Liberating Stroke Patients: Removing Feeding Tubes Safely

Swallowing problems are common after a stroke, with almost half of stroke patients initially experiencing dysphagia. Feeding tubes are a standard method for providing nutrition to patients who cannot swallow, and they can be temporary or permanent. A stroke patient may be weaned off a feeding tube if their swallowing function improves, and their doctor determines that they can meet their nutritional needs by mouth.

Nasogastric (NG) tubes: a thin tube that goes from the nose to the stomach

A nasogastric (NG) tube is a thin, flexible plastic tube that is inserted through the nose and into the stomach. It is used for short-term feeding and administering medication to hospitalised patients. It is often used for patients who are unable to eat and drink enough on their own, such as those with difficulty swallowing, digestive problems, or those who need extra calories. The tube can also be used to remove substances from the stomach, such as in cases of poisoning or to relieve pressure and prevent regurgitation.

The process of inserting an NG tube begins with the patient being placed in an upright sitting position. The healthcare provider will then lubricate the tube and insert it through one of the nostrils, guiding it down the throat and into the oesophagus. The patient may be asked to sip water or take a deep breath to help advance the tube. Once the tube reaches the correct length, it is secured with tape. The correct placement of the tube is then verified through a chest X-ray or an aspirate pH test.

It is important to take care of the NG tube and the skin around the nostrils to prevent irritation. The tube should be flushed after each feeding to release any remaining formula. The skin around the nose should be cleaned regularly, and the bandage or dressing should be removed gently. If irritation occurs, the tube can be moved to the other nostril.

An NG tube can usually be placed while the patient is awake, and the procedure typically lasts for 30 to 45 minutes. It can be used for four to six weeks before it needs to be removed or replaced with a long-term feeding tube.

Percutaneous endoscopic gastrostomy (PEG) tubes: inserted directly into the stomach through the skin

Percutaneous endoscopic gastrostomy (PEG) is a procedure to place a feeding tube directly into the stomach through the abdomen. This method is used for patients who have difficulty swallowing or cannot get the required nutrition by mouth. The procedure is performed under local or intravenous anaesthesia and takes around 20 to 30 minutes, allowing the patient to return home on the same day or the next morning.

Before the procedure, the surgeon will meet with the patient to discuss the procedure and review their medical history, including any heart conditions, bleeding risks, or medication allergies. The patient may need to adjust their medication and will be instructed to not eat or drink at least eight hours before the surgery.

During the procedure, the surgeon makes a small incision in the upper abdomen and places the tube through the incision, connecting it to the stomach. The tube is then secured with a disc called an external bumper to prevent it from moving further into the stomach. The patient will be able to see 6 to 12 inches of the tube coming out of the incision area.

After the procedure, the patient will experience some pain from the incision and may have cramping from gas buildup. This should subside within 24 to 48 hours. The patient will have a bandage over the incision site, which the surgeon will instruct them to remove after one to two days. The patient will also need to clean the PEG tube daily to prevent complications.

PEG tubes are typically used for long-term feeding, usually beyond 30 days, and can last for several months or years. They are commonly used for patients with neurological conditions or swallowing disorders, such as stroke, cerebral tumors, head and neck cancers, and multiple sclerosis. PEG tubes provide a secure method of feeding, reducing the risk of complications associated with other feeding tubes. However, there are also risks and complications associated with PEG tubes, including accidental tube dislodgement, aspiration, infection, and perforation.

Tube feeding at home: what to consider and how to cope

Tube feeding, also known as enteral nutrition, is a method of delivering liquid nutrition directly into a person's digestive system through a feeding tube. This is necessary for individuals who are unable to eat or digest food normally, including those with conditions like stroke, Parkinson's disease, cancer, or digestive issues. Here are some essential considerations and guidelines for managing tube feeding at home:

Types of Feeding Tubes:

• Nasogastric Tube (NGT): Inserted through the nose and into the stomach, commonly used for short-term feeding.
• Percutaneous Endoscopic Gastrostomy Tube (PEG): A more secure method for long-term nutritional support, inserted directly into the stomach through a surgical incision.
• Orogastric Tube (OG): Similar to NGT but inserted through the mouth, used for short-term feeding.
• Jejunostomy Tube (J Tube): Placed through an incision in the abdomen, delivering nutrition directly to the middle section of the small intestine.

Considerations for Tube Feeding at Home:

• Nutritional Requirements: Ensure you understand the nutritional needs of the individual and follow the prescribed feeding schedule. Tube feeding will provide essential nutrients such as calories, protein, carbohydrates, fats, vitamins, and minerals.
• Feeding Procedure: Follow the instructions provided by your healthcare team for administering tube feeding, including the proper positioning during feeding to reduce the risk of aspiration.
• Tube Care and Maintenance: Keep the tube and the surrounding skin area clean and dry to prevent infections. Regularly flush the tube with lukewarm water to prevent clogging, especially before and after feeding and medication administration.
• Formula Storage and Handling: Store unopened formula in a cool, dry place, and refrigerate any unused opened formula for no more than 24 hours. Always check the expiration date before use.
• Medications: Consult your healthcare provider about administering medications through the feeding tube. Some medications can be crushed or dissolved, while others should be given in liquid form.
• Potential Side Effects: Be aware of possible side effects such as irritation, nausea, stomach problems, or tube dislocation. Contact your healthcare provider if any issues arise.
• Social and Emotional Aspects: Tube feeding can impact social activities and emotional well-being. It's important to maintain open communication with family and friends and seek support if needed.

