02544
2013
PENXXX10.1177/0148607113502544Journal of Parenteral and Enteral NutritionQuilliot et al
Brief Communication
Self-Insertion of a Nasogastric Tube for Home Enteral Nutrition: A Pilot Study Didier Quilliot, MD, PhD1,2; Camille Zallot, MD2,3; Aurélie Malgras, MD1; Adeline Germain, MD2,4; Laurent Bresler, MD, PhD4; Ahmet Ayav, MD, PhD2,4; Marc-André Bigard, MD, PhD3; Laurent Peyrin-Biroulet, MD, PhD2,3; and Olivier Ziegler, MD, PhD1,2
Journal of Parenteral and Enteral Nutrition Volume 38 Number 7 September 2014 895–900 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113502544 jpen.sagepub.com hosted at online.sagepub.com
Abstract Background: Enteral tube feeding can be a source of discomfort and reluctance from patients. We evaluated for the first time the tolerability of self-insertion of a nasogastric (NG) tube for home enteral nutrition (EN). Materials and Methods: All patients requiring enteral tube feeding for chronic diseases were enrolled in a therapeutic patient education (TPE) program at Nancy University Hospital. Results: In our department, between November 2008 and August 2012, 66 patients received EN with an NG tube. Twenty-nine of 66 had self-insertion of the NG tube (median age, 44 years), 17 had an anatomical contraindication, and 20 were excluded because of cognitive disability or language barrier or refusal. Twenty-eight of 29 patients completed the TPE program. One patient died of pancreatic cancer in palliative care during the study. Median follow-up was 20 months (interquartile range [IQR], 4–31). Median gain weight was 3.1 kg (IQR, 1.8–6.0) (P = .0002). Median duration of self-insertion of the NG tube was 3 months (IQR, 2–5), and it was well tolerated by all 29 patients. Two patients described minor adverse events: abdominal pain and nausea for 1 patient and epistaxis leading to temporary discontinuation of EN for another patient. A group of 10 consecutive patients previously had a long-term NG tube for EN. If they had the choice between a self-inserted NG tube and a long-term NG tube, all 10 patients reported they would prefer to start again with the self-inserted NG tube. Conclusion: This pilot study suggests that self-insertion of an NG tube may be efficacious and well tolerated in patients receiving EN for chronic conditions. (JPEN J Parenter Enteral Nutr. 2014;38:895-900)
Keywords enteral tube feeding; self-insertion of nasogastric tube; self-management; home enteral nutrition; therapeutic patient education
Clinical Relevancy Statement Guidelines on artificial enteral nutrition (EN) recommend a nasogastric (NG) tube for short-term duration or percutaneous endoscopic gastrostomy and jejunostomy for a period exceeding 2–3 weeks. Enteral tube feeding (ETF) can be a source of discomfort and reluctance from patients. We propose an alternative method for EN with a self-insertion of the NG tube for home EN. These findings are clinically relevant for feeding patients who require EN.
Introduction Enteral tube feeding (ETF) is used to feed patients who cannot attain adequate oral intake from food and/or nutrition supplements or who cannot eat/drink safely.1 Improving or maintaining nutrition status is the main aim of ETF.2 Over the past 2 decades, numerous studies on home enteral nutrition (EN) demonstrated that it is a valid and safe technique for nutrition support.3,4 Long-term ETF can be a source of discomfort and esophagitis and predisposes to nasal and maxillary sinus inflammation.5,6 Furthermore, some patients are reluctant to have ETF because of cosmetic unacceptability, risk of unwanted extubation, sick leave, and negative impact on
quality of life, leading to poor adherence to ETF in home care.7,8 We developed a therapeutic patient education (TPE) program with the aim of teaching self-insertion of the NG tube, based on the experience from self-catherization in urinary tract diseases as described by Lapides et al9 in 1972.10 Self-insertion
From the 1Department of Nutrition, Nancy University Hospital, Vandoeuvre-les-Nancy, France; 2INSERM U954, Medical Faculty and CHU of Nancy, Vandoeuvre-les-Nancy, France; 3Department of Gastroenterology, Nancy University Hospital, Vandoeuvre-les-Nancy, France; and 4Department of Hepatobiliary, Digestive and Endocrine Surgery, Nancy University Hospital, Vandoeuvre-les-Nancy, France. Didier Quilliot and Camille Zallot contributed equally to this work. Financial disclosure: None declared. Received for publication March 25, 2013; accepted for publication August 1, 2013. This article originally appeared online on October 18, 2013. Corresponding Author: Didier Quilliot, MD, PhD, Department of Nutrition, Nancy University Hospital, Allée du Morvan, 54511 Vandœuvre-lès-Nancy, France. Email: [email protected]
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Table 1. Therapeutic Patient Education Program. Time 8:00-8:30 am 8:30-9:00 am 9:00-9:30 am 9:30-10:00 am 10:00-11:00 am
11:00 am 12:00-1:00 pm 1:00-3:00 pm 3:00-4:00 pm
4:00-6:00 pm 6:30-7:00 pm 9:00-9:30 pm 9:30 pm to 9:00 am
Day 1 Welcome, installation, recording vital signs Data collection
Day 2
Day 3
Discontinuation of EN products and removal of tube by patient Recording vital signs Lunch Break
Discontinuation of EN products and removal of tube by patient Recording vital signs Lunch If necessary: Workshop 3 “Self-insertion of the tube” Final evaluation
Workshop 1 “Hygiene” + workshop Workshop 5 “Discontinue the EN 2 “Discovering the equipment” products” + workshop 6 “Remove with the nurse the tube” + workshop 7 “Hygiene and surveillance” Break Lunch Lunch Break Chest x-ray prescription by medical Service provider staff Workshop 3 “Self-insertion of the Workshop 3 “Self-insertion of the tube” + workshop 4 “Preparation tube” + Workshop 8 “Screening and administration of EN for complications” with the nurse products” with the nurse Chest x-ray Break Data collection Dinner Dinner Preparation and administration of Preparation and administration of EN products with the nurse EN products with the nurse Monitoring for complications Monitoring for complications
Break Discharge
EN, enteral nutrition.
