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(Chest. 2004;125:587-591.)
© 2004 American College of Chest Physicians

Transpyloric Feeding Tube Placement in Critically Ill Patients Using Electromyogram and Erythromycin Infusion*

Howard Levy, MB BChD, PhD, FCCP; James Hayes, PhD, PE; Michel Boivin, MD, FCCP and Todd Tomba, BSEE

* From the Division of Pulmonary and Critical Care (Drs. Levy and Boivin), Department of Medicine, University of New Mexico, Albuquerque, NM; and Ross Products Division (Dr. Hayes and Mr. Tomba), Abbott Laboratories, Columbus, OH.

Correspondence to: Michel Boivin, MD, FCCP, Division of Pulmonary/Critical Care Medicine, University of New Mexico Health Sciences Center, 5ACC, 2211 Lomas Blvd NE, Albuquerque, NM 87131-5271; e-mail: mboivin{at}salud.unm.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: Transpyloric feeding is desirable in critically ill patients who often have gastroparesis; however, correct placement is difficult, requiring fluoroscopy, endoscopy, or time-consuming blind attempts. This study evaluated the success rate and time required to place transpyloric tubes using erythromycin infusion and GI electromyogram (EMG) signal.

Design: Observational trial.

Setting: University hospital medical ICU.

Patients: Thirty-nine patients receiving mechanical ventilation for respiratory failure (n = 13), pancreatitis (n = 9), ARDS (n = 8), neurologic disease (n = 4), major surgery (n = 3), and GI disease (n = 2) were enrolled (25 men and 14 women; mean age, 48.4 years; range, 21 to 82 years).

Interventions: Unweighted Flexiflo 10F feeding tubes were modified by the placement of an electrode 4 to 8 cm from the tip to record electromyogram (EMG) signals (Ross Products Division; Columbus, OH). Gastric signals are high amplitude with a frequency of 3 cycles per minute, while the duodenum and jejunum are low amplitude and 11 to 13 cycles per minute. Erythromycin was infused at a dose of 3 mg/kg to enhance gastric motor activity and emptying. The transpyloric tube was placed in the stomach, and its position was confirmed by EMG, then slowly advanced until duodenal EMG was detected. Tube position was determined by abdominal radiography.

Measurements and results: Thirty-one of 39 placements were immediately successful (initial success rate, 80%), 23 jejunal and 8 duodenal, requiring an average 7.8 min (range, 3 to 31 min). Six attempts in five patients were initial failures but were repeated, reaching the duodenum in one patient and the jejunum in four patients.

Conclusion: Erythromycin infusion and EMG guidance can facilitate rapid transpyloric feeding tube placement in critically ill patients at the bedside.

Key Words: critical care • electromyography • enteral feeding • erythromycin • GI motility • intubation, GI • nutrition • transpyloric


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Transpyloric feeding is often desirable in critically ill patients who frequently have impaired stomach emptying due to the severity of their illness and the use of narcotics and other pharmacologic agents that decrease gastric motility. In a study1 of early gastric feeding, intake by the fifth day has ranged between 30% and 70% of calculated needs, and gastric feeding is unsuccessful in up to 20% of patients.

Only 5 to 15% of feeding tubes pass spontaneously into the small bowel in critically ill patients, even with the use of metoclopramide.2 3 Transpyloric feeding tube placement is difficult, frequently requiring time-consuming blind attempts (with frequent failures), transport to radiology for fluoroscopic guidance, or a bedside endoscopic procedure.4 5 6 7 8 Other studies have showed the benefits of air insufflation,9 unweighted tubes,10 operator experience,11 magnets,12 or multiple attempts,13 but success rates in these studies still have not surpassed 75%. Another work14 has shown that using real-time pH guidance can increase the success rate of transpyloric tube placement.

Erythromycin is a motilin analog that promotes gastric motility by stimulating the gastric migrating motor complex15 16 and promotes the passage of feeding tubes into the transpyloric position. Recording of the electromyogram (EMG) from the wall of the GI tract allows differentiation between gastric and small-bowel location (Fig 1 ). Using this continual feedback, the operator can make multiple attempts to cross the pylorus without obtaining a radiograph after each attempt at tube advancement. This study evaluates the success rate and time required to place transpyloric feeding tubes in critically ill patients using erythromycin infusion and GI EMG signal guidance.



