XXX10.1177/0194599810391726Leder et alOtolaryngology—Head and Neck Surgery XX(X) © The Author(s) 2010 Reprints and permission: sagepub.com/journalsPermissions.nav
Original Research—General Otolaryngology
Effect of Orogastric Tubes on Aspiration Status and Recommendations for Oral Feeding
Otolaryngology– Head and Neck Surgery 144(3) 372–375 © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599810391726 http://otojournal.org
Steven B. Leder, PhD, CCC-SLP1, Cathy L. Lazarus, PhD, CCC-SLP2, Debra M. Suiter, PhD, CCC-SLP3, and Lynn M. Acton, MS, CCC-SLP4
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. To investigate the effects, if any, of the presence of an orogastric tube on incidence of aspiration and oral diet recommendations. Study Design. Case series with planned data collection. Setting. Large, urban, tertiary care teaching hospital. Subjects and Methods. Referred sample of 10 consecutively enrolled inpatients (2 pediatric, aged 17 days and 3 months, respectively; and 8 adults, mean age 63 years). An orogastric tube was present for the first videofluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing and then removed for the second swallow study. Results. There were no significant differences (P = 1.0) for both overall incidence of aspiration and aspiration by food consistency (liquid or puree) dependent on orogastric tube presence. All 9 participants recommended for an oral diet ate successfully. Conclusions. An orogastric tube did not affect incidence of aspiration. A videofluoroscopic or endoscopic evaluation of swallowing can be performed with an orogastric tube present, and there is no contraindication to keeping an orogastric tube in place to supplement oral alimentation until prandial nutrition is adequate. Keywords deglutition, deglutition disorders, orogastric tube, aspiration Received July 7, 2010; revised October 14, 2010; accepted November 3, 2010.
T
he only report in the literature relevant to feeding with an orogastric (OG) tube reported no retrograde aspiration (defined as aspiration of refluxed gastric contents) with newborn babies.1 No data are available pertaining to anterograde
aspiration (defined as aspiration during oral alimentation due to oropharyngeal dysphagia) concomitant with the frequent use of an OG tube in the adult intensive care unit setting. This deficiency needs to be addressed since an OG tube is a foreign object that traverses the entire pathway a food bolus travels during all 3 stages of swallowing (from the oral cavity through the pharynx and into the esophagus) with a corresponding a priori assumption of a negative impact on safe and efficient swallowing. A nasogastric (NG) tube does not cross the oral cavity but is present in the pharynx and esophagus, and its effect on the incidence of anterograde aspiration has been of interest. NG tube placement was investigated in before-and-after feeding trials with 10 normal adults2 and 223 and 254 stroke patients, respectively. No significant differences in aspiration rates were reported. A large-scale study using 2 separate but comparable groups (ie, 630 with and 630 without NG tubes) corroborated findings of no significant differences in aspiration rates for both liquid and puree food consistencies.5 Therefore, although aspiration may occur coincidently with NG tube use,6-9 no causal relationship has been demonstrated.2-5 It is unknown if the presence of an OG tube results in increased oropharyngeal dysphagia and aspiration risk. The purposes of the present investigation were to determine what effect, if any, the presence of an OG tube has on the incidence of anterograde aspiration as determined by objective evaluation of swallowing using both liquid and puree bolus consistencies and if diet recommendations can be made for patients who require an OG tube. 1
Department of Surgery, Section of Otolaryngology,Yale University School of Medicine, New Haven, Connecticut, USA 2 Thyroid Head and Neck Research Center, Beth Israel Medical Center, New York, New York, USA 3 Veterans Affairs Medical Center, Memphis, Tennessee, USA 4 Yale–New Haven Hospital, New Haven, Connecticut, USA Corresponding Author: Steven B. Leder, PhD, Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, PO Box 208041, New Haven, CT 06520-8041, USA Email:
[email protected]
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Leder et al Table 1. Participant Demographics, Aspiration Status, and Diet Recommendations Participant No./ Gender/Chronological Age (y/mo/d)
Diagnosis
Tube Type
FEES or VFSS
1/F/65y3m
Guillain-Barré
OGT
FEES
2/F/77y0m
Trauma (fall)
OGT/NGT
FEES
3/F/76y0m
Ovarian cancer
OGT/NGT
FEES
4/F/76y2m
Intraparenchymal hemorrhage Trauma (fall)
OGT/NGT
FEES
OGT/NGT
FEES
OGT
FEES
2 OGTsb
FEES
OGT
VFSS
OGT/NGT
FEES
OGT
VFSS
5 OGT
8 FEES
5 OGT/NGT
2 VFSS