of NG tube insertion was first described in 1995 in a patient with Crohn’s disease but has never been evaluated in a cohort of patients enrolled in a TPE program.11,12 According to the World Health Organization definition, TPE helps patients to acquire or maintain the skills they need to manage their life with a chronic disease in the best possible way.13 We evaluated for the first time the efficacy and tolerability of self-insertion of an NG tube in 29 patients requiring EN and enrolled in a TPE program.
undernutrition, improvement of quality of life in patients with a tube feeding, perioperative nutrition, and maintaining remission in chronic active diseases (as defined by European Society for Clinical Nutrition and Metabolism [ESPEN] guidelines2), anorexia nervosa, and bulimia nervosa. Patients were ineligible if they had swallowing dysfunction; ear, nose, or throat (ENT) surgery; anatomical abnormalities of ENT; cognitive disability; or language barrier preventing therapeutic education.
Patients and Methods
Therapeutic Patient Education Program14
Ethics
We first made an educational diagnosis of spatial and temporal orientation, learning ability, sight and hearing capabilities, adequate housing condition, and personal hygiene. These first steps included instructions on indications and principles on EN. Therapeutic contract between medical staff and the patient was then established. In a second step, we defined a personalized TPE program with learning priorities. We planned and provided individual or group TPE sessions set during a 3-day hospitalization as described in Table 1. Throughout this second step, the patient’s education evaluation was based on acquisition of skills (preparation and administration of EN products, role of hydration, administering medications, and related care of the NG tube).
All eligible patients gave their written informed consent. The study protocol was approved by the ARS (Agence Régionale de Santé) of Lorraine, France (permit number J4G9045PRO/2010).
Study Population This prospective observational study was conducted in a referral center in France (University Hospital of Nancy). Patients who had a follow-up by a clinical nutritionist and who needed nutrition assistance with EN or who received EN with an NG tube for at least 1 month were included in the TPE program. Indications for EN were prevention and treatment of
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Table 2. Questionnaire Administered to a Subgroup of Patients. Question
Response
Since the beginning of self-insertion of the NG tube, how have the following items evolved? ● Home activities ● Social activities ● Work ● Family relationship ● Physical well-being ● Mental well-being Do you feel this evolution is due to home enteral nutrition? On the whole, how much do you feel self-insertion of the NG tube has been beneficial for you?
If you have the choice between a selfinserted NG tube or a long-term NG tube, what do you prefer?
Better Stable Worse Yes No Very beneficial Quite beneficial Rather beneficial Not beneficial A bad thing A very bad thing Self-inserted NG tube Long-term NG tube
NG, nasogastric.
Finally, we assessed the implementation of skills and TPE into clinical practice: assessment on disease, treatment, hygiene, adaptability to a new situation, management and control of treatment, and technical processes. Following the ETP program, the patient was given a booklet about self-insertion of the NG tube, including information about the NG tube position, storage and administration conditions of EN, inventory of necessary equipment, steps of installation of EN products, screening for complications, conduct to adopt in case of adverse events, and contact information about nutrition medical staff.
Patient Monitoring After the 3-day TPE program in the hospital, patients went back home. EN products and materials necessary for home EN were dispensed by services healthcare. They were followed by a nurse’s phone calls. Patients were seen as outpatients on days 14 and 30 and thereafter every 2–3 months. A detailed report was made each month by services healthcare to medical staff.
NG Tube Fine-bore 8–10 French gauge NG tubes in silicone without probe were used. First, the NG tube was placed by an experienced physician or nurse. The position of the NG tube was always confirmed by x-ray and checked by injecting air
through it and listening for bubbles with a stethoscope. At this time, the length of tube was determined. Then, the patient inserted and checked the NG tube by himself or herself under surveillance of a nurse. The position of the NG tube was checked after each insertion by injecting air through it and listening for bubbles with a stethoscope. The length of the feeding tube to the nostril was determined during the first installation.
Tolerability Patients were followed by a nurse’s phone calls and with the first clinical visit between weeks 2 and 4 and thereafter every 2–3 months. According to the French legislation, home care service planned a visit the first day at home, a phone call on day 2 or 3 after hospital outcome, and then a visit at home on day 14 and then every 3 months.15 At each clinical visit, weight gain and adherence to treatment were evaluated, and all adverse events were recorded. Adverse events were detailed in the report made each month by services healthcare. Adherence to treatment was self-reported by each patient at the medical visit. Consumption of feeding bags was followed by services healthcare. A questionnaire developped in 2000 by Schneider et al. has be adapted and could be administred to the last consecutive patients (Table 2).
Outcomes and Statistical Analysis The outcome measures were weight gain and tolerability. The intention-to-treat (ITT) population included all patients who received at least 1 day of EN by self-administrated NG tube. Results are shown as mean and standard deviation (SD), median values (interquartile range [IQR]), frequency distribution (quartiles), or proportions, as appropriate. The variables were evaluated using the Student t test. P < .05 was considered statistically significant for all tests.
