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Journal of the American College of Nutrition, Vol. 19, No. 4, 446-451 (2000)
Published by the American College of Nutrition

Original Research

Placement of Nasoenteral Feeding Tubes Using Magnetic Guidance: Retesting a New Technique

Burcu Ozdemir, MD, Michelle Frost, RN, James Hayes, PhD and Dennis H. Sullivan, MD, FACN

Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System and Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas (B.O., M.F., D.H.S.)
Abbott Laboratories, Ross Products Division, Columbus, Ohio (J.H.)

Address reprint requests to: Dennis H. Sullivan, MD, Geriatric Research Education and Clinical Center (182/LR), Central Arkansas Veterans Healthcare System, 4300 West 7th Street, Little Rock, AR 72205. E-mail: SullivanDennisH{at}exchange.uams.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Objective: To study a new technique of intubating the small bowel using a newly developed nasoenteral feeding tube fitted with a magnet in its tip and guided for placement with an external magnet.

Methods: The study was performed in medical and surgical wards of a university-affiliated Department of Veterans Affairs hospital on 42 patients referred by their attending physicians for tube placement. The newly designed feeding tube was inserted per nares into the stomach using traditional technique. As the tube was advanced, movement of the hand-held steering magnet was designed to guide the tip of the magnetic nasoenteral tube along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. Portable abdominal radiography confirmed the anatomic location of the tube tip.

Results: Fifty-one intubations were performed on 42 subjects. In 45 intubations (88%), tubes passed into the duodenum. Twenty-seven (53%) met criteria for optimal placement in the second portion of the duodenum or distally. Six of 11 tubes (55%) that were not optimally placed were advanced to the distal duodenum on repositioning. Median procedure time for the initial intubations was 30 minutes (interquartile range 15–40). Median procedure time for last 10 intubations improved to 13 minutes (interquartile range 5–20). No complications were related to the procedure.

Conclusions: Enteral feeding tube placement using external magnetic guidance is a promising, novel technique which is deserving of further study.

Key words: enteral nutrition, intubation, gastrointestinal, nutritional support, duodenum


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The purpose of this study was to investigate a new technique of intubating the small bowel using a specially designed nasoenteral tube that has a magnet built into its tip [1]. Placement is accomplished by guiding the tube into the small bowel using a larger, external, hand-held magnet. The research team had not worked with this type of nasoenteral tube prior to the start of the study. Results are contrasted with those from historical controls.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
This study was conducted at a university-affiliated Department of Veterans Affairs hospital. Participants were hospitalized subjects referred by their attending physicians for assistance with feeding tube placement. Subjects were excluded from the study if they (1) had previously undergone major abdominal surgery that altered the anatomy of the gastrointestinal tract [e.g., Bilroth I or II], (2) had any implantable electronic device [e.g., pacemaker, defibrillator], (3) had a body mass index >45, (4) were pregnant or (5) were likely to need a magnetic resonance imaging scan while receiving enteral support. In accordance with the ethical standards of the Department of Veterans Affairs and the Human Research Advisory Committee of the University of Arkansas for Medical Sciences, study participants received oral and written explanations of the study, including possible risks involved, prior to signing informed-consent documents. As described below, subjects recruited into another study evaluating the efficacy of enteral nutrition support served as historical controls. The two studies ran in sequence. The control subjects were recruited between June 1997 and June 1998. The magnet study ran from June to September 1998.

Equipment used for this study was provided by Ross Products Division (Abbott Laboratories, Columbus, OH) and included specially designed 115 cm long, small-bore (10 and 12 Fr) weighted-tip polyurethane nasoenteral tubes and an external hand-held steering magnet. The tubes were modeled after commercially available weighted-tip nasoenteral feeding tubes, except that each tube contained a small rare earth magnet (37MGOe, Neodymium-Iron-Boron-Dysprosium) in the distal tip instead of a tungsten weight (Fig. 1). The tubes also had markings 54 cm and 80 cm from the tip, which represented the approximate length of tube needed to reach the stomach and then the duodenum in an average adult. Designed for external use to guide tube placement inside the subject, the cylindrical steering magnet (45MGOe, Neodymium-Iron-Boron, Dysprosium) measured four inches in diameter by two inches thick and was encased in a vinyl-coated aluminum frame with an attached handle. The entire apparatus weighed approximately eight pounds.



