HOME TUBE FEEDING BASICS UBC DIETETICS PROGRAM Module 1 of 2 SCOPE - - PowerPoint PPT Presentation

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HOME TUBE FEEDING BASICS UBC DIETETICS PROGRAM Module 1 of 2 SCOPE - - PowerPoint PPT Presentation

Aug 17, 2022 240 likes •591 views

HOME TUBE FEEDING BASICS UBC DIETETICS PROGRAM Module 1 of 2 SCOPE OF THESE MODULES Modules 1 & 2 address the following Nutrition Care Process steps Intervention Monitoring and Evaluation Assessment and Diagnosis are not explicitly

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HOME TUBE FEEDING BASICS

Module 1 of 2

UBC DIETETICS PROGRAM

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SCOPE OF THESE MODULES

Modules 1 & 2 address the following Nutrition Care Process steps

  • Intervention
  • Monitoring and Evaluation

Assessment and Diagnosis are not explicitly addressed in these modules, but are critical parts of providing tube feeding nutrition care Refer to your prior learning on assessment and diagnosis related to tube feeding nutrition care

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LEARNING OBJECTIVES FOR THIS MODULE

  • 1. Demonstrate knowledge of indications for

home tube feeding

  • 2. Determine a home tube feeding care plan
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OUTLINE FOR THIS MODULE

  • Overview of home tube feeding
  • Development of a tube feed schedule
  • Tube feed delivery methods
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OVERVIEW OF HOME TUBE FEEDING

Indications for home tube feeding

  • For individuals with a functional GI tract
  • When oral intake is not possible or safe – tube feed exclusively
  • When oral intake is not sufficient to meet nutritional needs –

tube feed to supplement intake

  • Need for tube feeding may be short-term or longer-term,

depending on situation

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OVERVIEW OF HOME TUBE FEEDING

Situations that may require home tube feeding

  • Dysphagia, related to:
  • Cancer (e.g. esophageal, gastric, laryngeal)
  • Stroke
  • Achalasia
  • GI surgery
  • Inflammatory Bowel Disease with malnutrition
  • Chemotherapy/radiation treatment
  • Palliative prognosis
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OVERVIEW OF HOME TUBE FEEDING

Home Tube Feeding is Suitable When:

  • It is acceptable to the individual and their family
  • The benefits outweigh the burdens and risks
  • The individual has resources, and is competent to manage tube

feeding at home safely

  • Tube access is appropriate
  • Long-term tube type (e.g. PEG, G-tube or J-tube) is optimal
  • If NG/NJ tube is used - can individual and caregiver(s) manage?

Most often not appropriate

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DEVELOPMENT OF A TUBE FEED SCHEDULE

  • 1. Determine the type and required volume of tube

feed formula

  • Selection of formula depends on a number of factors
  • Refer to site-specific list(s) of enteral products for formula

choices

  • Try to not mix two types of formula or recommend half

cans/boxes when possible

  • Individuals may choose to use a formula available in

hospital or an equivalent made by another company

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DEVELOPMENT OF A TUBE FEED SCHEDULE

Common formula types Indications

Isotonic (1.0 kcal/ml) Standard product used for management of many conditions Calorie dense (1.2, 1.5 or 2.0 kcal/ml)

Also often contain higher protein

Elevated calorie and protein needs Shortened feeding schedules Fluid restriction/volume sensitivity Fibre-containing

Some products may also contain higher calories and protein

Maintain bowel function High protein Increased protein requirements Pressure ulcers (tissue maintenance/repair)

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DEVELOPMENT OF A TUBE FEED SCHEDULE

Specialty formulas (selected examples) Indications

Renal-specific Acute or chronic renal failure Electrolyte restriction Diabetes-specific Diabetes Impaired glucose tolerance Acute stress-induced hyperglycemia Semi-elemental or elemental Gastrointestinal impairment Malabsorption Allergies/intolerances Food-based formulas Some individuals may choose to make these at home, or purchase a commercially made version Intolerance to standard formulas Option for those who desire a real food component