Results Characteristics of the 29 Patients In our department, between November 2008 and August 2012, 66 patients received EN with the NG tube. Twenty-nine of 66 had self-insertion of the NG tube. Seventeen had an anatomical contrindication for the TPE program, and 20 were excluded because of cognitive disability or language barrier or refusal. A total of 29 adult patients (28 inpatients and 1 outpatient) were enrolled in the TPE program and were educated to self-insertion of the NG tube. Of the 29 patients, 69% (n = 20) were women. The median age was 44 years (IQR, 28–59). Thus, the ITT population consisted of 29 patients. The baseline
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Table 3. Characteristics of the 29 Patients Enrolled in the Program. Characteristic Age, median, y Weight, median, kg Male sex, No. (%) Indications for EN, No. (%) Cancer Eating disorders Inflammatory bowel disease Short bowel syndrome Chronic respiratory failure Idiopathic gastroparesis Total gastrectomy Chronic pancreatitis Preoperative nutrition Previous use of a long-term NG tube for EN
Self-Administration of NG Tube (n = 29) 44 44 9 (31) 8 (28) 8 (28) 5 (17) 3 (10) 2 (7) 1 1 1 5 (17) 10 (34)
EN, enteral nutrition; NG, nasogastric.
characteristics of the patients are shown in Table 3. Indications for EN were cancer for 8 patients (28%), eating disorders for 8 patients (28%), inflammatory bowel disease for 5 patients (17%), short bowel syndrome for 3 patients (10%), chronic respiratory failure for 2 patients, idiopathic gastroparesis for 1 patient, total gastrectomy for 1 patient, and chronic pancreatitis for 1 patient. Five patients (17%) had EN for preoperative management. All 29 patients accepted self-insertion of the NG tube. Twenty-eight of the 29 patients completed the TPE program. One patient stopped the TPE program due to general physical deterioration because of pancreatic cancer in palliative care and died of pancreatic cancer during study period on October 10, 2010. Median follow-up was 20 months (IQR, 4–31).
Tolerability The NG tube was well tolerated by all 29 patients. No major adverse events were reported. Minor adverse events were reported for 2 patients (Table 4): the first one had abdominal pain and nausea during ETF, while the second had epistaxis and needed a temporary discontinuation of EN. None of these adverse events led to discontinuation of the TPE program. The last 10 consecutive patients were interviewed about tolerability of self-inserting the NG tube using the questionnaire developed by Schneider et al.16 We first evaluated the evolution over time of the following items from the beginning of self-insertion of the NG tube to the end of EN (n = 10): improvement for home activities was reported for 4 patients, stable for 5, and worsened for 1; social activities evolved better for 3 patients, stable for 5, and worsened for 2; family relationship evolved better for 5 patients and
stable for 5; physical well-being evolved better for 5 patients, stable for 4, and worsened for 1; and mental well-being evolved better for 5 patients, stable for 3, and worsened for 2 (Figure 1). Nine of 10 patients felt that this benefit was due to self-insertion of NG tube. Self-insertion of the NG tube has been beneficial for 8 patients, quite beneficial for 1 patient, and rather beneficial for 1 patient. To compare previous use of the NG tube with current use of the self-inserted NG tube, all 10 patients were asked the following question: “If you have the choice between a selfinserted NG tube or a long-term NG tube, what do you prefer?” (question 3). All 10 patients stated that they would prefer to start again with the self-inserted NG tube (Figure 2).
Efficacy At program entry, the median weight was 44.0 kg (IQR, 39.4– 55.2; Figure 3). Among the 28 patients who completed the program, the median weight at the end of EN was 50.6 kg (IQR, 42.4–58.9). Median gain weight was 3.1 kg (IQR, 1.8–6.0). Two patients lost weight. The first patient received EN for short bowel syndrome during 33 months; thereafter, parenteral nutrition was initiated. The second patient received EN for malnutrition after duodenopancreatectomy during 5 months. Anorexia nervosa was usually evaluated by the MorganRussell outcome assessment, which provides a quantitative score from 0–12 based on the mean of 5 subscales covering nutrition status, menstruation, mental state, psychosexual adjustment, and socioeconomic status.17 In our study, only data about nutrition status were collected. Of note, patients receiving ETF for eating disorders were excluded from the analysis. Median weight gain was 3.5 kg (IQR, 2–6.6) (P = .0002). Eighteen of the 20 (90%) patients had an increase in weight from study inclusion to the end of EN. The median final weight was 50.8 kg (IQR, 43.9–60.6). Two patients had a decrease in weight (–1.2 kg and –2.1 kg). Median duration of ETF with the self-inserted NG tube was 3 months (IQR, 2–5; Table 3).
Discussion To our knowledge, this is the first clinical experience on the efficacy and tolerability of the self-insertion of an NG tube. European guidelines on artificial EN recommend an NG tube for short-term duration or percutaneous endoscopic gastrostomy and jejunostomy for a period exceeding 2–3 weeks.18 We propose an alternative method for EN with a self-inserted NG tube for home EN. The program has been specifically developed to enhance self-management in EN by experienced health professionals in cooperation with patient representatives to strengthen patients’ perspective and ensure feasibility. This study examined the feasibility, patient acceptability and tolerability, and short-term outcomes of a self-inserted NG tube in ETF. The median duration of home EN was 3 months,
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Table 4. Efficacy and Tolerability of Self-Insertion of the Nasogastric Tube. Patient No. Duration of EN, mo Initial Weight, kg
Final Weight, kg
1 2 3 4 5a
2 27 3 3 1
47.8 56.0 50.0 40.0 63.0
50.3 52.8 53.0 42.2 61.0
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
9 5 4 2 5 8 5 2 11 2 2 5 2 3 2 1
36.1 67.0 44.0 105.5 37.3 45.0 55.0 42.0 39.0 70.0 50.7 44.6 35.4 55.2 41.0 81.0
40.0 75.0 50.8 112.0 37.2 50.8 60.5 46.0 47.4 77.0 52.7 43.4 37.1 58.3 44.0 89.1
% of Weight Loss at Study Entry
Adverse Event(s) BMI at Study Entry 16.7 16.7
Nausea, abdominal pain
12 25 14 30 34
14.0 20.6 13.6 18.0 16.0 32.6 14.9 16.0 19.0
Epistaxis
31 12 13 19 15 13 27 24 22 17 23 19 32 20
13.7 20.9 16.6 16.6 16.4 18.7 15.0 28.4
Patients with eating disorders (n = 8) were excluded from Table 4, leaving 21 patients. BMI, body mass index; EN, enteral nutrition. a This patient died of pancreatic cancer in palliative care during the study.