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  		Fig. 1. The specially designed 115 cm long, small-bore weighted-tip polyurethane nasoenteral feeding tube positioned within the distal portion of the duodenum. The tube contains a small rare earth magnet in its distal tip instead of a tungsten weight.

 
Placement of the tube was performed at the subject’s bedside by one person. No fluoroscopic or endoscopic guidance was used. A stopwatch recorded the time required to complete the procedure. After the stopwatch was started, each subject was prepped by introducing approximately 1 cc of 2% viscous lidocaine into one nostril for lubrication and local anesthesia. If there were contraindications to the use of lidocaine, plain water-soluble lubricant was used. The feeding tube was then inserted per nares and advanced to the stomach using standard bedside technique. To confirm intragastric placement, one of the investigators used a syringe to inject approximately 20 to 30 cc of air through the tube while listening with a stethoscope placed over the epigastrium. After the tube was judged to be in the stomach, an aspirate was obtained and tested for pH using pH indicator paper (Insta-Chek 0-13, Brooklyn, NY). The hand-held magnet was then placed externally over the epigastrium and moved slowly across the right upper abdominal quadrant along the lower rib margins to the midaxillary line. The movement of the hand-held steering magnet was designed to guide the tip of the magnetic tube along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. While the external magnet was maneuvered over the abdomen, the nasoenteral tube was slowly advanced. In many subjects, it was possible to feel the external magnet "pulling" the tube inside the subject. When the tube was inserted approximately 10 cm past the 80 cm mark representing the estimated distance to the jejunum, an attempt was made to obtain a second aspirate. If this attempt was unsuccessful, up to three additional attempts were made after injecting 5 mL boluses of water through the tube. If an aspirate was obtained, the pH of the fluid was measured. The feeding tube was not repositioned based on the pH reading. At the end of the study, the relationship between the pH readings and the position of the tube on x-ray film was examined.

After the tube was secured, portable abdominal radiographs were obtained to confirm the tube’s position. A tube was considered to be in the small bowel if the tube crossed the midline, then followed the expected curvature of the duodenum, and the outline of the stomach was visible to the left of the tube. In four cases, the anatomical location of the tip could not be determined with certainty from the plain radiographs. In these cases, 20 cc of half-strength gastrografin was injected into the tube and a bedside radiograph was repeated. In all four cases, the exact location of the tube was clearly evident after the use of the contrast.

Based on the original study objectives, the procedure was deemed successful if the weighted tip and the ports (i.e., the distal 4 cm) of the tube were positioned past the pylorus. However, placement of the tube in the second portion of the duodenum or distally was considered optimal. If the x-ray film demonstrated that optimal placement of the tube was not obtained, up to two additional attempts at repositioning the tube were made contingent upon approval of both the subject and the attending physician. Not all subjects agreed to tube repositioning.

The first step in repositioning was to withdraw the tube to the point where the tip was estimated to be just distal to the gastroesophageal junction. The estimated distance the tube was withdrawn was based on measurements taken from the abdominal x-ray film. After the tube was withdrawn the appropriate distance, the external magnet was applied again and the tube was advanced as before.

No prokinetic agents were used during the initial intubations. Because x-ray film showed that four subjects had large dilated stomachs, they were given intravenous erythromycin (3 mg/kg over 10 to 15 minutes) immediately prior to the second or third attempt to intubate the small bowel. The data from these four intubations are presented separately.

The historical control group consisted of subjects recruited into a second intervention trial. Each subject had been randomized to the treatment group and had a nasoenteral feeding tube placed by one of the authors (DHS) on one or more occasions as described previously [2]. Tube placement was accomplished at the bedside without the use of either promotility agents or fluoroscopy. During the placement procedure, the authors attempted to facilitate small bowel intubation using various bedside techniques including patient positioning and spinning the tubes as they were advanced. The tubes utilized were also provided by Ross Products Division of Abbott Laboratories and were identical to the tubes used in the present study except they featured tungsten weights and not magnets in the tips. Aspirates were not checked for pH, but tube position was confirmed using the same radiographic techniques as in the present study.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Forty-two subjects (one female) from the medical and surgical wards of the hospital met the study criteria and were enrolled in the program. The average age of the participants was 69 ± 12 years (range, 39 to 87 years), and the average body mass index (BMI) was 23 ± 6 (range, 13.8 to 42.0). Twenty subjects (47.6%) were mechanically ventilated at the time of the study. The only surgical patient was recovering from a recent coronary artery by-pass procedure. Several of the subjects had complicating gastrointestinal problems including four with recent acute upper gastrointestinal bleeds and two with ascites. Seventeen (40%) were diabetic, 14 (33%) were receiving narcotics and 26 (62%) were receiving acid suppression therapy (proton pump inhibitors, antacids or H2 receptor blockers).