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  • Establish volume of formula needed based on calculated

nutrition and fluid requirements

  • Gradual progression to goal volume may be needed

depending on factors such as tube feed tolerance and refeeding risk

  • Consider changing to a more concentrated formula (e.g. 1.5 or

2 cal/ml) if you want to limit the volume of tube feeds (however, may need additional water flushes to meet fluid requirements)

DEVELOPMENT OF A TUBE FEED SCHEDULE

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DEVELOPMENT OF A TUBE FEED SCHEDULE

  • 2. Design the administration schedule

Options:

  • Continuous
  • Intermittent
  • Nocturnal/Cyclic
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DEVELOPMENT OF A TUBE FEED SCHEDULE

Continuous Feeds

  • Tube feeds are run 24 hours per day, often at a steady rate
  • Not commonly used for home tube feeding
  • Useful for individuals that can only tolerate small feed

volumes or have hard to control blood sugars Considerations

  • Restricts ambulation/activity
  • Requires a pump
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DEVELOPMENT OF A TUBE FEED SCHEDULE

Intermittent Feeds

  • Tube feeds only run for part of the day, typically split into 3-4

feeds per day

  • Can be used to simulate mealtimes (when tube feeding is used

exclusively) or as “top-up feeds” to supplement oral intake Useful for

  • Individuals that can tolerate medium to large feed volumes
  • Individuals who do not want to be hooked up to tube feeds all

day

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DEVELOPMENT OF A TUBE FEED SCHEDULE

Cyclic (Nocturnal) Feeds

  • Tube feeds are delivered at night time only, often while asleep
  • Useful for individuals that can tolerate at least medium volumes

and who may be eating during the day

  • May be preferred by individuals who work/study during the day

Considerations

  • Increased need to use the bathroom at night
  • Head of bed must be > 30 degrees while sleeping
  • May need to get up and add more feed during the night
  • Requires a feeding pump
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DEVELOPMENT OF A TUBE FEED SCHEDULE

  • 3. Determine water flushes

Water flushes are administered to:

  • Provide hydration
  • Keep tube clear
  • Administer medications

Considerations:

  • Free water in tube feed formula and flushes contribute to
  • verall fluid requirement
  • Extra water needed for emesis, diarrhea, fever
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TUBE FEED DELIVERY METHODS

Options

  • Syringe
  • Gravity
  • Pump
  • Closed Systems
  • Open Systems
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TUBE FEED DELIVERY METHODS

Syringe

  • Fastest and most cost-effective method; becoming more

prevalent as first choice for intermittent feeding

  • Sometimes referred to as “bolus feeding”
  • Tolerated better when tube terminus is in the stomach (e.g.

G tube, PEG)

  • Individual or caregiver(s) must have manual dexterity and

strength to administer feeds with syringe

  • IV pole not needed
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SYRINGE FEEDING

Demonstration of syringe feeding:

https://www.youtube.com/watch?v=EYs2xR-e3To

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TUBE FEED DELIVERY METHODS

Gravity

  • Typically recommended for intermittent feeds, and when

tube terminus is in the stomach (e.g. G tube, PEG tube)

  • May be used in combination with syringe method if tolerated
  • IV pole not always required
  • Gravity feeding may be used instead of pump feeding for a

variety of reasons: cost, convenience, minimal skill needed to

  • perate, ease of use
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GRAVITY FEEDING

Demonstration of gravity feeding: https://www.youtube.com/watch?v=LD5bPwArd2Q

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TUBE FEED DELIVERY METHODS

Pump

  • Typically recommended for
  • Small bowel feeding (e.g. J tube), but can also be used

in other parts of the GI tract

  • Thicker/energy dense formulas (e.g. 2.0cal/ml)
  • Continuous or nocturnal feeds
  • Slower feeding rates
  • Hospital-based feeding
  • May be required for intermittent feeds if cannot tolerate

syringe or gravity

  • IV pole needed for some pumps
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PUMP EXAMPLES

