accurate
compared with the
two-step x-ray. The
colorimetric device
failed to detect CO2 in
one instance in which
the tube was placed in
the trachea.
“Based on the trials undertaken to date,
there is strong evidence to support the
use of capnography or colorimetric
capnometry for identification of feeding
tube placement in mechanically
ventilated patients…there is a paucity of
evidence to support the combination of
biochemical measurements, magnetic
detection and ultrasonography to locate
feeding tube position.”
Based on this review, CO2 detection could
be a cost-effective, efficient means to
increase patient safety related to feeding
tube placement.
It was determined that the one instance
in which the colorimetric device failed to
detect CO2 occurred because the devices
were being reused and it was used to the
point of failure. “When not reused, we
found the devices to be extremely
accurate in determining the placement of
NG feeding tubes.”
Technique appears accurate, requires
easily available materials and represents
a significant time savings over standard
two step x-ray approach.
Kindopp, A., Drover,
J., & Heyland, D.
(2001). Capnography
confirms correct
feeding tube
placement in
intensive care unit
patients. Canadian
Journal of Anesthesia,
48, 705-710.
6
Test accuracy
and potential
time savings
for
capnography
as compared
with a twostep x-ray
method for
placing
feeding tubes
in critically ill
patients
One hundred
feeding tube
placements in
a tertiary care
intensive care
unit on adult
patients
All feeding tube
placements utilized a
two step x-ray
approach, but
capnography was
added to the procedure
at the midway position
(30 cm for oral or 35
cm for nasal approach).
The feeding tubes were
10 French dual port
feeding tubes with
stylette. Tubes were
placed to 30 or 35 cm
and then 30 ml of air
was pushed through
the tube to clear any
secretions that may
interfere with gas
aspiration.
Capnography tubing
was attached and an xray obtained. The
feeding tube was
interpreted as being in
the esophagus,
trachea-bronchial, not
visible, or
indeterminate. Based
on the x-ray the
procedure was then
completed if feeding
tube was in the
esophagus.
Of the 100 feeding
tubes attempted, 11
were placed into the
respiratory system as
diagnosed by x-ray.
Capnography
identified all 11 of
these placements. In
this study,
capnography was
100% sensitive and
100% specific.
It is not surprising that 11% of tube
placements were intra-tracheal because
ICU patients are high risk for
complications associated with feeding
tube placement. The finding of carbon
dioxide with normal capnograms is
“unequivocal evidence” that the feeding
tube is in the respiratory track.
Capnography use adds only seconds to
tube placement unlike the traditional two
step x-ray approach. “A scenario
involving a feeding tube repeatedly
entering a patient’s respiratory system is
an example where capnography could
shave hours off the total time required
for placement.”
Eliminating at least one x-ray per
placement is more comfortable for the
patient and more convenient for bedside
staff and the patient. Also placement
time could be significantly decreased.
Krenitsky, J. (2011).
Blind bedside
placement of feeding
tubes: Treatment or
threat? Nutrition
Issues in
Gastroenterology, 93,
32-42.
7
Discuss
incidence and
risk factors for
bronchopleural
placement of
feeding tubes
as well as
strategies to
prevent
bronchopulmonary
injury.
8 observational
studies that
report on the
incidence of
SBFT
displacement
and injury.
Review and summary
of literature related to
SBFT displacement and
injury, risk factors, and
strategies for
prevention.
Small bore feeding
tubes allow passage
of the SBFT through
the smaller
bronchioles and the
stylette provides
rigidity to penetrate
lung tissue and cause
pneumothorax.
Reports on incidence
varied between
studies (1.2 to 2%) but
several authors
commented that
incidence is likely
underestimated due
to missed events. Risk
factors include altered
mental status,
tracheostomy or ET
tubes, critical illness,
absent cough reflex,
non-cooperative
patients, and
anatomic
abnormalities.
Prevention strategies
include two-step
protocol that
evaluated placement
at 25-35 cm and after
final placement using
x-ray, capnography, or
colorimetric CO2
detectors. Other
strategies include
Electromagnetic
visualization.
Although the incidence is relatively low
(1.2-2%), the large number of tubes
placed translated to a substantial number
of injuries and deaths (approximately
3,600- 8,400 pulmonary injures and up to
3,600 deaths in the US). “Recent
guidelines still endorse blind SBFT
placement, but as new data has emerged
recent guidelines encourage CO2
monitoring as a safety enhanced
protocol.
This article gives compelling evidence for
new protocols related to bedside feeding
tube placement. The author points out
that the equipment must be readily
available, easy to use, and there must be
a sufficient number of trained staff or else
noncompliance with new protocols is
likely to occur.
Methany, N. &
Meert, K. (2014).
Effectiveness of an
electromagnetic
feeding tube
placement device in
detecting inadvertent
respiratory
placement. American
Journal of Critical
Care, 23 (3), 240-247.
5
Describe peer
reviewed
studies that
report on
detection of
malpositioned
tubes inserted
using EMT
placement
devices and
events
reported to
the FDA’s
MAUDE
database
6 peer
reviewed
studies
published
between 2007
and 2012 and
21 adverse
event reports
from MAUDE
database for
2007-2012
Ovid MEDLINE search
was performed to find
peer-reviewed studies
that referred to use of
the electromagnetic
tube placement device
to detect
malpositioned feeding
tubes. Online search
was conducted of the
MAUDE database
using the brand names
Cortrack, Corflo Ultra
Lite, Corflo Feeding
tube with Transmistting
Stylet, and Corflow NG
Tube.
