Home enteral nutrition

Manpreet S. Mundi, M.D., Home Parenteral and Enteral Nutrition, Mayo Clinic: I'm the medical director of the home enteral nutrition program and kind of oversee the entire program and what our program consists of is a combination of nurses, dietitians and physicians who have expertise in nutrition. Our job is to visit with the patients before they're thinking about tube feeding and really talk to them about the ins and outs of what this entire process involves. This way they can make an informed decision and when they do so, they go ahead and move forward and get a tube placed. Typically these are placed in the abdomen. We then see them afterwards and then walk them through their first feeding. Once we're pretty confident that, you know, they can handle this at home, then they continue the process at home. We then follow them afterwards at home. Usually they'll get a call from us 24 to 48 hours after. Another touch point, a week after and then another touch point six weeks after. So a lot of our patients think this is overkill, but with this entire process, we've been able to catch a lot of complications and issues that can come up and really these would lead to complications or they would lead to frustration for the patient or even ER visits in the middle of the night. So with the program we've developed, we think we can prevent a lot of it and provide really high quality care.

The most common complications are things like infection. Others, at the site of insertion, you can get some granulation tissue developing. Some are rare complications but, you know, things like abdominal pain because of a buried bumper. The tubes have a bumper at the end of them and sometimes if it's too tight, they can, you know, cause issues there, so those are the most common things. We also in nutrition work with the dietitians very closely to oversee and make sure that the formula is okay. So as an example, if we have a patient go out on a certain formula that does not contain fiber, they may have diarrhea or other problems so then we would call in and change the formula. So we're working on all of these issues to make sure the patients do okay.

These tubes can be placed a number of ways, so at the Mayo Clinic, we have three different departments that deal with this. Our most common is our gastroenterologist. They will go in endoscopically so an endoscope through the mouth, illuminating either the stomach or sometimes we use the intestines as a source, so they'll illuminate that and then go ahead and insert the tube that way. Interventional radiology also places a number of tubes for us and they use a CT scanner to kind of look at the location and then the other option is surgery. So our thoracic surgeons and a number of other surgeons also place these tubes but the essence of it is that there's something that's causing the patient not to be able to eat safely and so we're essentially bypassing the mouth and the esophagus and going directly into either the stomach or the intestines and providing these feeds.

Some of the most most common reasons that I see are patients who've had a stroke. So these individuals no longer can protect their airway, so they're at danger of if they were to eat, aspirate, and so the food would go into the lungs and cause a really bad pneumonia that can be very severe. Other common causes are throat cancers, mouth cancers. So in these cases again they're not able to eat or they've had major surgery because of the cancer or radiation which is another common cause. So because of this, they may have severe pain with a little intake and can't even drink water anymore, so that then so we then shift to providing feeds, you know, through the stomach until we can get them through the radiation.

Lisa M. Epp, RDN, LD, Home Enteral Nutrition, Mayo Clinic: There are two ways that you can administer nutrition through a feeding tube. Less common would be directly into the intestine but more common would be with the feeding tube directly into the stomach that may look like this. So on the inside of the stomach, you would have a bumper, making sure the tube did not fall out. Through the skin, you would have a small amount of tubing and on the outside of the skin, this would be sitting lightly. This adapter would allow you to put food, water or medication through your tube. There are a couple of different ways we can do that. The first way would be with a drip bag. This would allow me to hang a bag on an IV pole, take my container of food and pour it into the bag, and then over a thirty- to sixty-minute period of time, while watching the news or reading the paper, that would slowly go into my feeding tube. People who are more active or maybe have a little bit busier schedule might like to feed with a syringe, so this would allow me to take the syringe and put it on the end of my feeding tube and take my can of food and just pour that into my tube. That would slowly go into my stomach over a shorter period of time to allow me to get on with the rest of my day.

Lisa M. Epp, RDN, LD, Home Enteral Nutrition, Mayo Clinic: My name is Lisa Epp and I'm a dietitian at Mayo Clinic. I'm here today to talk to you a little bit about the new to tube feeding connectors that will be coming soon. There have been problems with tube feeding formula being connected to the wrong tube. This has prompted a change in feeding tube connectors. An international group has been created to develop a new design called ENfit®. This new design will improve patient safety by allowing only feeding tubes to be connected with tube feeding equipment such as bags and syringes. Mayo Clinic is committed to safety and is working toward making this transition an easy one for you. This is what your current feeding tube may look like. The feeding bags that you receive at home may have an end that looks like this which is allowing you to provide your tube feeding formula. In the next year, bags will change and will look something like this. This will make it impossible for you to feed into your current feeding tube, therefore a transition adaptor will be available so you can screw that on to the new feeding bag and insert it into your current feeding tube. Sometime in the next year that transition piece will be going away which will require you to have a new feeding tube placed to allow you to screw your feeding bag on to your feeding tube to get feedings. You may do your feedings with a syringe or administer water or medications with a syringe. That works well into your current feeding tube like this, however next year, you will be getting new syringes that also have that different end. You will need the transition adapter for your syringes as well. You will screw those on to the end of the syringe to put in your food, water or medication into the tube. Within the next year, again, that transition piece will be going away which would require a new feeding tube to give food, water or medication through your tube. For updates about this process, visit stayconnected.org and if you have any questions, ask your health care provider.

Lisa M. Epp, RDN, LD, Home Enteral Nutrition, Mayo Clinic: Before removing your nasal feeding tube at home, verify with your healthcare provider that it is okay for you to remove your own feeding tube. Sit down, lean over the trash can or sink and have a towel ready to wipe your mouth or nose if needed. First, remove the tape from your nose, grab the tube right outside your nostril and in one motion, pull the tube quickly as far as your arm can reach. Then, using the other hand, finish pulling the tube all the way out. If you go slowly, it may cause more gagging.

Lisa M. Epp, RDN, LD, Home Enteral Nutrition, Mayo Clinic: My name is Lisa and I'm a dietitian at Mayo Clinic in Rochester Minnesota. If you have a feeding tube, you may be aware that there has been an international redesign of feeding tubes and equipment. This was done for safety reasons to prevent tube feeding formula from being administered into the wrong tube. These tubes are commonly known as ENFit®. Once you get your feeding tube changed, there will be some things that you need to know. First, your syringes will look differently. Instead of inserting your syringe into the tube, you will need to screw the syringe onto the end of your tube. If you feed with the feeding bag, your bag already has removable adapters. You will need to remove the adapter in order to screw the end of the bag onto your tube. Because of the design of the tube, we want you to clean the tube once a day with a multi-use brush. Instructions for the use of the brush will be included in your home tube feeding supplies. Lastly, if you use your tube for venting, you'll need an enteral drainage bag. This screws on to the end of your feeding tube as well. If you have any further questions or need additional supplies for home, please contact your healthcare provider.