Mental well-being Do you f eel evolution of quality of lif e is do to home enteral nutrition ?
Physical well-being Family rela onship r
Il you have the choice between self inserted NG tube or long term NG tube, what do you pref er ?
Social ac vi es me ac vi es Hom 0% 0
20 0%
40% Be er
60% % Stable
80% %
0%
100% %
20%
40% Yes
Worse
60% No
80%
100%
Figure 1. Evolution over time of several items from the beginning of self-insertion of the nasogastric tube to the end of enteral nutrition (n = 10).
Figure 2. Feelings and preferences about self-insertion of the nasogastric (NG) tube (n = 10).
showing that self-insertion of the NG tube can be done for a long period. One patient has been using self-insertion of the NG tube for more than 27 months with a good efficacy and tolerability profile. We consider that all patients completed the program, even though 1 patient died of pancreatic cancer during study period. Benefit of self-insertion of the NG tube was investigated using a questionnaire: improvements in home activities, social
activities, family relationship, physical well-being, and mental well-being were the major benefits reported by patients. In addition, all patients were able to remove their feeding tubes for part of the day. We observed a good acceptance of the selfmanagement for ETF, further highlighting the feasibility of self-insertion of the NG tube in clinical practice. Indeed, all patients completed the TPE program. Importantly, if patients had the choice between the self-inserted NG tube and
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Journal of Parenteral and Enteral Nutrition 38(7) Acknowledgments
25
We are grateful to all our colleagues who participated in the therapeutic education program.
24
Median BMI
23 22
p=0.0002
21 20 19 18 17 16 15
BMI before disease onset
BMI at study inclusion
BMI at discontinuation of enteral nutrition
Figure 3. Evolution of median body mass index (BMI) values (n = 29).
long-term NG tube, all would prefer self-insertion of the NG tube in our study. The partnership with the nursing staff of the hospital played an important part throughout the pilot program. Several patients had already benefited from EN. Taking the patient’s experience into account is important in a TPE program. In 2001, Schneider et al19 had already evaluated that longterm nutrition support in home EN had good tolerance. In our study, EN seemed to be well tolerated. Only minor adverse events (abdominal pain, nausea, and epistaxis) occurred during the study. Those minor events are usually described in EN with an NG tube.5,6 Importantly, none of the adverse events led to study discontinuation. The indication of self-insertion of the NG tube in patients with eating disorders has been debated. In many binge-eating/ vomiting patients, abstinence cannot be obtained from classic treatments, and tube feeding could reduce such episodes in patients hospitalized with anorexia nervosa.17 In our experience, these indications seem to be limited because of difficulties in obtaining a good adherence to treatment, even though some of our patients were treated at home. In our study, median weight gain was 3.5 kg (IQR, 2–6.6) (P = .0002) after a follow-up of 3 months. Taken together, these findings indicate that self-insertion of the NG tube is effective. In long-term home EN patients, an improvement in quality of life has been reported.18 Limitations of our study are lack of a control group to compare the quality of life between patients with self-insertion of the NG tube and patients with permanent tube feeding. However, in our study, 9 patients had a permanent tube before self-insertion; all these patients stated they would have preferred self-insertion of the NG tube. In conclusion, self-insertion of NG tube can only be achieved through a program of therapeutic education and after careful assessment of the patients’ skills. It may be effective and well tolerated in patients eligible for this program and who require EN for home EN. The benefits in terms of quality of life need to be confirmed in large prospective studies and controlled trials.
References 1. Lochs H, Steinhardt HJ, Klaus-Wentz B, et al. Comparison of enteral nutrition and drug treatment in active Crohn’s disease: results of the European Cooperative Crohn’s Disease Study. IV. Gastroenterology. 1991;101:881-888. 2. Lochs H, Dejong C, Hammarqvist F, et al. ESPEN guidelines on enteral nutrition: gastroenterology. Clin Nutr. 2006;25:260-274. 3. Paccagnella A, Baruffi C, Pizzolato D, et al. Home enteral nutrition in adults: a five-year (2001-2005) epidemiological analysis. Clin Nutr. 2008;27:378-385. 4. De Luis DA, Aller R, de Luis J, et al. Clinical and biochemical characteristics of patients with home enteral nutrition in an area of Spain. Eur J Clin Nutr. 2003;57:612-615. 5. Duncan HD, Silk DB. Problems of treatment—enteral nutrition. In: Nightingale J, ed. Intestinal Failure. London, UK: Greenwich Medical Media Ltd; 2001:477-496. 6. Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut. 2003;52(suppl 7):vii1-vii12. 7. Keymling M. Technical aspects of enteral nutrition. Gut. 1994;35: S77-S80. 8. Loeser C, von Herz U, Kuchler T, Rzehak P, Muller MJ. Quality of life and nutritional state in patients on home enteral tube feeding. Nutrition. 2003;19:605-611. 9. Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent selfcatheterization in the treatment of urinary tract disease. J Urol. 1972;107: 458-461. 10. Le Breton F, Guinet A, Verollet D, Jousse M, Amarenco G. Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review. Ann Phys Rehabil Med. 2012;55:201-212. 11. Reimers TM, Vance MD, Young RJ. Teaching self-administration of nasogastric tube insertion to an adolescent with Crohn disease. J Appl Behav Anal. 1995;28:231-232. 12. Wilschanski M, Sherman P, Pencharz P, Davis L, Corey M, Griffiths A. Supplementary enteral nutrition maintains remission in paediatric Crohn’s disease. Gut. 1996;38(4):543-548. 13. World Health Organization (WHO). Therapeutic Patient Education— Continuing Education Programme for Health Care Providers in the Field of Prevention of Chronic Diseases. Geneva, Switzerland: WHO; 1998. 14. HAS. Therapeutic Patient Education (TPE): Definition, Goals and Organisation—Quick Reference Guide. 2007. http://www.has-sante.fr/ portail/upload/docs/application/pdf/2008-12/therapeutic_patient_education_tpe_-_definition_goals_and_organisation_-_quick_reference_ guide.pdf 15. Arrêté du 19 février 2010 rectifiant l’arrêté du 9 novembre 2009. Journal Official de la République Française. 2010;46:3512. 16. Schneider SM, Pouget I, Staccini P, Rampal P, Hebuterne X. Quality of life in long-term home enteral nutrition patients. Clin Nutr. 2000;19: 23-28. 17. Morgan HG, Hayward AE. Clinical assessment of anorexia nervosa: the Morgan-Russell outcome assessment schedule. Br J Psychiatry. 1988;152:367-371. 18. Loser C, Aschl G, Hebuterne X, et al. ESPEN guidelines on artificial enteral nutrition—percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24:848-861. 19. Schneider SM, Raina C, Pugliese P, Pouget I, Rampal P, Hebuterne X. Outcome of patients treated with home enteral nutrition. JPEN J Parenter Enteral Nutr. 2001;25:203-209.