A total of 51 intubations was performed on the 42 subjects (nine subjects had additional tubes inserted after the prior tube had been inadvertently removed). In 45 (88%) of the insertions, tube passage beyond the pylorus was confirmed by plain radiography (Table 1). However, only 27 cases (53%) met our criteria for optimal placement in the second portion of the duodenum or distally. For those cases in which optimal tube placement was not obtained, an offer was made to reposition the tube. In 13 of these cases, the subject and attending physician consented to the repositioning. In 11 cases, the tube was repositioned without the use of a promotility agent. Six (55%) of these attempts were successful in advancing the tube beyond the first portion of the duodenum (Table 1). For two subjects, whose small bowel could not be intubated after the tube was repositioned, erythromycin was administered prior to an additional attempt at tube repositioning.


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  		Table 1. Anatomic Position of the Nasoenteral Tube Tip after Each Attempt

 
In total, four subjects were given intravenous erythromycin immediately prior to tube repositioning. All four had marked gastric atony on x-ray film, and the one or two previous attempts to properly position the tube using only the steering magnet had failed. After administration of erythromycin, the magnet was used successfully to advance the tube to the third portion of the duodenum or beyond in all four cases.

Overall, 41 subjects (98%) met the original study criteria of success (advancement of feeding tube beyond the pyloris without the use of a promotility agent) at least once. The one remaining subject was delirious and became agitated during the initial attempt to pass a feeding tube. The procedure was aborted, and the family declined further attempts at tube passage. The feeding tube was optimally placed (advanced to the second portion of the duodenum or beyond) in 29 subjects (71%).

The median [mean ± SD] procedure time for the initial procedure (prior to any tube repositioning) was 30 [30 ± 18] minutes (interquartile range 15 to 40 minutes) (Table 2). As the research team gained experience, the time needed to complete the procedure decreased considerably. The last 10 intubations performed were completed in a median [mean ± SD] of 13 [16±14] minutes (interquartile range 5 to 20 minutes). Throughout the study, cognitively impaired patients tended to require extra procedure times. It was usually necessary to talk these subjects through the first part of the procedure which involved passing the tube through the nose into the stomach. There were no complications related to the procedure.


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  		Table 2. Tube Placement Times (Rounded to Nearest 5 Minutes)

 
Aspirates were obtained at the beginning and at the end of the procedure for the first 29 tube insertions. However, obtaining an aspirate was often difficult and frequently required several injections of water and additional procedure time. Further, the pH of the aspirate was not a good indicator of tube location. In 11 cases (38%), the aspirate obtained at the start of the procedure (when the tube was assessed to be in the stomach) had a pH greater than 3 (range 4 to 8, median 5). In two cases, no aspirate could be obtained at the start of the procedure. At the end of each procedure, a second aspirate was obtained. In 12 cases, x-ray film confirmed that the tube was distal to the second portion of the duodenum when the second aspirate was obtained. Two of these aspirates were acidic. One case had a pH of 1 and another had a pH of 3.

There were 21 subjects (20 males) in the historical control group. Compared with the intervention group, the control subjects were of comparable age (69±12 vs. 74±7, p=.07) and BMI (23±6 vs. 22±4, p=.31). The intervention group differed from the controls in that only one was post-surgical whereas all the controls were recuperating from surgical repair of an acute hip fracture (2% vs. 100% post-surgical, p<.01). Subjects in the intervention group were also more likely to be diabetic (40% vs. 10%, p=.01) or to be on a ventilator (48% vs. 0%, p<.01).

