SCCM Resource Library-55-Improving Retention of Feeding Tubes in Pediatric Patients: An RCT Using the Nasal Bridle

Video Transcription

Hello, my name is Megan Foster and I'm the third year Pediatric Critical Care Fellow at the University of Texas Health Science Center in San Antonio.  Today I'm going to be discussing my research project, which looked at improving the retention of feeding tubes in pediatric patients using the nasal bridle.  The nasal bridles for my project were provided by Applied Medical Technology Incorporated. The opinions and conclusions are those of the authors and do not reflect the views of  Applied Medical Technology Incorporated. I have no financial disclosures to disclose. As we all know, feeding tubes are frequently placed in both the adult and pediatric ICU  as a way to administer medications and nutrition. It was our observation in the pediatric ICU that we were having frequent feeding tube dislodgement.  As you can imagine, this leads to patients missing both medications, missing nutrition, sometimes for minutes and sometimes for hours.  There was repeated discomfort of tube replacement and repeated radiation exposure for tube replacement.  We had an increased use of hospital resources, not only in the tubes that were being replaced, but also the staff who had to replace these tubes, the radiology techs who had to come  perform the x-rays, and the cost of the x-rays themselves. We knew there had to be a better way. In our review of the adult literature, we found a meta-analysis published in 2014 in  the Journal of Nutrition and Clinical Practice that reviewed six studies using a nasal bridle, and all six studies showed a reduction in tube dislodgement when tubes were secured  with the nasal bridle. Another study published in 2019 in the British Journal of Nursing showed that tubes secured  with tape were dislodged 57% of the time compared with tubes secured with the bridle, which were dislodged 17% of the time.  The third study we looked at was in the Journal of Burn in 2018, and that's where these two graphics came from.  This one on the left, you can see throughout the study the average number of feeding tubes placed in the tape compared to the bridle group, the number of abdominal x-rays performed  in the tape versus the bridle group, and finally, the number of tube dislodgements per 10 tube days, which in the tape group was 0.9 dislodgements per 10 tube days compared  to the bridle group, which was just 0.2 dislodgements per 10 tube days. Over here on the right, we have the feeding tube survival curve, the blue line demonstrating  tubes secured with tape, and the red line demonstrating tubes secured with the nasal bridle, and you can see the significant difference in feeding tube survival for those secured  with the bridle compared to those secured with tape.  If you've never seen the bridle before, this is what it looks like on the outside of the body. It's a device that utilizes the structure of the nasal cavity, it's FDA approved for  use in pediatrics, and it's manufactured by several companies. For the purposes of our study, we used the Bridle Pro device manufactured by AMT, and  this is a picture of it in a pediatric patient. So you can see in this picture, the feeding tube goes into the left nostril, and there's  a blue silicone tubing that goes in and around the back of the vomer bone to secure the tube. The device is placed with two probes that have a magnet on the back connecting behind  the vomer bone, and the tube is thread behind the bone. You can imagine if any pressure is placed on the feeding tube, there will be pressure  on the back of the vomer bone, which will hopefully prevent feeding tube dislodgement. The bridle is designed in such a way that if enough pressure is placed on the tube,  the tube will be able to slip through the bridle without causing damage to the nasal cavity.  There are a few studies in pediatrics using the nasal bridle, but all of the ones we were able to find were done on an outpatient basis.  This first study, published in the Pediatric Surgical Nursing Journal in 2018, secured all feeding tubes with a bridle and demonstrated that only one of the 14 tubes were dislodged.  These patients were specifically patients who had undergone TE fistula repair or congenital diaphragmatic hernia repair and then were sent home with a feeding tube and bridle.  Another study published in 2020 in the Pediatric Journal of Otolaryngology did a comparative study securing tubes with bridles compared to tape.  These patients also feeding tubes were secured and patients were sent home. On follow-up, they found that none of the tubes secured with bridles were dislodged  compared to 16 that were secured with tape being dislodged.  Our study design was a prospective open-label randomized control trial. When we assessed patients for eligibility, the inclusion criteria included any patients  who needed a nasoenteric feeding tube, whether it be NG, OP, or post-pyloric. Patients had to be inpatient at University Hospital, and we looked at all pediatric patients  age 0 to 18. Exclusionary criteria are those included in the package insert, which included facial  trauma, nasal airway obstructions, thrombocytopenia to less than 100,000, or any patients who had undergone septoplasty or bone-by-bone grafting.  Of all the patients that we assessed, 13 were excluded for not meeting the criteria, and we randomized 32 groups, 32 patients, 16 to the tape group and 16 to the bridle group.  In each group, one patient was withdrawn. In the tape group, this was a patient who was transferred to a different institution on the first day of enrollment, so he was withdrawn.  And in the bridle group, there was a patient who had an allergic reaction to the silicone tubing, and she was withdrawn. Fifteen patients completed the study in each group.  This is our demographic table. You can see 15 patients in each group with no statistical significance, statistically significant difference between either group.  We compared patients' age, the percentage of male to female, patients' weight, whether  patients had an NG or NJ tube, and the number of patients who were intubated on tube placement. We had a few complications to report.  In the bridle group, there was one patient who experienced the allergic reaction to silicone tubing.  This is actually a picture of her, so you can see the erythema in the nasal cavity, which resolved upon bridle removal.  And there were three patients in the tape group who experienced significant skin breakdown from the tape securement. This is our results slide.  You can see that of the 15 patients in the bridle group, three of the tubes were dislodged, which was 20%, compared to the tape group, which had 12 dislodgements per 15 tubes.  We looked at the time to dislodgement for each group, and despite there being some dislodgements  in the bridle group, it took longer for tubes to be dislodged, 6.67 days, compared to the tape group when tubes were dislodged on an average of 4.2 days.  Our number of dislodgements per 100 tube days was 0.16 for the bridle group, compared to 2.11 for the tape group.  These are some pictures of patients in our unit who were in the bridle arm. You can see this little kiddo on the left who had congenital heart surgery.  He had his bridle and feeding tube in place for 30 days, and this patient on the right was a victim of a house fire who randomized to the bridle group, and the surgeons were  very happy that he was in the bridle group, and we could secure his tube without having to tape it to his face.  As a result of our study, we concluded that securement of nasoenteric feeding tubes with a nasal bridle significantly reduces tube dislodgement.  The AMT bridle may be a safe and effective method to ensure consistent delivery of nutrition and medications to hospitalized children.  I would like to thank Dr. Meyer and Dr. Amijo for being my mentors for the project, and I would also like to thank Applied Medical Technology for supplying the bridles.  I'm happy to take any questions at this time, and I appreciate you joining and listening to my presentation.