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2013
PENXXX10.1177/0148607113502544Journal of Parenteral and Enteral NutritionQuilliot et al
Brief Communication
Self-Insertion of a Nasogastric Tube for Home Enteral Nutrition: A Pilot Study Didier Quilliot, MD, PhD1,2; Camille Zallot, MD2,3; Aurélie Malgras, MD1; Adeline Germain, MD2,4; Laurent Bresler, MD, PhD4; Ahmet Ayav, MD, PhD2,4; Marc-André Bigard, MD, PhD3; Laurent Peyrin-Biroulet, MD, PhD2,3; and Olivier Ziegler, MD, PhD1,2
Journal of Parenteral and Enteral Nutrition Volume 38 Number 7 September 2014 895–900 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113502544 jpen.sagepub.com hosted at online.sagepub.com
Abstract Background: Enteral tube feeding can be a source of discomfort and reluctance from patients. We evaluated for the first time the tolerability of self-insertion of a nasogastric (NG) tube for home enteral nutrition (EN). Materials and Methods: All patients requiring enteral tube feeding for chronic diseases were enrolled in a therapeutic patient education (TPE) program at Nancy University Hospital. Results: In our department, between November 2008 and August 2012, 66 patients received EN with an NG tube. Twenty-nine of 66 had self-insertion of the NG tube (median age, 44 years), 17 had an anatomical contraindication, and 20 were excluded because of cognitive disability or language barrier or refusal. Twenty-eight of 29 patients completed the TPE program. One patient died of pancreatic cancer in palliative care during the study. Median follow-up was 20 months (interquartile range [IQR], 4–31). Median gain weight was 3.1 kg (IQR, 1.8–6.0) (P = .0002). Median duration of self-insertion of the NG tube was 3 months (IQR, 2–5), and it was well tolerated by all 29 patients. Two patients described minor adverse events: abdominal pain and nausea for 1 patient and epistaxis leading to temporary discontinuation of EN for another patient. A group of 10 consecutive patients previously had a long-term NG tube for EN. If they had the choice between a self-inserted NG tube and a long-term NG tube, all 10 patients reported they would prefer to start again with the self-inserted NG tube. Conclusion: This pilot study suggests that self-insertion of an NG tube may be efficacious and well tolerated in patients receiving EN for chronic conditions. (JPEN J Parenter Enteral Nutr. 2014;38:895-900)
Keywords enteral tube feeding; self-insertion of nasogastric tube; self-management; home enteral nutrition; therapeutic patient education
Clinical Relevancy Statement Guidelines on artificial enteral nutrition (EN) recommend a nasogastric (NG) tube for short-term duration or percutaneous endoscopic gastrostomy and jejunostomy for a period exceeding 2–3 weeks. Enteral tube feeding (ETF) can be a source of discomfort and reluctance from patients. We propose an alternative method for EN with a self-insertion of the NG tube for home EN. These findings are clinically relevant for feeding patients who require EN.