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  		Figure 1.. Abdominal radiograph of modified feeding tube with electrodes at the distal tip, with placement in the distal duodenum.

 

   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Transpyloric feeding tubes were requested by attending physicians. Informed consent was obtained, including permission to record the EMG signal. Unweighted Flexiflo 10F feeding tubes with an internal stylet (Ross Products Division; Columbus, OH) were modified by the placement of a silver wire unipolar triple electrode 4 cm, 6 cm, and 8 cm from the tip to record EMG signals by contact with the mucosa (Fig 1) . The signal transmitted from the electrode was filtered and amplified by the direct current-powered R1000 research amplifier (Ross Laboratories; Columbus, OH); its Paynter bandpass filter operates from 0.03 to 15 Hz with a 40 decibel per decade roll-off. The 60-Hz attenuation is 50-decibel minimum. Signal gain is controlled by an internal switch. High-pass was set at two pole per frequency with cutoff of 0.03 Hz, and low-pass was set at six pole per frequency with cutoff of 1 Hz. The myoelectric GI signal is digitized by a 12-bit data translation DT 2801 analog/digital board (Data Translations; Marlborough, MA) on a personal computer, and can be stored on disk or printed as a real-time amplitude time plot. Gastric signals are high amplitude with a frequency of 3 cycles per minute, while the duodenum and jejunum are low amplitude and 11 to 13 cycles per minute (Fig 2 ). Erythromycin lactobionate was infused at initiation of the procedure at a dose of 3 mg/kg administered over 10 min to enhance the gastric migratory motor complex activity and accelerate emptying.



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  		Figure 2.. Continuous EMG recording as feeding tube is advanced from the stomach to a jejunal location. Note the 3 cycle per minute, large-amplitude gastric wave becoming a 10 cycle per minute, small-amplitude duodenal signal. Large vertical lines represent 1-min intervals.

 
The transpyloric tube was placed in the stomach, and its position was confirmed by auscultation and EMG real-time printout. The tube was then slowly advanced until duodenal/jejunal EMG was detected on a continuous record. If a small-bowel signal was not detected, the feeding tube was withdrawn to the stomach and advanced again until it was successfully located in a transpyloric position. Tube position was determined based on evaluation of the abdominal radiograph after the attempts. Time to enteric placement was measured to the first unequivocal small-bowel EMG signal that was maintained for 3 min.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Thirty-nine critically ill patients receiving mechanical ventilation for respiratory failure (n = 13), pancreatitis (n = 9), ARDS (n = 8), neurologic disease (n = 4; Guillain-Barre, status epilepticus, cerebrovascular hemorrhage, and coma), major surgery (n = 3; coronary bypass graft, splenectomy, and pulmonary embolectomy), and GI disease (n = 2; hepatic failure, cirrhosis) underwent 55 attempts of transpyloric tube placement. There were 25 men and 14 women (mean age, 48.4 years; range, 21 to 82 years).

Thirty-one placements were successful on the first attempt, 23 in a jejunal location and 8 in the duodenum, requiring an average 7.8 min (range, 3 to 31 min). Placement success on the first attempt was therefore 80% (31 of 39 placements).

In five patients with unsuccessful initial tube placement as documented by abdominal radiography, repeated attempts were successful. Although one of these patients required a third attempt, ultimately the tubes reached the duodenum in one patient and the jejunum in four patients. Considering the duration of all successful placements, initial or repeated, the average time to place was 9.2 min (range, 3 to 51 min). Considering repeated attempts, the transpyloric success rate was 36 of 39 placements (92%).

Three separate attempts were unsuccessful in one patient who could not receive erythromycin due to allergy (total duration, 27 min), and two attempts failed to leave the stomach of a patient who had distorted bowel anatomy after splenectomy (29 min); in another patient, a 30-min attempt failed for unclear reasons. To summarize, of 39 patients, 31 attempts were successful initially, 4 attempts were successful after a second attempt, 1 attempt was successful after a third attempt, and 3 attempts never crossed into the duodenum.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Transpyloric feeding improves the delivery of enteral nutrition to the critically ill. Roberts et al1 were able to supply 83 ± 7% of needs at 24 h and 92 ± 4% of needs at 72 h, with 73% of patients receiving > 90% of calculated need, using concentrated formula infused distal to the pylorus (mean ± SD).