5/F/73y0m 6/M/22y10m 7M/59y0m 8/F/0y0m17d 9/F/52y1m 10/F/0y3m Totals 2 males; 8 females Age range, 17 d to 77 y
Trauma (motor vehicle crash) Trauma (motor vehicle crash) Cardiomyopathy Trauma (motor vehicle crash) Apert syndrome
Aspiration Status First With and Then Without OGT Diet Recommendation + Aspiration liquid only − Aspiration liquid/ puree − Aspiration liquid/ puree + Aspiration both liquid/puree − Aspirationa puree + Aspiration liquid only − Aspiration liquid/ puree − Aspiration liquid/ puree − Aspiration liquid/ puree − Aspiration liquid/ puree 6 − aspiration liquid/ puree 1 − aspiration puree
Honey-thick liquid/ puree diet Liquid/puree diet Regular diet Nil by mouth Honey-thick liquid/ puree diet Honey-thick liquid/ puree diet Liquid/puree diet Liquid diet Liquid/puree diet Liquid dietc 9 oral alimentation 1 nil by mouth
2 + aspiration liquid 1 + aspiration liquid/ puree
Abbreviations: FEES, fiber-optic endoscopic evaluation of swallowing; NGT, nasogastric tube; OGT, orogastric tube;VFSS, videofluoroscopic swallow study. a Liquids not given because patient was unable to suck with straw or drink from cup. b Facial trauma necessitated 2 OGTs: 1 large bore for abdominal decompression and 1 small bore for nutrition delivery. c Severe oral phase dysphagia precluded recommendations of puree consistency.
Methods Subjects This study was approved by the Human Investigation Committee, Yale University School of Medicine. Ten consecutive inpatients (2 pediatric patients, aged 17 days and 3 months, respectively; and 8 adults, age range 22-77 years, mean 63 years and 2 months), who were referred for dysphagia evaluations from a large, urban, tertiary care teaching hospital in a prospective manner from January to October 2009, participated in this study. Duration of OG tube use ranged from 6 to 35 days (mean 20.6 days with a standard deviation of 7.5). All adult participants had large-bore OG tubes (18 Fr, 6.0 mm diameter), and when an NG tube was also present, it was always a small-bore tube (8 Fr, 2.7 mm diameter). Pediatric participants had pediatric feeding tubes (5 Fr, 1.7 mm diameter). Table 1 shows participant demographics, aspiration status, and feeding recommendations.
Procedures The OG tube was always present for the first objective swallowing evaluation (ie, fiber-optic endoscopic evaluation of
swallowing [FEES] or videofluoroscopic swallow study [VFSS]). After successful completion of initial testing, the OG tube was removed and a second swallowing evaluation performed within 5 minutes. Adult participants received the standard FEES protocol10,11 with slight modifications. Briefly, each naris was examined visually and the scope passed through the most patent naris without administration of a topical anesthetic or vasoconstrictor to the nasal mucosa, thereby eliminating any potential adverse anesthetic reaction and assuring the endoscopist of a safe physiologic examination.12 The base of tongue, pharynx, and larynx was viewed, and swallowing was evaluated directly with 6 food boluses of approximately 5 mL volume each. The first food challenge consisted of 3 boluses of puree consistency (yellow pudding) followed by 3 liquid boluses (white milk) because these colors have excellent contrast with pharyngeal and laryngeal mucosa.13 All participants were allowed to swallow spontaneously (ie, without a verbal command to swallow).14 FEES equipment consisted of a 3.6-mm-diameter flexible fiber-optic rhinolaryngoscope (ENF-P3; Olympus, Center Valley, Pennsylvania), light source (CLK-4; Olympus),
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camera (MN401E; ELMO USA, Plainview, New York), and color monitor (RJ4049WA01; Magnavox, Fort Wayne, Indiana). All VFSS procedures were performed with each pediatric participant seated upright in a tumble-forms chair with the head and neck in the neutral position and the chest and abdomen in the true lateral plane (Eleva system, Philips Medical Systems, Hamburg, Germany). The fluoroscopy images included the lips anteriorly to the pharyngeal wall posteriorly and the soft palate superiorly to the sixth cervical vertebra inferiorly. Swallowing was evaluated with the first 6 to 10 liquid boluses of singlecontrast liquid barium sulfate suspension (E-Z Paque; E-Z-Em, Lake Success, New York) delivered via bottle nipple. Evaluations were videotaped for review. Both test/retest agreement performed 4 to 6 months after initial testing and intra- and interrater reliability for identification of aspiration status were 100%. Aspiration was defined as entry of material into the airway below the level of the true vocal folds.15 A safe swallow was defined as no aspiration, and an unsafe swallow was defined as aspiration of liquid or puree consistency at any time during FEES or VFSS. A successful diet recommendation was defined as oral alimentation without overt signs of dysphagia 1 day after testing.