Introduction Enteral tube feeding (ETF) is used to feed patients who cannot attain adequate oral intake from food and/or nutrition supplements or who cannot eat/drink safely.1 Improving or maintaining nutrition status is the main aim of ETF.2 Over the past 2 decades, numerous studies on home enteral nutrition (EN) demonstrated that it is a valid and safe technique for nutrition support.3,4 Long-term ETF can be a source of discomfort and esophagitis and predisposes to nasal and maxillary sinus inflammation.5,6 Furthermore, some patients are reluctant to have ETF because of cosmetic unacceptability, risk of unwanted extubation, sick leave, and negative impact on
quality of life, leading to poor adherence to ETF in home care.7,8 We developed a therapeutic patient education (TPE) program with the aim of teaching self-insertion of the NG tube, based on the experience from self-catherization in urinary tract diseases as described by Lapides et al9 in 1972.10 Self-insertion
From the 1Department of Nutrition, Nancy University Hospital, Vandoeuvre-les-Nancy, France; 2INSERM U954, Medical Faculty and CHU of Nancy, Vandoeuvre-les-Nancy, France; 3Department of Gastroenterology, Nancy University Hospital, Vandoeuvre-les-Nancy, France; and 4Department of Hepatobiliary, Digestive and Endocrine Surgery, Nancy University Hospital, Vandoeuvre-les-Nancy, France. Didier Quilliot and Camille Zallot contributed equally to this work. Financial disclosure: None declared. Received for publication March 25, 2013; accepted for publication August 1, 2013. This article originally appeared online on October 18, 2013. Corresponding Author: Didier Quilliot, MD, PhD, Department of Nutrition, Nancy University Hospital, Allée du Morvan, 54511 Vandœuvre-lès-Nancy, France. Email: [email protected]
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Journal of Parenteral and Enteral Nutrition 38(7)
Table 1. Therapeutic Patient Education Program. Time 8:00-8:30 am 8:30-9:00 am 9:00-9:30 am 9:30-10:00 am 10:00-11:00 am
11:00 am 12:00-1:00 pm 1:00-3:00 pm 3:00-4:00 pm
4:00-6:00 pm 6:30-7:00 pm 9:00-9:30 pm 9:30 pm to 9:00 am
Day 1 Welcome, installation, recording vital signs Data collection
Day 2
Day 3
Discontinuation of EN products and removal of tube by patient Recording vital signs Lunch Break
Discontinuation of EN products and removal of tube by patient Recording vital signs Lunch If necessary: Workshop 3 “Self-insertion of the tube” Final evaluation
Workshop 1 “Hygiene” + workshop Workshop 5 “Discontinue the EN 2 “Discovering the equipment” products” + workshop 6 “Remove with the nurse the tube” + workshop 7 “Hygiene and surveillance” Break Lunch Lunch Break Chest x-ray prescription by medical Service provider staff Workshop 3 “Self-insertion of the Workshop 3 “Self-insertion of the tube” + workshop 4 “Preparation tube” + Workshop 8 “Screening and administration of EN for complications” with the nurse products” with the nurse Chest x-ray Break Data collection Dinner Dinner Preparation and administration of Preparation and administration of EN products with the nurse EN products with the nurse Monitoring for complications Monitoring for complications
Break Discharge
EN, enteral nutrition.
of NG tube insertion was first described in 1995 in a patient with Crohn’s disease but has never been evaluated in a cohort of patients enrolled in a TPE program.11,12 According to the World Health Organization definition, TPE helps patients to acquire or maintain the skills they need to manage their life with a chronic disease in the best possible way.13 We evaluated for the first time the efficacy and tolerability of self-insertion of an NG tube in 29 patients requiring EN and enrolled in a TPE program.
undernutrition, improvement of quality of life in patients with a tube feeding, perioperative nutrition, and maintaining remission in chronic active diseases (as defined by European Society for Clinical Nutrition and Metabolism [ESPEN] guidelines2), anorexia nervosa, and bulimia nervosa. Patients were ineligible if they had swallowing dysfunction; ear, nose, or throat (ENT) surgery; anatomical abnormalities of ENT; cognitive disability; or language barrier preventing therapeutic education.
Patients and Methods
Therapeutic Patient Education Program14
Ethics
We first made an educational diagnosis of spatial and temporal orientation, learning ability, sight and hearing capabilities, adequate housing condition, and personal hygiene. These first steps included instructions on indications and principles on EN. Therapeutic contract between medical staff and the patient was then established. In a second step, we defined a personalized TPE program with learning priorities. We planned and provided individual or group TPE sessions set during a 3-day hospitalization as described in Table 1. Throughout this second step, the patient’s education evaluation was based on acquisition of skills (preparation and administration of EN products, role of hydration, administering medications, and related care of the NG tube).
All eligible patients gave their written informed consent. The study protocol was approved by the ARS (Agence Régionale de Santé) of Lorraine, France (permit number J4G9045PRO/2010).
Study Population This prospective observational study was conducted in a referral center in France (University Hospital of Nancy). Patients who had a follow-up by a clinical nutritionist and who needed nutrition assistance with EN or who received EN with an NG tube for at least 1 month were included in the TPE program. Indications for EN were prevention and treatment of
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Table 2. Questionnaire Administered to a Subgroup of Patients. Question
Response
Since the beginning of self-insertion of the NG tube, how have the following items evolved? ● Home activities ● Social activities ● Work ● Family relationship ● Physical well-being ● Mental well-being Do you feel this evolution is due to home enteral nutrition? On the whole, how much do you feel self-insertion of the NG tube has been beneficial for you?
If you have the choice between a selfinserted NG tube or a long-term NG tube, what do you prefer?
Better Stable Worse Yes No Very beneficial Quite beneficial Rather beneficial Not beneficial A bad thing A very bad thing Self-inserted NG tube Long-term NG tube
NG, nasogastric.
Finally, we assessed the implementation of skills and TPE into clinical practice: assessment on disease, treatment, hygiene, adaptability to a new situation, management and control of treatment, and technical processes. Following the ETP program, the patient was given a booklet about self-insertion of the NG tube, including information about the NG tube position, storage and administration conditions of EN, inventory of necessary equipment, steps of installation of EN products, screening for complications, conduct to adopt in case of adverse events, and contact information about nutrition medical staff.
Patient Monitoring After the 3-day TPE program in the hospital, patients went back home. EN products and materials necessary for home EN were dispensed by services healthcare. They were followed by a nurse’s phone calls. Patients were seen as outpatients on days 14 and 30 and thereafter every 2–3 months. A detailed report was made each month by services healthcare to medical staff.
