The route of nutrition delivery

Is there significant benefit or risk associated with the route chosen for delivery of nutrition? Would total parenteral nutrition (TPN) increase the bacteremia rate, but decrease the incidence of aspiration pneumonia, for instance? Could jejunal feeding reduce the likelihood of esophageal reflux and thus lower the pneumonia rate when compared to gastric feeding?

Gastric vs non-gastric enteral feeding

Gastrostomy feeding of 10 neurologically dysphagic patients was compared to 20 fed by nasogastric tube in Scotland [50]. The nasogastric tube was a "fine bore" 20 French tube. After 28 days, the gastrostomy patient group suffered two aspiration pneumonias and one wound infection versus no pneumonias for the nasogastric group. Another small study compared ventilated Canadian trauma patients receiving gastric versus duodenal feedings via nasal or oral tubes. Forty three gastrically fed patients had 18 clinically diagnosed pneumonias versus 10 pneumonias in the 37 patients receiving duodenal feedings. No difference was statistically discernible with the sample size used. Nasogastric and nasoduodenal feeding of ventilated patients was compared in 44 California medical ICU patients [51]. The pneumonia, bacteremia and mortality rates were indistinguishable.

Jejunal feedings were compared to gastric feedings in 38 Boston medical and surgical ICU patients. The jejunal tubes were placed perorally. About half of each group was ventilated. Two gastrically fed patients developed pneumonia versus none of the jejunally fed [52]. Such a small study is not convincing.

Two meta-analyses have been published which analyzed the differences between gastric and non-gastric enteral feeding. One [53] found a relative risk of 0.76 of developing a pneumonia for small bowel (duodenal or jejunal) feedings. The other [54] found no proven benefit in preventing pneumonia by employing small bowel feedings. The consensus statement of a North American summit on aspiration in critically ill patients likewise concluded that good evidence does not exist for small bowel feedings unless proven aspiration occurs and then jejunal feedings were recommended [55]. This consensus group did recommend continuous enteral feeding rather than bolus feeding apparently based on the study carried out on 60 Nebraskan patients receiving nasogastric feedings [56]. This study only followed elderly patients for seven days. All patients were assessed clinically for aspiration and continuously fed patients had one-half the aspiration rate of intermittently fed patients. This difference was not statistically significant.