Of the 30 tubes placed in the control group, x-rays obtained at the end of the procedure revealed 27 (90%) to be curled in the stomach, one (3%) to be in the first portion of the duodenum and two (7%) to be in the third portion of the duodenum. Four tubes were repositioned once, and two were repositioned twice. In all cases, the tubes remained in the stomach.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Many patients have illness-induced gastroparesis, which causes intolerance of gastric feedings [3–5]. Because the motility of the small bowel is more likely to be preserved, feedings delivered distal to the pylorus are often better tolerated by these patients [4–9]. However, intubation of the small bowel using standard bedside techniques of nasoenteral tube placement is often impossible in acutely ill patients [10]. Although a greater likelihood of success can be achieved by passing the tubes under endoscopic or fluoroscopic guidance, these methods are expensive and not always available to be performed at the bedside [11–12].

To avoid the high cost of tube placement and the need to transport sick patients to procedure rooms, several specially designed nasoenteral tubes and newer bedside techniques of placing the tubes have recently been developed. High rates of success have been reported with several of these techniques [13–16]. Marian et al. achieved 15% spontaneous transpyloric passage after 72 hours by using a lateral decubitis positioning technique with subjects on mechanical ventilation [10]. In a study by Stern et al. using weighted-tip tubes, erythromycin administration resulted in 75% passage within one day versus 14% with placebo [15]. Other studies have reported similar results with weighted tip tubes and motility agents [14,17]. Some studies have described bedside techniques with success rates up to 92%; however, such high rates of success have not been confirmed, suggesting that they are probably dependent on the skills of the provider [13].

This study confirms the effectiveness with which the small bowel can be intubated using a magnetically-guided feeding tube. In the original evaluation of this system, Gabriel et al. reported that magnetically-guided tubes were successfully positioned beyond the pylorus on the first attempt in 88% of the cases (37 of 42 insertions) [1]. Nearly half of the tubes (48%) were optimally placed in the second portion of the duodenum or beyond. In this study, an identical rate of post-pyloric tube passage was attained, and 53% of tubes were distal to the first portion of the duodenum. This rate of success was attained with only limited experience using the system. Prior to the start of this study, the investigative team had not utilized the magnetically-guided tube system.

Although not an optimal study design, the inclusion of the historical controls provides additional evidence of the effectiveness of the magnetically-guided feeding tube for intubating the small bowel. Utilizing similar, but non-magnetically guided nasoenteral feeding tubes, the same investigative team had placed only three of 30 tubes (10%) into the small bowel on the initial attempt in a prior study. Despite an unrecorded number of hours dedicated to the task, multiple attempts at repositioning the tubes were uniformly unsuccessful. Factors other than the magnetically-guided tube could have contributed to the difference in the rates of success between the two studies, including the increased experience of the investigative team and differences in the patient populations studied. This possibility will need to be excluded in a subsequent, randomized, controlled trial. There is also a need to examine the length of time that the tubes remain in the small bowel because this was not evaluated in the current study.

In the current study, the median time spent on each procedure was approximately 30 minutes, an acceptable time for bedside manipulation. In their study, Gabriel et al. reported an average length of time for tube placement to be 15 minutes [1]. Two factors may have contributed to the differences in procedure time between the two studies. First, our goal was to maneuver the tip of the tube to the jejunum in all subjects, whereas the initial goal of the earlier study was to achieve postpyloric placement. Secondly, in the beginning of our study, we aggressively attempted to obtain aspirates, only to find that the procedure is extremely time-consuming, especially at the level of the duodenum. Other investigators have noted the same problem. In a study by Harrison et al., the inability to aspirate insufflated air confirmed the transpyloric position of a feeding tube [18]. After we terminated efforts to aspirate, procedure time decreased from 30 minutes to 13 minutes.