EnteraLite Infinity (Bowers Medical)

  • Max rate 600 ml/hr
  • Small pump (<1 lb) ideal for

active lifestyles

  • IV pole not required

Refer to Health Authority site specific information for available pumps

Image source: http://infinityfeedingpump.com/virtual-pump/

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PUMP EXAMPLES

Compat (Medline)

  • Max rate 295 ml/hr
  • Large pump ideal for more sedentary

lifestyles or when dexterity or vision are issues (has large buttons)

  • IV pole recommended for use

Refer to Health Authority site specific information for available pumps

Image source: http://www.medline.com/product/Compat-Enteral-Feeding-Pumps/Pumps/Z05-PF10589;ecomsessionid=JjwvzQ2kdAEDzc136y7Mcw__?_requestid=10480993

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PUMP FEEDING

Demonstration of pump feeding (with an open system): https://www.youtube.com/watch?v=XZh0XZ_pTIk

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TUBE FEED DELIVERY METHODS

Closed System

  • Pre-filled 1 liter or 1.5 liter container or pouch of formula
  • Containers are spiked/pierced with a feeding set before feeding
  • Typically used with pumps, some products may be suitable for gravity

delivery (check with product guides and reps)

  • Feeding sets need to be compatible with the brand of pump

Syringe for flushes

Images sourced from: https://www.nestlehealthscience.ca/en and https://www.cardinalhealth.ca/en/docs/05_NUTRITION.pdf

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TUBE FEED DELIVERY METHODS

Closed System

Advantages

  • More convenient (no cleaning involved)
  • Sterile- less risk of contamination
  • Typically 48 hour hang time (refer to product guides for details)

Disadvantages

  • Only available in 1 liter or 1.5 liter sizes
  • Not refillable or reusable
  • Requires a new spike set for each bottle or pouch
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TUBE FEED DELIVERY METHODS

Open System

  • Ready-to-use liquid formula in tetras, bottles or cans
  • Formula is poured into a feeding bag or administered with

a syringe for feeding

  • Can be used for pump, gravity or syringe feeding
  • Different equipment required for pump vs. gravity vs.

syringe feeding

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TUBE FEED DELIVERY METHODS

Syringe feeding with an open system requires: syringes for formula and water flushes, formula (images are examples only)

Images sourced from: https://www.nestlehealthscience.ca/en/brands/isosource/isosource and https://www.nestlehealthscience.ca/en/mytubefeedingadult

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TUBE FEED DELIVERY METHODS

Gravity feeding with an open system requires: a gravity set (bag and tubing), formula, syringes for water flushes (images are examples only)

Images sourced from: https://www.nestlehealthscience.ca/en/mytubefeedingadult and https://www.cardinalhealth.ca/en/docs/05_NUTRITION.pdf

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Pump feeding with an open system requires: bags, tubing, a pump, formula, syringes for water flushes (images are examples only)

TUBE FEED DELIVERY METHODS

Images sourced from: https://www.nestlehealthscience.ca/en/mytubefeedingadult and https://www.cardinalhealth.ca/en/docs/05_NUTRITION.pdf

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TUBE FEED DELIVERY METHODS

Open System

Advantages

  • Cost effective
  • May have less feed waste

Disadvantages

  • More labour required to prepare and clean
  • Increased risk for bacterial contamination
  • Typically 8-12 hour hang time (refer to product guides for details)
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APPLY YOUR LEARNING

How might an individual’s medical condition(s) and goals of care affect the home tube feeding care plan? What factors should be considered when selecting the optimal enteral nutrition formula(s) for home tube feeding? What factors should be considered when selecting the optimal delivery method for home tube feeding?

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Thank you to the UBC Dietetic Education Core Council Home Tube Feeding Working Group, and British Columbia Health Authorities for contributing to the development of these modules