Elsevier

Clinical Nutrition

Original article

Small-bore feeding tube versus large-bore sump tube for early enteral nutrition in mechanically ventilated patients: A nationwide inpatient database study☆

Summary

Background & aims

When physicians start nasogastric tube feeding in mechanically ventilated patients, they have two choices of feeding tube device: a large-bore sump tube or a small-bore feeding tube. Some physicians may prefer to initiate enteral nutrition via the large-bore sump tube that is already in place, and others may prefer to use the small-bore feeding tube. However, it remains unknown whether small-bore feeding tubes or large-bore sump tubes are better for early enteral nutrition. The present study aimed to compare outcomes between these two types of feeding tubes in mechanically ventilated patients.

Methods

Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified adult patients who underwent invasive mechanical ventilation for ≥2 days in intensive care units and received nasogastric tube feeding within 2 days of starting mechanical ventilation. We categorized these patients as receiving early enteral nutrition via small-bore feeding tube (8- to 12-Fr single-lumen tubes) or via large-bore sump tube. Propensity score-matched analyses were performed to compare 28-day in-hospital mortality and hospital-acquired pneumonia between the two groups.

Results

A total of 79,656 patients were included. Of these patients, 20,178 (25%) were in the small-bore feeding tube group. One-to-one propensity score matching created 20,061 matched pairs. Compared with those in the large-bore sump tube group, patients in the small-bore feeding tube group had significantly higher 28-day in-hospital mortality (17.0% versus 15.6%; hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14) and a significantly higher prevalence of hospital-acquired pneumonia (9.3% versus 8.5%; odds ratio, 1.11; 95% confidence interval, 1.02 to 1.21).

Conclusions

This nationwide observational study suggests that small-bore feeding tubes may not be associated with better clinical outcomes but rather with increased mortality and hospital-acquired pneumonia. Because of the uncertainty regarding the mechanism of our findings, further studies are warranted.

Introduction

Multiple guidelines recommend early enteral nutrition (within 48 h) in mechanically ventilated patients [[1], [2], [3], [4]]. Nasogastric tube feeding is used as the standard approach for early enteral nutrition [1,5]. When physicians start nasogastric tube feeding in mechanically ventilated patients, they have two choices of feeding tube device: a large-bore sump tube or a small-bore feeding tube. A large-bore dual-lumen sump drainage tube is often placed at the time of intubation in emergency room patients or in surgical patients to evacuate air or fluid retained in the stomach [6]. Some physicians may thus prefer to initiate enteral nutrition via the tube that is already in place. However, others may prefer to use the small-bore feeding tube at the time of intubation or to replace the large-bore sump tube with a small-bore feeding tube at the start of enteral nutrition because of concerns about sinusitis, epistaxis, nasal septal ulceration, swallowing dysfunction, or silent aspiration [[7], [8], [9], [10]].

To date, few studies have evaluated the effects of these two feeding tube devices. A previous small observational study of 79 mechanically ventilated patients with 10-Fr nasogastric/orogastric feeding tubes and 87 patients with 14- to 18-Fr nasogastric/orogastric sump tubes showed that the frequency of pepsin-positive tracheal secretions and the incidence of pneumonia were almost identical between the two groups [8]. Another small observational study of 62 mechanically ventilated patients who received both a 10-Fr feeding tube and a 14- to 18-Fr sump tube showed that the gastric residual volume obtained from the large-bore sump tube was about 1.5 times greater than that obtained from the 10-Fr feeding tube [9]. One study of 15 healthy adults showed that a 14-Fr tube increased discomfort and difficulty when swallowing compared with an 8-Fr tube [10]. No randomized controlled trials or comparative observational studies have evaluated clinically relevant outcomes, including mortality and hospital-acquired pneumonia. Existing guidelines from the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism do not address which tubes should be used for enteral nutrition in critically ill patients [1,2]. The Japanese guidelines for nutrition support therapy in critically ill patients weakly recommend the use of smaller-bore tubes, but this recommendation is based on very low-quality evidence [4].

Therefore, the present study aimed to compare outcomes between small-bore feeding tubes and large-bore sump tubes for early enteral nutrition in mechanically ventilated patients, using a national inpatient database in Japan.

Section snippets

Data source

This retrospective observational study was performed using routinely collected data. Informed consent from individual patients was not required because of the anonymous nature of the data. We used the Japanese Diagnosis Procedure Combination inpatient database, which contains discharge abstracts and administrative claims data from more than 1200 acute-care hospitals, covering approximately 90% of all tertiary-care emergency hospitals in Japan. The database includes the following data: age; sex;

Results

After applying the inclusion and exclusion criteria, a total of 79,656 patients were included in the present study (Fig. 1). Of these patients, 20,178 (25%) were in the small-bore feeding tube group, and 59,478 (75%) were in the large-bore sump tube group. Among the 20,178 patients in the small-bore feeding tube group, 12,187 (60%) had a small-bore feeding tube inserted on the first day of mechanical ventilation and 7991 (40%) had a small-bore feeding tube inserted on the second day of

Discussion

This study was a large-scale investigation of the effect of small-bore feeding tubes versus large-bore sump tubes for early enteral nutrition in mechanically ventilated patients, using a nationwide inpatient database in Japan. The results showed that early enteral nutrition via small-bore feeding tube was significantly associated with higher 28-day in-hospital mortality and hospital-acquired pneumonia. There were statistically significant differences in length of hospital stay and

Conclusion

This nationwide observational study suggests that early enteral nutrition via small-bore feeding tube in mechanically ventilated patients may not be associated with better clinical outcomes but rather with increased 28-day in-hospital mortality and hospital-acquired pneumonia. Because of the uncertainty regarding the mechanism of our findings, further studies are required.

Funding statement

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and 20AA2005) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (20H03907).

Author contribution

HO designed the research; HM and KF conducted the research; HO and HY analyzed the data; HO and HY wrote the paper; and HO had primary responsibility for the final content. All authors read and approved the final manuscript.

Conflicts of interest

All authors declare that they have no conflict of interest.

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