Access Routes/Tube Types

Details: Last Updated: 24 March 2018

Enteral nutrition is often considered to be simpler than parenteral nutrition. Although nasogastric feeding is relatively common in hospital and gastrostomy feeding is the most common form of tube feeding in the community, in the past few decades more complex enteral access routes have become available and these may require specialist intervention by healthcare professionals, both for tube insertion and maintenance.

Despite the frequent use of nasogastric tubes for nutrition, an excellent standard of care is needed to avoid the hazard of feeding down an inappropriately placed nasogastric tube - this is a “never event” in NHS England (http://www.nrls.npsa.nhs.uk/resources/collections/never-events/core-list/misplaced-naso-or-orogastric-tube-not-detected-prior-to-use/). pH testing of aspirate is the recommended first-line method of checking tip position for nasogastric tubes and Chest X-ray second-line. X-rays must be interpreted by appropriately trained staff as misinterpretation has been the cause of a number of complications and deaths.

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Tube type	Timeframe	Common indications	Common Insertion methods	Hazards	Key interventions	Common issues
Naso-gastric Fine bore feeding tubes ≤12fr	Short-term- generally less than 30 days	Early post stroke Inadequate oral intake Acute swallowing problem	Bedside	Ensuring tip in stomach www.nnng.org.uk/download-guidelines/ naso-gastric-tube-insertion.pdf www.nrls.npsa.nhs.uk	pH of aspirate on insertion then prior to every tube use/ daily if fed over 24 hours to check tip position. Also check if- 1) Any new or unexplained respiratory symptoms or if oxygen saturations decrease. 2) Episodes of vomiting, retching or coughing spasms.	Repeated displacement Retention devices may be useful nnng.org.uk/download-guidelines/ Blockage 50ml enteral syringe + warm water care with medications nutrition-support/enteral-nutrition/medications
Naso-jejunal	Short-term - generally less than 90 days	Reduced gastric emptying Pathology in oesophagus or stomach	Bedside magnetic imager Endoscopy Radiological screening	Insertion more complex	Xray after insertion to check tip position then if tube moves or symptoms.	Blockage may be kinked if too much tube inserted - pull back to 80-100cm at nose avoid drugs if at all possible 50ml enteral syringe + warm water Displacement Retention devices may be useful
Gastrostomy	Long-term – generally more than 30 days	Longer term in neurological disease Oesophageal pathology Head and neck cancer Brain injury	Endoscopy Radiology –push or pull technique Surgery	Inadequate assessment before insertion Complications of insertion – peritonitis/inadvertent puncture of colon/bleeding/infection, risk of aspiration Displacement	Advance/Rotation 1-2weekly pH check if tube replaced appropriate 72 hour post procedure care	Displacement If less than 4 weeks post-insertion, great care needed for replacement If more than 4 weeks post-insertion, re-insertion spare tube or catheter as soon as possible to avoid closure of tract. Closure of tract can occur within 4 hours!! Foley catheters are not licensed for feed/water/fluid administration and should only be used only be used on a temporary basis until appropriate g- tube available Local leakage Skin protection Consider whether bumper too tight Abscess Antibiotics May need removal of gastrostomy Buried bumper buried-bumper-diagnosis.pdf buried-bumper-management.pdf Damage to tube Connections often replaceable
Jejunostomy	Long-term - generally over 30 days	Gastroparesis As NJ but longer term	Endoscopy (direct) Endoscopy (extension via gastrostomy) Radiology (transgastric) Surgery	More difficult to insert than gastrostomy Complications of insertion – peritonitis/inadvertent puncture of colon/bleeding/infection Extensions liable to displacement Small bowel volvulus		Displacement If less than 4 weeks post-insertion, great care needed for replacement If more than 4 weeks post-insertion, re-insertion spare tube or catheter as soon as possible to avoid closure of tract. Blockage 50ml enteral syringe + warm water Local leakage Skin protection Consider whether bumper too tight Abscess Antibiotics May need removal of jejunostomy Damage to tube Connections often replaceable