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npo status/asp pneum and enteral feeding



     Here are some of my thoughts on your contribution:
     First, there are two terms that are associated with specialized
nutrition support.  They are "enteral nutrition" and "parenteral
nutrition." Enteral nutrition is defined as the administration of
nutrients via the gastrointestinal tract either orally or by tube,
catheter, or stoma distal to the oral cavity.  Parenteral nutrition is
defined as the administration of nutrients intravenously either by means
of a large central vein (usually the superior vena cava), or a
peripheral vein (usually in the hand or forearm).
     There is a large and growing body of evidence in the literature
about people who do not get enough nutrition/hydration orally.  I have
seen a lot of studies that show not all such people are candidates for
feeding tubes because of a poorly functioning gut or esophagus.  In the
presence of medical problems like these, feeding tubes can promote
infections, pneumonia, or death.
     In your posting, you excluded cases of aspiration resulting from
reflux from your argument.  The issue of reflux is at the very root of
the question about whether feeding tubes can prevent aspiration
pneumonia; why would you exclude it?
     Many people who receive their nutrition and hydration through a
feeding tube are obtunded, comatose, or too sick to have an appetite.
Even if their oral/oropharyngeal mechanisms are impaired, they are not
likely to voluntarily compromise their airways with food or beverages.
If these folks are not candidates for feeding tubes, they periodically
demonstrate aspiration related lower respiratory conditions including
(but not limited to) aspiration pneumonia.  Sometimes, as has been
pointed out by others, the consequences are more severe.
     If people aspirate funky oral secretions because their swallowing
mechanism is incompetent and their mouth care is poor, they can become
ill (or worse).
     You are right to point out that there are no easy answers in our
field.  Even if we were not asked to help others make moral, ethical or
philosophical decisions, our jobs and responsibilities could not be
called easy or obvious.  We are called on to read and understand
gigantic amounts of literature, data and anecdotal evidence, not all of
it clear or conclusive.  Like some of our colleagues in respiratory
therapy who believe an inflated cuff offers effective, long lasting
airway protection from aspirated material, we sometimes have
preconceived notions that die hard.  Sometimes things we learned in
graduate school turn out to be false (anyone out there remember the
neurochronaxic theory of voice production?), and stuff our mothers
taught us turns out to be right on the money (If you don't eat good
food, you won't get to be strong and healthy).
     I believe you are right when you say that the rationale for feeding
recommendations must be made based on supporting, properly researched
evidence WITH the patient's individual medical history and circumstances
in mind AND is in agreement with the wishes of an adequately and
well-informed patient/POA/family/physician.  I believe you are right to
question whether an oral diet will compromise a person's respiratory
status just because he has a diagnosis of dysphagia.
     Just my two cents.

Scott



Cathy Wilson wrote:

>  Food for thought (no pun intended) concerning the reports of
> increased incidence of aspiration pneumonia with enterally fed
> patients: Perhaps the patients who are enterally fed and develop
> aspiration pneumonia (excluding cases of secondary aspiration
> resulting from reflux) do so because of lack of adherence to
> NPO/swallowing precautions.  It is likely that the patients who are
> recommended for enteral feedings are rightly identified due to severe
> risk of primary aspiration, however due to lack of compliance either
> on part of patient, family, or staff, the patient ingests and
> aspirates on an "off-limits" substance and thus develops the pneumonia
> in spite of the recommended non-oral feeding method.  I am not stating
> that this is so in all or any cases.  Just a thought.  I am sure we
> all have sympathy for our dysphagic patients who must follow the
> various compensatory strategies in our clinical bag of tricks employed
> to increase swallow safety.  Thickened liquids by spoons for those who
> love to "gulp" is an enormous sacrifice.  Tucking the chin to the
> chest to swallow during meals for a sociable person who has for 70
> years enjoyed looking up into her husband's eyes across the table to
> chat and discuss the day's events is not an easy thing to remember for
> every single bite of every single meal , esp as it defies social
> interactive pragmatics.  For a person who is NPO the tempation must be
> great to abstain from a nice cold drink to drench the mouth and throat
> on a hot day  or how about turning down a slice of NY cheesecake?  I
> know that if I were being tube fed, it would take great restraint in
> order to be 100% compliant.

> I am not disputing the sources that have been cited by Istyles with
> regards to asp pneumonia and enterally fed patients and I am greatly
> appreciative for the information he has contributed.  I am just posing
> a "chicken and the egg" question that has no simple answer.  For the
> enterally fed patient are the increased rates of pneumonia, URI, etc.
> due to the presence of the tube alone or do they result secondary to
> the dysphagic conditions that determined the need for tube placement
> in the first place?  Is the tube preventing at least some aspiration
> or is it aggrevating it (excluding GER)? Is an oral diet going to
> compromise respiratory status or is an oral diet going to increase
> protection for the larynx/lungs compared with possible
> tube-fedside-effects?The rationale for feeding recommendations must be
> made based on supporting, properly researched evidence WITH the
> patients individual med hx and circumstances in mind AND is in
> agreement with the wishes of an adequately and well-informed
> patient/POA/family/physician. What are others thoughts on this?






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