Optimizing Enteral Nutrition and Reducing Risk of Aspiration Pneumonia

Enteral feeding is associated with several factors that may result in reflux of gastric contents and aspiration: the supine position of the patient, the presence of a nasogastric tube, gastric contents, and delayed emptying of the stomach. Intuitively, placing the tip of the feeding tube into the intestine rather than the stomach should reduce aspiration, and the Canadian clinical practice guidelines recommend postpyloric feeding. On the other hand, a meta-analysis comparing gastric and post-pyloric feeding did not show any significant difference in the incidence of pneumonia between patients fed into the stomach and those fed beyond the pylorus. Although enteral feeding is widely practiced as the route of choice, in a study of 103 patients admitted to an ICU who were observed prospectively for the development of nosocomial pneumonia, there was evidence that feeding contributed to pneumonia. In that study, a multivariate analysis concluded that continuous enteral feeding, but not the nasogastric tube, was an independent risk factor for nosocomial pneumonia and patients who developed pneumonia had a significantly higher mortality of 43.5% compared to 18.8% for those who did not develop pneumonia. Clearly, more studies need to be done to determine the best approach to prevent pneumonia.

The use of prokinetics is another way of promoting gastric emptying. In a placebo controlled randomized trial of 305 patients receiving enteral feeding, giving metoclopramide did not reduce the incidence of pneumonia. Erythromycin, a motilin receptor agonist, is another powerful prokinetic agent. In a randomized controlled trial the benefit of erythromycin was questionable. There was no difference in the rate of pneumonia between the placebo and erythromycin-treated patients. The previous studies unfortunately involved small numbers of patients, and there is a need for larger trials of small bowel feeding and prokinetics to establish their role in promoting enteral feeding and reducing the risk of aspiration.

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