Evidence-Based Practice in Nursing Feeding Tube Insertion and Placement Confirmation

Background: Enteral nutrition therapy is frequently used in the treatment of critically ill patients. This population, however, remains at a high risk for feeding tube misplacement because of altered levels of consciousness and diminished reflexes. Care processes like sedation and mechanical ventilation contribute to a patient’s risk for misplacement. Pulmonary, esophageal, intestinal, intracranial, and gastric placements are all possible. Misplacement is associated with many complications including: fatalities, aspiration, hemothorax, pneumothorax, pleural effusion, empyema, tracheal/pulmonary perforation, vocal cord injury, pneumonia, pneumonitis, dumping syndrome, and psychological distress. Other important considerations are delays in the administration of nutrition, hydration, medication and X-ray exposure. Current guidelines at one metro area medical center typically require two radiographs, a chest X-ray performed at 35 cm and a final abdominal X-ray, to confirm placement of small-bore feeding tubes. A physician (MD) or advanced practice provider (APP) reviews, interprets, and approves the images to initiate feeding, hydration, and medication administration. However, confirmation methods include observation for respiratory distress, aspiration tests, air bolus auscultation, capnography sensing, electromagnetic (EMS) visualization, and radiograph imaging. Identification of the best procedure for preventing misplacement and further complications is required. Purpose: This project reviews current nursing literature to evaluate guidelines for the insertion and placement of small-bore (Dobhoff) feeding tubes in critical care adult populations, and determine the implications that these findings have on safe feeding and reduced complications. Methods: A literature search was conducted using the following databases: Academic Search Premier, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and PubMed. Keywords such as “feeding tube”, “small bore”, “narrow bore”, and “dobhoff/dobbhoff” were searched in combination with the terms “placement”, verification”, “confirmation”, “test”, and “best practice”. Thirty-eight studies were reviewed and analyzed to find quality articles published between 2013-2018. Results: All articles were ranked level two regarding the quality and validity of their methodology and design. A systematic review conducted in 2015 assessed the accuracy of pH, auscultation, and capnography. Findings revealed that two of three placements (67%) were misclassified because of auscultation. This method did not differentiate between feeding tube placements and it is not supported by evidence. Comparatively, capnography sensors demonstrated a 100% accuracy rate in 12 total insertions. A systematic review published in 2015 supported these findings with a 98.6% accuracy rate in 72 insertions, which was confirmed by capnography. While these findings are strong, sample sizes tested remain small. Additionally, this method only detected pulmonary placements. Among this group, there were 13 esophageal and two intestinal placements. Because of this, capnography must be used in combination with another confirmatory method. Aspiration test rates varied between trials, ranging from a 62% accuracy rate in 72 insertions to an 86.8% accuracy in 393 insertions and a 93% accuracy rate in 645 insertions. Inconsistent results may occur because of ambiguous and subjective aspiration assessments. Unfortunately, another study found that 44% of placements could not obtain fluid to determine a pH and 37% of the successful aspirations still required X-ray confirmation. These complications and delays make pH testing unrealistic in the critical care setting. However, EMS imaging exhibited a 100% accuracy rate in 120 insertions. 7% of insertions were initially misplaced, but they were corrected in real time to prevent pulmonary trauma. Another study evaluated EMS confirmation of 1140 placements. This method demonstrated a 97.5% accuracy rate, and a significant decrease in placement time and radiological exposure. This reduced feeding delays, pneumothorax complications, and X-ray misinterpretation errors. However, EMS remains vulnerable to tube migration, operator error, and differences in patient anatomy. Implications for Practice: These findings show that an abdominal radiograph before the initiation of feeding, hydration, and medication administration remains the gold standard for feeding tube placement confirmation in critically ill patients. Health care providers should continue to confirm esophageal placement at 35 cm using a chest X-ray, capnography, or EMS technology to reduce complications and the need for multiple radiographs. Additionally, a final abdominal radiograph should continue to be obtained to confirm gastric placement regardless of the method used to confirm esophageal placement. Auscultation as a method of verification is not supported by evidence and should, therefore, be eliminated from practice. Further research opportunities may explore the development of EMS-guided feeding tube insertions to minimize errors associated with operator training and experience.