Abstract
Introduction: Enteral nutrition is a preferred and safe method for patients hospitalized in special wards, which despite its many advantages, has complications such as respiratory aspiration. Aspiration pneumonia is responsible for 15-20% of hospital infections and 39% increase in costs, and it is also considered one of the ten causes of death in the United States, which can be prevented by choosing the best nutrition method.
Purpose: This research was conducted to determine the rate of respiratory aspiration of two feeding methods of alternating bolus tubes and alternating diameters of cases in patients hospitalized in special departments.
Materials and methods: In this semi-experimental study, 72 patients hospitalized in the ICU and trauma department who were fed by tube method were divided into two groups, intermittent bolus and alternating diameters of cases, after examining the variables of the fields. In the intermittent bolus method, for three days, 150 to 300 cc of food liquid was gavage to the patient 7 times a day and every 3 hours for a period of 10 to 15 minutes by means of a 60 cc syringe, and in the type of intermittent drips, the same amount of food was given to the patient's stomach for 30 to 60 minutes with the help of a nutritional bag hanging at the base of the head. Respiratory aspiration was added to all 1% methylene blue food solutions at the rate of 0.5 cc per 500 cc of food, and if the patient needed suction, whenever a blue color caused by methylene blue was observed in the patient's lung secretions during respiratory tube suction, respiratory aspiration was confirmed for the patient. Results: The findings showed that the rate of respiratory aspiration in the feeding method of intermittent blus tubes was 5.6% and in the type of intermittent diameters of cases was 0, and Fisher's exact test did not show a statistically significant difference between the two groups (p > 0.47).
Conclusion: Considering the non-significance of the rate of respiratory aspiration in the two groups, it can be mentioned that the intermittent blus method is still a method Standard nutrition is introduced in the books and if it is done according to the correct principles, it reduces the risk of aspiration.
Key words: respiratory aspiration, hospitalized patients, enteral nutrition
Statement of the problem:
Nutrition is considered one of the basic and physiological needs of humans. Every living being depends on proper nutrition to obtain energy, which leads to the balance of the body and the hemodynamic status of the person. This need changes when a person is admitted to the hospital, and depending on the type of illness and the condition of the person, this change and transformation may be very large (1,2).
Among the patients whose nutritional status undergoes extensive changes, there are patients admitted to the special department, especially ICU. Adequate and appropriate nutrition is the foundation and basis of success of all treatments, which accelerates recovery, reduces disease complications, and reduces costs. Many patients hospitalized in the special department need more energy due to being in a stressful situation such as sepsis [1], surgery, trauma and organ failure, and due to reasons such as reduced level of consciousness, physical obstacles to the passage of food, wounds, tumors, respiratory failure, lung infections, burns, etc., they are not able to meet their nutritional needs in a natural way. Therefore, they are at risk of malnutrition[2](2,3,4,5). Weight loss during hospitalization is common and it is estimated that half of hospitalized patients in Europe and North America suffer from malnutrition (6).
Malnutrition is also a common problem in ICU patients (7). Studies show that the rate of malnutrition in ICU patients is 30 to 55%, which leads to heart muscle weakness, blood pressure reduction, defects in collagen synthesis, delayed wound healing, immune system defects and the subsequent increase in infection, respiratory muscle weakness and the inability to separate the patient from the ventilator [3] and as a result, the length of hospitalization in the ICU increases.Studies show that the rate of malnutrition in ICU patients is 30 to 55%, which leads to heart muscle weakness, blood pressure reduction, collagen synthesis defects, wound healing delay, immune system defects and the subsequent increase in infection, respiratory muscle weakness, and the inability to separate the patient from the ventilator [3] and as a result, increasing the duration of hospitalization and increasing costs and death (3,4,7,8). These problems are more serious in the elderly, so that according to the available studies, the elderly patients who had poor nutritional status during the days of hospitalization, not only the death rate in them was 8 times higher, even the risk of death within 90 days after discharge was 2.9 times higher (9). Also, in a study conducted on patients hospitalized in ICU, approximately 36% of patients received less than 90% of their required energy (10), a study conducted by Cora [4], in order to evaluate the nutritional status of patients during the first 72 hours of hospitalization, showed that the rate of complications in malnourished patients is significantly higher than in patients with adequate nutritional status (P < 0.01) (8). Therefore, nutritional support is considered essential and vital.
Due to the inability of patients to meet their nutritional needs, the artificial nutrition method is necessarily used, which includes tube and intravenous nutrition (11,12). Studies and evidence show the superiority of intravenous feeding (13,14). In this regard, Skurlak et al.[5], during a study in 2008, named the intravenous feeding method as the preferred method in feeding ICI patients (15). Compared to intravenous feeding, this type of nutritional method is safer, cheaper and more reliable and has many physiological benefits (16) and is clearly superior to intravenous nutrition in terms of prescription and monitoring. The intestinal epithelium acts as a barrier against the invasion of pathogenic organisms, and during intravenous feeding and complete rest of the intestine, progressive atrophy and disintegration of the intestinal mucosa occurs, which leads to the transfer of pathogens in the intestinal tract into the systemic circulation and as a result of septicemia [6, 17]. Also, Zaluga[7] stated in a study in 2006 that feeding rivers improves intestinal mucous membrane, reduces septicemia and reduces hospital stay. The result of the study conducted by Artenin et al.[8] of 4000 patients hospitalized in ICU during the first 48 hours of hospitalization showed that in patients receiving intravenous nutrition, the length of stay in the hospital and also the mortality rate were significantly reduced (19). In this regard, Serpa et al.[9] (2003) also concluded during another study in Sao Paulo[10] that feeding the intestines leads to the preservation of intestinal mucosa, better absorption of nutrients, improvement of immune response, reduction of costs and complications (20). Also, according to the opinion of the American Nutrition Association, mortality from blood infection and complications following infection are lower in patients with intravenous nutrition than those receiving intravenous nutrition. Dudek [11], citing Kurtz [12], during a research in 2007 to compare the effects of intravenous and intravenous nutrition, states that there is still a need for a lot of research on the effectiveness of each of these methods and its effect on the mortality rate (21).
In the tube feeding method, the feeding method is determined according to the location of the tube in the digestive system, patient tolerance, ease of access, and costs. There are four types of methods in this type of feeding, which include: intermittent drops[13], intermittent bolus[14], periodic[15] and continuous[16]. These methods are implemented using syringes, feeding pumps and food bags (5, 17). In addition to its many benefits, tube feeding has side effects such as diarrhea, vomiting, nausea, constipation, dumping syndrome[17], hyperglycemia[18], hypercapnia[19], electrolyte disorders, and also aspiration[20] (22), which can be partially controlled by choosing the best feeding method. Aspiration of stomach contents is one of the serious but preventable complications in tube feeding patients, which can even lead to death (14,17,21). There is a lot of evidence that shows that the majority of patients hospitalized in the intensive care unit who are fed through a tube and are also under mechanical ventilation have at least one case of aspiration during their feeding days (23). Respiratory aspiration causes pneumonia (24), which appears in the form of fever, leukocytosis [21], increased respiratory secretions, pulmonary congestion in physical examination along with the appearance or change of infiltration in radiography. This problem leads to an increase in the duration of hospitalization (25,26,27). Matani et al[22] also showed during a study in 2008 that the risk of pneumonia in patients with aspiration is 4 times higher (28).