Electromagnetic-guided versus endoscopic placement of nasoenteral feeding tubes: protocol for a systematic review and meta-analysis

IntroductionCurrent evidence supporting the utility of electromagnetic (EM)-guided method as the preferred technique for nasoenteral feeding tube placement is limited. We plan to provide a meta-analysis to compare the performance of EM-guided versus endoscopic placement.Methods and analysisRandomised controlled trials evaluating EM-guided versus endoscopic placement will be searched in MEDLINE, EMBASE and CENTRAL from database inception to 30 September 2020. Data on study design, participant characteristics, intervention details and outcomes will be extracted. Primary outcomes to be assessed are complications. Secondary outcomes include procedure success rate, total procedure time, patient recommendation, length of hospital stay and mortality. Study quality will be assessed using the Cochrane risk of bias tool. Data will be combined with a random effects model. The results will be presented as a risk ratio for dichotomous data and weighted mean difference for continuous data. Publication bias will be visualised using funnel plots. We will quantify the effect of potential effect modifiers by meta-regression if appropriate. The quality of evidence will be evaluated according to the Grading of Recommendations Assessment, Development and Evaluation framework.Ethics and disseminationThis study will not use primary data, and therefore formal ethical approval is not required. The findings will be disseminated through peer-reviewed journals and committee conferences.PROSPERO registration numberCRD42020172427.

Electromagnetic-Guided Versus Endoscopic Placement of Nasoenteral Feeding Tubes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives: Current evidence supporting the utility of electromagnetic (EM)-guided method as the preferred technique for nasoenteral feeding tube placement is limited. We conducted a meta-analysis to compare the performance of EM-guided versus endoscopic placement.Methods: We searched several databases for all randomized controlled trials evaluating the EM-guided vs. endoscopic placement of nasoenteral feeding tubes up to 28 July 2020. Primary outcome was procedure success rate. Secondary outcomes included reinsertion rate, number of attempts, placement-related complications, tube-related complications, insertion time, total procedure time, patient discomfort, recommendation scores, length of hospital stay, mortality, and total costs. Results: Four trials involving 536 patients were qualified for the final analysis. There was no difference between the two groups in procedure success rate (RR 0.97; 95% CI: 0.91-1.03), reinsertion rate (RR 0.84; 95% CI: 0.59-1.20), number of attempts (WMD -0.23; 95% CI: -0.99-0.53), placement-related complications (RR 0.78; 95% CI: 0.41-1.49), tube-related complications (RR 1.08; 95% CI: 0.82-1.44), total procedure time (WMD -18.09; 95% CI: -38.66-2.47), length of hospital stay (WMD 1.57; 95% CI: -0.33-3.47), ICU mortality (RR 0.80; 95% CI: 0.50-1.29), in-hospital mortality (RR 0.87; 95% CI: 0.59-1.28), and total costs (SMD -1.80; 95% CI: -3.96-0.36). The EM group was associated with longer insertion time (WMD 4.3; 95% CI: 0.2-8.39), higher patient discomfort level (WMD 1.28; 95% CI: 0.46-2.1), and higher recommendation scores (WMD 1.67; 95% CI: 0.24-3.10).Conclusions: EM-guided placement showed similar efficacy, safety and cost-effectiveness when compared with endoscopic placement of nasoenteral feeding tubes.

Evaluation of a Nasoenteral Feeding Tube With Balloon to Facilitate Placement

Background Enteral feeding is essential for critically ill, head trauma, and burn patients who are unable to swallow. Objective To evaluate a new nasoenteral feeding tube with distal tip balloon designed to facilitate post-pyloric migration and avoid misplacement in the trachea. Methods A case series was conducted in 50 critically ill patients aged 19 to 89 years receiving mechanical ventilation and requiring enteral nutrition in a teaching hospital. Patients received a soft, flexible, kink-resistant nasoenteral feeding tube with a balloon near the distal tip to enhance postpyloric migration by peristalsis. The feeding tube was inserted with a novel thread technique to reduce posterior nasopharyngeal trauma and tube misplacement. Pulse oximetry provided early detection of misplacement into the trachea. Placement was verified by abdominal radiography performed shortly after the procedure and repeated within 24 hours if needed. Results Postpyloric placement was achieved at 30 minutes in 24% of patients and by the following morning in 70% of patients. Tracheal intubation occurred in 1 patient but was recognized and corrected without injury. No tube occlusion from kinking occurred. Conclusions Early gastric or postpyloric feeding can be provided with this novel feeding tube. Its use facilitates quick bedside recognition of accidental misplacement in the trachea, reducing the chance of pneumothorax. The tip balloon reduces deeper placement into a lung and promotes distal migration into the small intestine. The design prevents occlusion from kinking, which is common with conventional feeding tubes. Nurses easily adopted the tube and insertion technique.

Safety and Efficacy of Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes versus Standard Placement

Although enteral feeding in critically ill patients has been shown to be beneficial, reliable postpyloric placement of feeding tubes remains a challenge. The standard of care involves blind placement, frequently requiring multiple attempts, and radiographs. To evaluate the effect of electromagnetic-guided bedside placement in reducing time to establishment of feeding, lung placement, use of radiography, and cost, we initiated a prospective trial using electromagnetic-guided bedside placement and compared them to a retrospective cohort. Fifty-three consecutive placements of nasoenteral feeding tubes were made using electromagnetic-guidance on patients requiring enteral nutrition in a surgical intensive care unit at a tertiary care center. Sixty-three placement attempts in the preceding seven months served as controls. There were no significant differences between the two groups in terms of age, sex, weight, body mass index, hiatal or ventral hernias, or previous esophageal/gastric operations. The number of radiographs needed per patient, need for fluoroscopy, radiology charge per patient for the tube placement, and time from first attempt at placement to confirmation of postpyloric location were lower for the electromagnetic-guided group. Use of electromagnetic guidance allows reliable and cost-effective postpyloric enteral feeding tube placement compared with blind insertion.