NG Tube Fine-bore 8–10 French gauge NG tubes in silicone without probe were used. First, the NG tube was placed by an experienced physician or nurse. The position of the NG tube was always confirmed by x-ray and checked by injecting air
through it and listening for bubbles with a stethoscope. At this time, the length of tube was determined. Then, the patient inserted and checked the NG tube by himself or herself under surveillance of a nurse. The position of the NG tube was checked after each insertion by injecting air through it and listening for bubbles with a stethoscope. The length of the feeding tube to the nostril was determined during the first installation.
Tolerability Patients were followed by a nurse’s phone calls and with the first clinical visit between weeks 2 and 4 and thereafter every 2–3 months. According to the French legislation, home care service planned a visit the first day at home, a phone call on day 2 or 3 after hospital outcome, and then a visit at home on day 14 and then every 3 months.15 At each clinical visit, weight gain and adherence to treatment were evaluated, and all adverse events were recorded. Adverse events were detailed in the report made each month by services healthcare. Adherence to treatment was self-reported by each patient at the medical visit. Consumption of feeding bags was followed by services healthcare. A questionnaire developped in 2000 by Schneider et al. has be adapted and could be administred to the last consecutive patients (Table 2).
Outcomes and Statistical Analysis The outcome measures were weight gain and tolerability. The intention-to-treat (ITT) population included all patients who received at least 1 day of EN by self-administrated NG tube. Results are shown as mean and standard deviation (SD), median values (interquartile range [IQR]), frequency distribution (quartiles), or proportions, as appropriate. The variables were evaluated using the Student t test. P < .05 was considered statistically significant for all tests.
Results Characteristics of the 29 Patients In our department, between November 2008 and August 2012, 66 patients received EN with the NG tube. Twenty-nine of 66 had self-insertion of the NG tube. Seventeen had an anatomical contrindication for the TPE program, and 20 were excluded because of cognitive disability or language barrier or refusal. A total of 29 adult patients (28 inpatients and 1 outpatient) were enrolled in the TPE program and were educated to self-insertion of the NG tube. Of the 29 patients, 69% (n = 20) were women. The median age was 44 years (IQR, 28–59). Thus, the ITT population consisted of 29 patients. The baseline
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Table 3. Characteristics of the 29 Patients Enrolled in the Program. Characteristic Age, median, y Weight, median, kg Male sex, No. (%) Indications for EN, No. (%) Cancer Eating disorders Inflammatory bowel disease Short bowel syndrome Chronic respiratory failure Idiopathic gastroparesis Total gastrectomy Chronic pancreatitis Preoperative nutrition Previous use of a long-term NG tube for EN
Self-Administration of NG Tube (n = 29) 44 44 9 (31) 8 (28) 8 (28) 5 (17) 3 (10) 2 (7) 1 1 1 5 (17) 10 (34)
EN, enteral nutrition; NG, nasogastric.
characteristics of the patients are shown in Table 3. Indications for EN were cancer for 8 patients (28%), eating disorders for 8 patients (28%), inflammatory bowel disease for 5 patients (17%), short bowel syndrome for 3 patients (10%), chronic respiratory failure for 2 patients, idiopathic gastroparesis for 1 patient, total gastrectomy for 1 patient, and chronic pancreatitis for 1 patient. Five patients (17%) had EN for preoperative management. All 29 patients accepted self-insertion of the NG tube. Twenty-eight of the 29 patients completed the TPE program. One patient stopped the TPE program due to general physical deterioration because of pancreatic cancer in palliative care and died of pancreatic cancer during study period on October 10, 2010. Median follow-up was 20 months (IQR, 4–31).
Tolerability The NG tube was well tolerated by all 29 patients. No major adverse events were reported. Minor adverse events were reported for 2 patients (Table 4): the first one had abdominal pain and nausea during ETF, while the second had epistaxis and needed a temporary discontinuation of EN. None of these adverse events led to discontinuation of the TPE program. The last 10 consecutive patients were interviewed about tolerability of self-inserting the NG tube using the questionnaire developed by Schneider et al.16 We first evaluated the evolution over time of the following items from the beginning of self-insertion of the NG tube to the end of EN (n = 10): improvement for home activities was reported for 4 patients, stable for 5, and worsened for 1; social activities evolved better for 3 patients, stable for 5, and worsened for 2; family relationship evolved better for 5 patients and
stable for 5; physical well-being evolved better for 5 patients, stable for 4, and worsened for 1; and mental well-being evolved better for 5 patients, stable for 3, and worsened for 2 (Figure 1). Nine of 10 patients felt that this benefit was due to self-insertion of NG tube. Self-insertion of the NG tube has been beneficial for 8 patients, quite beneficial for 1 patient, and rather beneficial for 1 patient. To compare previous use of the NG tube with current use of the self-inserted NG tube, all 10 patients were asked the following question: “If you have the choice between a selfinserted NG tube or a long-term NG tube, what do you prefer?” (question 3). All 10 patients stated that they would prefer to start again with the self-inserted NG tube (Figure 2).
Efficacy At program entry, the median weight was 44.0 kg (IQR, 39.4– 55.2; Figure 3). Among the 28 patients who completed the program, the median weight at the end of EN was 50.6 kg (IQR, 42.4–58.9). Median gain weight was 3.1 kg (IQR, 1.8–6.0). Two patients lost weight. The first patient received EN for short bowel syndrome during 33 months; thereafter, parenteral nutrition was initiated. The second patient received EN for malnutrition after duodenopancreatectomy during 5 months. Anorexia nervosa was usually evaluated by the MorganRussell outcome assessment, which provides a quantitative score from 0–12 based on the mean of 5 subscales covering nutrition status, menstruation, mental state, psychosexual adjustment, and socioeconomic status.17 In our study, only data about nutrition status were collected. Of note, patients receiving ETF for eating disorders were excluded from the analysis. Median weight gain was 3.5 kg (IQR, 2–6.6) (P = .0002). Eighteen of the 20 (90%) patients had an increase in weight from study inclusion to the end of EN. The median final weight was 50.8 kg (IQR, 43.9–60.6). Two patients had a decrease in weight (–1.2 kg and –2.1 kg). Median duration of ETF with the self-inserted NG tube was 3 months (IQR, 2–5; Table 3).