Ott et al7 found that fluoroscopy was successful in 94 of 104 patients (90%), with 53% of these reaching the jejunum. The small bowel was entered in 8.6 ± 5.6 min, and room time was 21.7 ± 8.4 min (mean ± SD). Unsuccessful attempts took 16.2 ± 5.4 min, but room time was 45.6 ± 18.4 min. Fluoroscopic failure led to successful endoscopic placement in an average of 13.4 min, but with only 29% reaching the jejunum. Our overall success rate is similar to that of fluoroscopy without the risks associated with a move to radiology and additional radiation. The success rate of EMG-directed placements is similar to endoscopic placement and reaches the jejunum more frequently. The cost to the patient of fluoroscopy or endoscopy is considerable.

Zaloga8 described a bedside method for placing small-bowel feeding tubes in critically ill patients. He succeeded in 92% of 231 attempts, with 3% in the first portion of the duodenum, 25% in the second portion, 47% in the third portion, and 17% in jejunum. This technique was labor intensive, with average time for placement being 40 ± 14 min (mean ± SD). A high level of expertise is required to identify pylorus entry. House staff and nurses were successful in 70 to 80% of attempts after training. While their method has the advantage of a being a reliable bedside method at this institution, the time required is considerably longer than the average 9.2 min of our study, which has the added advantage of a greater rate of jejunal placement (60%).

Erythromycin and related 14-member macrolide compounds inhibit the binding of motilin to its receptors, located on the gastric antrum and proximal duodenum, and act as agonists. Manometric recordings after erythromycin treatment have demonstrated increased amplitude, area under the curve, and duration of antral contraction.17 Kalliafas et al16 demonstrated that erythromycin at a dose of 200 mg significantly facilitated transpyloric tube placement in 18 of 29 patients (62%) randomized to erythromycin, compared with 7 of 23 patients (30%) who received placebo. The sum total of five studies13 14 18 19 20 in critically ill adult patients11 shows that in 107 total patients, the use of erythromycin to facilitate tube placement gave an average initial success rate of 56%. This group provides the best comparison group for our study, as a study of erythromycin-assisted tube placement in critically ill patients and shows its beneficial effect on tube placement success.

The stomach can be divided into two regions based on electrophysiologic parameters. The fundus and part of the proximal one third of the corpus are electrically inactive, but the remainder of the corpus and the entire antrum is active and has spontaneous electrical control activity (ECA). The ECA frequency is constant throughout this region at approximately three cycles per minute (Fig 1) , and is the same in many animal species and man.21 22 23 24 25 Human, dog, and cat duodenum and proximal jejunum have a frequency plateau region with a constant frequency between 10 cycles and 12 cycles per minute (Fig 1) , but more distally a variable frequency region exists.26 27 28 29 Based on the significant difference in ECA frequency of the stomach and small intestine, it is possible to determine the location of a feeding. The original equipment we used in this study, developed in the early 1990s, consisted of an amplifier the size of a shoebox that was connected to a desktop computer. The authors are attempting to have developed, using current technology, an amplifier the size of a deck of cards with output to a personal data assistant device, making it portable.

Our findings support the hypothesis that real-time, bedside information about tube-tip location facilitates the transpyloric placement of feeding tubes, and that such technology is feasible for bedside use in those in whom it could benefit most, the critically ill. EMG monitoring allows for rapid confirmation of transpyloric location and also allows repeated attempts prior to obtaining abdominal radiographic confirmation of tube location, minimizing radiation exposure in initially unsuccessful attempts. The potential additional costs associated with EMG guidance (simple technology no more complicated than an ECG) would likely be trivial compared with repeated blind attempts, fluoroscopy or endoscopy.


   Footnotes
 
Abbreviations: ECA = electrical control activity; EMG = electromyogram

This article was presented in abstract form at Chest 1994. The data were also presented in part as a presentation that was transcribed in a supplement to Nutrition in Clinical Practice 1997; 12:S28–S30.

Dr. Levy is currently employed by Eli Lilly and owns stock in the corporation.

Dr. Hayes is currently employed at Abbott Laboratories and owns stock in the corporation.

Mr. Tomba owns stock in Abbott Laboratories.

The study was funded by a grant from Ross Products, Abbott Laboratories.

Received for publication January 8, 2003. Accepted for publication July 18, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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