When to Contact Your Healthcare Provider:

• If the tube becomes dislodged or clogged.
• If there is leakage or bloating around the tube.
• If there are signs of infection or increased drainage at the tube site.
• If you experience nausea, vomiting, fever, or unexpected weight changes.
• If you have questions or concerns about the tube feeding process or the individual's tolerance to feeding.

Swallowing techniques and exercises to strengthen muscles in the throat, face and mouth

Swallowing exercises can help treat dysphagia, or difficulty swallowing, by strengthening the muscles and nerves associated with swallowing. These exercises should be done under the guidance of a medical professional, such as a speech-language pathologist or an occupational therapist, who will develop a customised program for each patient. Here are some examples of swallowing techniques and exercises that can help strengthen the muscles in the throat, face and mouth:

• Effortful Swallow: Collect saliva on the tongue, keep lips closed and tight, then swallow all the saliva at once as if swallowing a grape or a pill. This can be repeated up to 10 times in a session, with 3 sessions per day.
• Isokinetic (dynamic) Shaker: An exercise where the number of repetitions and sets are defined by the clinician. This involves specific movements that target the relevant muscles.
• Isometric (static) Shaker: Similar to the Isokinetic Shaker, but with a focus on static rather than dynamic movements. The duration and number of repetitions are set by the clinician.
• Jaw Thrust: Move the lower jaw forward, placing the lower teeth in front of the upper teeth. This exercise should be approached with caution by patients with jaw replacements.
• Lollipop Swallowing: Place a sugarless lollipop in the mouth, lick three times, then perform an effortful swallow.
• Masako Maneuver: Stick out the tongue between the front teeth and gently bite down to hold it in place. Swallow while keeping the tongue between the teeth.
• Mendelsohn Manoeuvre: Locate the Adam's apple by feeling the throat muscles move up and down when swallowing. Then, swallow and squeeze the throat muscles to hold the Adam's apple at its highest point.
• Yawn: Hold the stretched position of a yawn to increase the strength of the back of the tongue and throat muscles.
• Supraglottic Manoeuvre: Take a deep breath, hold it, swallow, and then cough. This can be practised with saliva before attempting with food or liquid.
• Tongue Strength Exercise: Using a tongue depressor, press the tip of the tongue against it and push up. To target different parts of the tongue, place the depressor in the middle or at the back and push up against the roof of the mouth.
• Tongue Range of Motion: Stick out the tongue, pull it back into the mouth, move the tip from side to side, and stretch it behind the top teeth.
• Tongue Retraction Exercise: Pull the back of the tongue as far back into the mouth as possible and hold.
• Effortful Pitch Glide: Say "eee" in a low pitch and gradually raise it to the highest possible tone, holding for a specified duration.
• Lip Range of Motion: Smile and hold, then stretch the lips into a smile while opening the jaw wide.

Changing diet and eating habits: how to adapt and what to eat

Understand the challenges

Changing eating habits can be very hard. You may have certain eating habits that have become a part of your daily life, so you don't realise they are unhealthy. Keeping a food journal for a week can help you learn about your eating habits. Write down what you eat, how much, and what times of the day you are eating. Include notes about what else you were doing and how you were feeling, such as being hungry, stressed, tired, or bored.

Identify patterns and set goals

At the end of the week, review your journal and look for patterns in your eating habits. Decide on one or two small, achievable goals at a time, such as drinking skim milk instead of whole milk, or eating fruit for dessert. Remember, small steps lead to more success in making long-term changes.

Identify triggers

Look at your journal and identify any regular or repetitive triggers that may be causing some of your eating habits. For example, do you always eat a snack when you feel stressed at work? Or do you always buy unhealthy snacks from the vending machine on your way to your desk? Start by focusing on one or two triggers that occur most often and think about what you can do to avoid them.

Plan your meals and snacks

Plan and prepare healthy meals and snacks to increase your chance of success. Keep healthy snacks at work and pack healthy lunches that you make at home. Plan your dinners at the beginning of the week and prepare some components ahead of time (such as chopping vegetables) so that you can put together a healthy meal more quickly at the end of the day.

Eat only when you are hungry

Eating when you feel worried, tense, or bored can lead to overeating. Learn the difference between physical hunger and habitual eating or eating as a response to stress or boredom. Call a friend or go for a walk instead.

Make healthier choices

Swap out unhealthy snacks for healthier options, such as fruit and yogurt in the afternoon. Control your portion sizes by taking only a small portion and putting the rest away. Eat on a plate or in a bowl instead of straight out of a bag. Eat only when you are hungry and put down your fork between bites.

Eat a healthy breakfast

A hearty, healthy breakfast will give your body the energy it needs to get you to lunch. If you are not hungry when you wake up, try a glass of milk or a small fruit and dairy-based smoothie.

Frequently asked questions