Specifically, the occurrence of aspiration with either liquid or puree consistency foods was the same whether an OG tube was present. This supports similar research that reported that an NG tube did not affect incidence of aspiration or swallowing success with either liquid or puree consistency foods.2-5 There is the potential for retrograde aspiration with OG tube use. The only study that investigated retrograde aspiration with OG tube use dealt with newborn babies and reported no effects.1 It is, however, unknown if similar results would be obtained with adults. Therefore, to minimize risk of reflux when an OG tube is in place, regardless of oral feeding status, it is recommended that the head of the bed remain elevated at 30° and that tube and/or oral feedings be stopped 20 to 30 minutes prior to repositioning the patient in bed. In addition, the oropharyngeal swallow was shown to be both robust and adaptable. Specific diet recommendations were made that resulted in successful oral alimentation following removal of the OG tube. Importantly, the present study confirms that a safe and successful swallow, defined as no aspiration during FEES or VFSS, can occur despite the presence of 3 foreign objects that traversed the food pathway (ie, OG tube, NG tube, and endoscope).
Results
Study Strengths and Limitations
The exact McNemar test (Stata Corp, College Station, Texas) indicated no significant differences (P = 1.0) for both overall incidence of aspiration and aspiration by food consistency (ie, liquid or puree), dependent on presence of an OG tube. Specifically, participants exhibited either no aspiration or aspiration with the same bolus consistency regardless of whether an OG tube was present (Table 1). The 2 goals of dysphagia testing—that is, to assess dysphagia and, when appropriate, to make recommendations for safe oral alimentation15—resulted in differing but successful diet recommendations (Table 1). All 9 participants recommended for an oral diet were eating successfully 1 day after testing, and no participants were referred for a repeat swallow evaluation during their hospital stay. Six participants (participants 2, 3, 7, 8, 9, 10) did not exhibit aspiration with both liquid and puree consistencies and were recommended for and successful with an appropriate oral diet. Successful diet recommendations for 2 participants (participants 1 and 6) were honey-thick liquids and puree due to aspiration with thin liquid consistencies. One participant (participant 5), who was unable to drink liquids, did not exhibit aspiration with puree and was successful with a honey-thick liquid and puree diet. Only 1 participant (participant 4) remained nil by mouth due to aspiration of both liquid and puree consistencies. Five of 10 (50%) participants (participants 2, 3, 4, 5, 9) had both an OG and NG tube present at the time of dysphagia testing (Table 1). Four (80%) of these participants swallowed successfully without aspiration despite the presence of 2 tubes plus the fiber-optic endoscope required for FEES.
Major strengths of this study that increased generalizability included participants accrued in a prospective, consecutive manner; spanning of the age spectrum with newborn, pediatric, and adult participants; and a wide variety of diagnoses representative of the inpatient population of a large, urban, tertiary care teaching hospital. A limitation of this study was the use of a referral-based population sample versus a randomized controlled research design. Future research with a larger sample size to corroborate the present findings would be beneficial.
Discussion
Disclosures
For the first time, it has been shown that presence of an OG tube did not affect incidence of aspiration and that successful diet recommendations can be made with an OG tube in place.
Sponsorships: None.
Conclusions The presence of an OG tube, regardless of age or diagnostic category, did not affect the incidence of aspiration for either liquid or puree food consistencies and allowed for specific diet recommendations to be made. Since an objective swallowing evaluation (ie, VFSS or FEES) can be performed with an OG tube in place, it is not necessary to remove an OG tube to evaluate dysphagia. Similarly, there is no contraindication to leaving an OG tube in place to supplement oral alimentation until prandial nutrition is adequate. Author Contributions Steven B. Leder, conception and design, acquisition of data, analysis and interpretation of data, drafting, final approval; Cathy L. Lazarus, conception and design, analysis and interpretation of data, revising, final approval; Debra M. Suiter, conception and design, analysis and interpretation of data, revising, final approval; Lynn M. Acton, acquisition of data, revising, final approval.
Competing interests: None. Funding source: None.
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