Video Summary

In this video, Megan Foster, a Pediatric Critical Care Fellow, discusses her research project on improving the retention of feeding tubes in pediatric patients using a nasal bridle. She explains that feeding tubes often get dislodged, leading to missed medications and nutrition, as well as increased discomfort and radiation exposure for tube replacement. Foster presents research studies that show a reduction in tube dislodgement when using the nasal bridle. Her study involved a randomized control trial with 32 patients, comparing the bridle group to the tape group. The bridle group had fewer tube dislodgements and longer time to dislodgement compared to the tape group, indicating that the nasal bridle is a safe and effective method for securing feeding tubes.

Asset Subtitle

Pediatrics, GI and Nutrition, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Megan S. Foster

Introduction/Hypothesis: Nasoenteric feeding tubes are commonly used in pediatrics as a way to deliver nutrition and medications. Traditionally, these tubes have been secured with adhesive tape to the face. However, unintentional tube dislodgement continues to be a common occurrence. Tube dislodgement leads to multiple tube replacements which causes discomfort and additional radiation exposure; delays in nutrition and medication administration; and increased consumption of hospital resources between the cost of replacement tubes, radiographs, and staff hours spent on these procedures.

Methods: This is a prospective, open-label, randomized control trial comparing the routine adhesive tape to the FDA approved AMTÂ® BridlePro as a mode for securement of nasoenteric feeding tubes. The study population included pediatric patients admitted to our inpatient areas who required a nasoenteric feeding tube. Our power analysis based on Fisher's Exact test recommended 30 patients be randomized to the control (tape) arm and 30 patients to the nasal bridle arm. The primary outcome was to assess the clinical efficacy of the nasal bridle system by the incidence of tube dislodgement. Secondary outcomes included time to tube dislodgement, minutes of missed nutrition, amount of additional radiation exposure, and cost of additional feeding tubes and radiographs. Adverse events including skin breakdown, discomfort, or other injury were also evaluated.

Results: Preliminary data after 30 patients suggests use of the AMTÂ® nasal bridle reduces attributable risk for feeding tube dislodgement by 60%, p<0.001. In log rank analysis, tubes secured with tape had 2.11 dislodgements per 100 tube days compared to 0.16 for tubes secured with the bridle, p<0.001. Additionally, tubes secured with tape had a faster time to tube dislodgment and larger amount of missed nutrition.

Conclusions: Securing nasoenteric feeding tubes with the AMTÂ® nasal bridle system significantly reduced tube dislodgements. Preliminary data supports that the AMTÂ® nasal bridle system may be a safe and effective method to ensure consistent delivery of nutrition and medications to hospitalized children.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area GI and Nutrition

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Nutrition

Year 2021

Keywords

Megan Foster

Pediatric Critical Care Fellow

feeding tubes

nasal bridle

tube dislodgement

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