Discussion To our knowledge, this is the first clinical experience on the efficacy and tolerability of the self-insertion of an NG tube. European guidelines on artificial EN recommend an NG tube for short-term duration or percutaneous endoscopic gastrostomy and jejunostomy for a period exceeding 2–3 weeks.18 We propose an alternative method for EN with a self-inserted NG tube for home EN. The program has been specifically developed to enhance self-management in EN by experienced health professionals in cooperation with patient representatives to strengthen patients’ perspective and ensure feasibility. This study examined the feasibility, patient acceptability and tolerability, and short-term outcomes of a self-inserted NG tube in ETF. The median duration of home EN was 3 months,
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Table 4. Efficacy and Tolerability of Self-Insertion of the Nasogastric Tube. Patient No. Duration of EN, mo Initial Weight, kg
Final Weight, kg
1 2 3 4 5a
2 27 3 3 1
47.8 56.0 50.0 40.0 63.0
50.3 52.8 53.0 42.2 61.0
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
9 5 4 2 5 8 5 2 11 2 2 5 2 3 2 1
36.1 67.0 44.0 105.5 37.3 45.0 55.0 42.0 39.0 70.0 50.7 44.6 35.4 55.2 41.0 81.0
40.0 75.0 50.8 112.0 37.2 50.8 60.5 46.0 47.4 77.0 52.7 43.4 37.1 58.3 44.0 89.1
% of Weight Loss at Study Entry
Adverse Event(s) BMI at Study Entry 16.7 16.7
Nausea, abdominal pain
12 25 14 30 34
14.0 20.6 13.6 18.0 16.0 32.6 14.9 16.0 19.0
Epistaxis
31 12 13 19 15 13 27 24 22 17 23 19 32 20
13.7 20.9 16.6 16.6 16.4 18.7 15.0 28.4
Patients with eating disorders (n = 8) were excluded from Table 4, leaving 21 patients. BMI, body mass index; EN, enteral nutrition. a This patient died of pancreatic cancer in palliative care during the study.
Mental well-being Do you f eel evolution of quality of lif e is do to home enteral nutrition ?
Physical well-being Family rela onship r
Il you have the choice between self inserted NG tube or long term NG tube, what do you pref er ?
Social ac vi es me ac vi es Hom 0% 0
20 0%
40% Be er
60% % Stable
80% %
0%
100% %
20%
40% Yes
Worse
60% No
80%
100%
Figure 1. Evolution over time of several items from the beginning of self-insertion of the nasogastric tube to the end of enteral nutrition (n = 10).
Figure 2. Feelings and preferences about self-insertion of the nasogastric (NG) tube (n = 10).
showing that self-insertion of the NG tube can be done for a long period. One patient has been using self-insertion of the NG tube for more than 27 months with a good efficacy and tolerability profile. We consider that all patients completed the program, even though 1 patient died of pancreatic cancer during study period. Benefit of self-insertion of the NG tube was investigated using a questionnaire: improvements in home activities, social
activities, family relationship, physical well-being, and mental well-being were the major benefits reported by patients. In addition, all patients were able to remove their feeding tubes for part of the day. We observed a good acceptance of the selfmanagement for ETF, further highlighting the feasibility of self-insertion of the NG tube in clinical practice. Indeed, all patients completed the TPE program. Importantly, if patients had the choice between the self-inserted NG tube and
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Journal of Parenteral and Enteral Nutrition 38(7) Acknowledgments
25
We are grateful to all our colleagues who participated in the therapeutic education program.
24
Median BMI
23 22
p=0.0002
21 20 19 18 17 16 15
BMI before disease onset
BMI at study inclusion
BMI at discontinuation of enteral nutrition
Figure 3. Evolution of median body mass index (BMI) values (n = 29).
long-term NG tube, all would prefer self-insertion of the NG tube in our study. The partnership with the nursing staff of the hospital played an important part throughout the pilot program. Several patients had already benefited from EN. Taking the patient’s experience into account is important in a TPE program. In 2001, Schneider et al19 had already evaluated that longterm nutrition support in home EN had good tolerance. In our study, EN seemed to be well tolerated. Only minor adverse events (abdominal pain, nausea, and epistaxis) occurred during the study. Those minor events are usually described in EN with an NG tube.5,6 Importantly, none of the adverse events led to study discontinuation. The indication of self-insertion of the NG tube in patients with eating disorders has been debated. In many binge-eating/ vomiting patients, abstinence cannot be obtained from classic treatments, and tube feeding could reduce such episodes in patients hospitalized with anorexia nervosa.17 In our experience, these indications seem to be limited because of difficulties in obtaining a good adherence to treatment, even though some of our patients were treated at home. In our study, median weight gain was 3.5 kg (IQR, 2–6.6) (P = .0002) after a follow-up of 3 months. Taken together, these findings indicate that self-insertion of the NG tube is effective. In long-term home EN patients, an improvement in quality of life has been reported.18 Limitations of our study are lack of a control group to compare the quality of life between patients with self-insertion of the NG tube and patients with permanent tube feeding. However, in our study, 9 patients had a permanent tube before self-insertion; all these patients stated they would have preferred self-insertion of the NG tube. In conclusion, self-insertion of NG tube can only be achieved through a program of therapeutic education and after careful assessment of the patients’ skills. It may be effective and well tolerated in patients eligible for this program and who require EN for home EN. The benefits in terms of quality of life need to be confirmed in large prospective studies and controlled trials.
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