During our study, the ultimate goal for each procedure was advancement of the tip of the tube to the distal duodenum or beyond. In several subjects, the tip did not advance further than the first portion of the duodenum on the first attempt at tube placement. This inability to advance the tube was probably due to anatomical differences in the subjects’ gastrointestinal systems and design limitations of the tube. Some people, especially the elderly, may have large stomachs and a duodenum angling 90 degrees posteriorly [19]. This was possibly the case in four of the subjects with large stomachs on x-ray. In these subjects, intubation of the distal duodenum and jejunal was successful only after erythromycin (3 mg/kg) was administered intravenously over 10 to 15 minutes immediately prior to the procedure. The erythromycin apparently altered the angle within the duodenum or some other anatomic feature of the stomach or proximal small bowel allowing the tube to pass distally. A tube designed with a newer, smaller tip might traverse the corner between the first and second portion of the duodenum more easily and may eliminate the need for administering erythromycin.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Compared to historical controls, this new technique of intubating the small bowel using a newly developed nasoenteral feeding tube fitted with a magnet in its tip and guided for placement with an external hand-held steering magnet is safe and effective. In most cases, the tube tip can be advanced to the second portion of the duodenum or distally with the magnet alone. However, using intravenous erythromycin with this technique increases the likelihood of distal duodenal or jejunal placement. It is not known whether the use of a motility agent alone would have produced comparable results. Additional studies are needed to investigate this issue and to determine whether a redesigned tube with a shorter tip would pass more readily beyond the first portion of the duodenum, thus reducing the need for the motility agent.


   ACKNOWLEDGMENTS
 
The authors would like to acknowledge Melinda Bopp, BS, from the Donald W. Reynolds Department of Geriatrics, University of Arkansas for the Medical Sciences, Little Rock, Arkansas, for her assistance with data collection and analysis of this manuscript. They would also like to acknowledge Marjorie Lacy, BA, also from the Donald W. Reynolds Department of Geriatrics, for her careful review and editing of this manuscript. The study was partially funded by a grant from Ross Products Division (Abbott Laboratories, Columbus, OH).

Received February 7, 2000. Accepted May 26, 2000.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Gabriel SA, Ackermann RJ, Castresana MR: A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med 25: 641–645, 1997.[Medline]
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  4. Ott L, Young B, Phillips R, McClain C, Adams L, Dempsey R, Tibbs P, Ryo UY: Altered gastric emptying in the head-injured patient: relationship to feeding intolerance. J Neurosurg 74: 738–742, 1991.[Medline]
  5. Nimmo WS: Drugs, diseases and altered gastric emptying. Clinical Pharmacokinet 1: 189–203, 1976.
  6. Babineau TJ, Blackburn GL: Time to consider early gut feeding. Crit Care Med 22: 191–193, 1994.[Medline]
  7. Bosscha K, Nieuwenhuijs VB, Vos A, Samsom M, Roelofs JM, Akkermans LM: Gastrointestinal motility and gastric tube feeding in mechanically ventilated patients. Crit Care Med 26: 1510–1517, 1998.[Medline]
  8. Grathwohl KW, Gibbons RV, Dillard TA, Horwhat JD, Roth BJ, Thompson JW, Cambier PA: Bedside videoscopic placement of feeding tubes: development of fiberoptics through the tube. Crit Care Med 25: 629–634, 1997.[Medline]
  9. McDonald WS, Sharp JR CW, Deitch EA: Immediate enteral feeding in burn patients is safe and effective. Ann Surg 213: 177–183, 1991.[Medline]
  10. Marian M, Rappaport W, Cunningham D, Thompson C, Esser M, Williams F, Warneke J, Hunter G: The failure of conventional methods to promote spontaneous transpyloric feeding tube passage and the safety of intragastric feeding in the critically ill ventilated patients. Surg Gynecol Obstet 176: 475–479, 1993.[Medline]
  11. Hillard AE, Waddell JJ, Metzler MH, McAlpin D: Fluoroscopically guided nasoenteric feeding tube placement versus bedside placement. South Med J 88: 425–428, 1995.[Medline]
  12. Ott DJ, Mattox HE, Gelfand DW, Chen MY, Wu WC: Enteral feeding tubes: placement by using fluoroscopy and endoscopy. AJR Am J Roentgenol 157: 769–771, 1991.[Abstract/Free Full Text]
  13. Zaloga GP: Bedside method for placing small bowel feeding tubes in critically ill patients: a prospective study. Chest 100: 1643–1646, 1991.[Abstract/Free Full Text]
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  15. Stern MA, Wolf DC: Erythromycin as a prokinetic agent: a prospective, randomized, controlled study of efficacy in nasoenteric tube placement. Am J Gastroenterol 89: 2011–2013, 1994.[Medline]
  16. Botoman VA, Kirtland SH, Moss RL: A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition. JPEN 18: 154–158, 1994.[Abstract]
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