A total of 1725 patient
had feeding tubes
inserted using ETP
device in the 6
studies. 5 of the
studies reported
being able to detect
tube deviations into
the airway during
tube insertion
procedure allowing
them to prevent
damage to the lung.
Pneumothroax was
not reported in any
patient whose tube
was placed with ETP
method. However,
positive results were
often dependent on
the skill level of the
person inserting the
tube.
MAUDE reports
showed 20 of 21
events involved
broncho-pulmonary
placements with 17
resulting in
pneumothorax. 2
deaths were reported.
Radiology also failed
to reveal malposition
of feeding tubes in 4
cases described in the
MAUDE database
because of
misinterpretation or
failure to read in a
timely manner.
The 6 peer reviewed studies revealed no
incidence of pneumothorax indicating
that ETP device can be used by select
personnel to avoid respiratory
complications. Characteristics of “select”
personnel include, advanced practice
status, experience in placing small-bore
tubes, and an extended training period
on use of the ETP device. However, the
findings of the peer reviewed studies are
incongruent with the reports from the
MAUDE database. These reports indicate
that “failure to detect malpositioned
tubes has led to serious morbidity and
mortality (17 cases of pneumothorax, 1
perforation of the esophagus with entry
of the tube into the pelvic region, and 2
deaths).
Electromagnetic tube placement allows
for visualization of feeding tube
placement, but also relies heavily on the
skill level of the person inserting the tube.
Also I feel that the findings from the
MAUDE database show that a single
confirmation strategy is unsafe. One
method could fail but having a second
method may help in that case.
Powers, J., Fischer,
M., Ziemba-Davis, M.,
Brown, J., & Phillips,
D. (2013). Elimination
of radiographic
confirmation for
small-bowel feeding
tubes in critical care.
American Journal of
Critical Care, 22(6),
521-526.
6
Evaluate SBFT
placement
verification
procedures in
critical care
patients from
use of EMPD
with x-ray
confirmation
to placement
using EMPD
without x-ray
confirmation.
904 feeding
tube
placements in
632 adult
critical care
patients
All nurses on the
critical care units were
trained to place feeding
tubes by using EMPD.
Training included
overview of anatomy,
parenteral and enteral
nutrition, and
indications and
contraindications for
post-pyloric feeding
tube as well as the
correct method of tube
placement. The nurse
had to demonstrate
proper procedure on a
mannequin, take and
examination, and three
SBFT placements were
observed and validated
by a previously trained
nurse. Feeding tubes
were placed at the
bedside and verified by
a second nurse. If there
was any question of
tube location an x-ray
was obtained.
Descriptive statistic
were used to quantify
the success rate of
small bowel placement
of feeding tubes,
misinterpretation of
feeding tube locations,
and the need for x-ray
verification.
904 SBFTs were
placed using EMPD.
97.2% were placed in
the small bowel and
2.8% were located in
the gastric portion of
the digestive tract. No
adverse events of
pulmonary
placements were
observed. X-ray
confirmation of
feeding tube location
was required in only
7.7% of the 904
placements.
Use of EMPD for feeding tube placement
enables safe and effective placement of
feeding tubes at the bedside. This
procedure reduces nurses’ workload and
hospital costs.
The positive outcomes for this study can
likely be attributed to the extensive
training that the bedside staff received.
EMPD could be a valuable resource if
nurses are given the correct training.
Roberts, S.,
Echeverria, P., &
Gabriel, S. (2007).
Devices and
techniques for
bedside enteral
feeding tube
placement. Nutrition
in Clinical Practice,
22(4), 412-420.
7
Review
technologies
available to
help assist and
guide bedside
gastric and
SBFT
placement
and provides
tips for
placement.
Research about
different techniques for
gastric and small bowel
feeding tubes was
reviewed and
summarized resulting
in a guideline for
clinical practice.
-Esophageal
placement should be
confirmed before
tube is advanced
further than 35 cm
from the nares.
-2 step x-ray method
is the gold standard
for safe placement of
NGTs
-Colorimetric CO2
detectors can
substitute for the two
step x-ray method. It
is efficient, easy to
use, disposable,
inexpensive, and has
been tested in
critically ill patients
with 100% accuracy.
-A magnetically
guided technique uses
a magnetic device to
manipulate the
feeding tube through
the GI tract in the
small intestine;
however, the feeding
tube would have to be
removed for MRIs and
the magnet has
potential to disable a
pacer
-Electromagnetic
guided tube
placement provides
real time visualization
of the feeding tube as
it progresses into the
small intestine.
The primary goal is safe and accurate
placement with optimal timing for the
initiation of enteral feeding. “The use of
the described devices and techniques can
assist the clinician placing feeding tubes
and help assure patient safety and
judicious use of resources.”
There are multiple options supported by
research that can help improve safe
placement gastric and small bowel tubes
at the bedside. It is important to consider
how each option may work for our
institution.