contribution was vital for the whole project. Jill, Mike, Rich, and Rob went above and beyond to have all the chapters completed on time and make sure the content was appropriate. Thank you all!
I want to dedicate this book to my mother who, despite all the difficulties, never left my side. She has been my inspiration all these years. Also, to Dr. Levinsky, who discussed the initial idea for the book with me. And finally, to all the people in my life who made a difference, thank you!
Ioannis Koutroulis
I’d like to first acknowledge, Ioannis, the creator of the book and our persevering leader. Through thick and thin, Ioannis remained upbeat and encouraging. Ioannis stayed enthusiastic, despite delays as a result of our heavy administrative and clinical workloads due to sustained high volumes and acuities in our emergency departments (EDs), inpatient areas, and intensive care units. With an eternally positive attitude, he even respectfully pushed us through a pandemic toward the completion of the “Hi-Tech Book” project. Thank you, Ioannis! My most genuine love and appreciation goes to my family – wife Debbie, my son Christopher, and my daughter Nicole. The importance of their continual support of my long ED shifts, constant meetings, and endless “homework” cannot be understated. They have forever tolerated “Daddy” in his study … reading, writing, typing, answering pages, making phone calls, etc. Finally, a special thank you to my mother who, with little education and even less money, somehow managed to raise three pretty good kids. Love you, mom.
Nick Tsarouhas
To my parents, who raised me to believe I can do anything.
To my mentors, who have showed me the way.
To my patients, who have inspired and humbled me.
And to my husband and daughters, my loves and light.
Jill C. Posner
1 Using and Troubleshooting Enteral Feeding Devices
Courtney E. Nelson1,2 and Thane A. Blinman3,4
1 Division of Emergency Medicine, Department of Pediatrics, AI DuPont Hospital for Children, Wilmington, DE, USA
2 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
3 Division of General and Thoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
4 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
Introduction
Enteral feeding devices deliver nutrition directly to the stomach and/or small intestine for patients with anatomic or physiological feeding impairments. Common indications for enteral feeding devices include feeding and swallowing dysfunction, severe gastroesophageal reflux, malnutrition, neurological disorders, and prolonged ventilation. Given the breadth of indications for enteral feeding devices, a clinician in any setting, and particularly those in the emergency department, is likely to encounter these devices on a daily basis. These are simple devices with a simple purpose, but their dysfunction is highly disruptive and worrisome to patients and their caregivers. This chapter will teach you how to manage the simplicity of a working enteral feeding device and navigate the intricacies of an unruly device.
Equipment/Device
Enteral feeding devices can be categorized into temporary and long‐term devices. Furthermore, the name for each device comes from its origin (nose, mouth, or stomach) and terminus (stomach or small intestine) (Table 1.1). Nasal and oral tubes are temporary and work well for patients with transient feeding difficulties. Gastrostomy tubes (G‐tube) and jejunostomy tubes (J‐tube) are ideal for more long‐term or permanent enteral nutrition. Enteral feeding devices are sized in French (Fr) units, which is the outer diameter of the tube in millimeters multiplied by three. A 9 Fr tube, for example, has an outer diameter of 3 mm. Tube lengths are usually given in centimeters and vary widely from very short low profile “button” type tubes to very long naso‐jejunal (NJ) tubes.
Table 1.1 Enteric feeding devices.
| Origin | Destination | Tube | Abbreviated | Placement |
| Temporary feeding devices | ||||
| Nose (naso‐) | Stomach (gastric) Duodenum Jejunum | Naso‐gastric Naso‐duodenal Naso‐jejunal | NG ND NJ | Bedside |
| Mouth (oro‐) | Oro‐gastric | OG | Bedside | |
| Long‐term feeding devices | ||||
| Percutaneous | Stomach Jejunum | Gastrica Gastro‐jejunostomy Jejunostomy | G‐tube GJ J‐tube | Surgically or endoscopically Fluoroscopically Fluoroscopically |
a Commonly, these tubes are called “PEG tubes”; however, a percutaneous endoscopic gastrostomy is a procedure and not a specific tube.
Temporary Feeding Devices
Naso‐gastric (NG), naso‐duodenal (ND), NJ, and oro‐gastric (OG) feeding tubes are used for short‐term enteral feeding, defined as that less than 12 weeks. OG tubes are reserved for patients in the intensive care unit and rarely seen in the emergency department. Temporary feeding tubes are typically constructed from polyurethane or silicone‐based polymers, both of which are flexible, reasonably durable, minimally reactive biologically, and, for most, immunologically inert. Polyurethane tubing has the added benefit of being made with a water‐activated lubricant to ease insertion and increased durability. Depending on the manufacturer, NG, NJ, ND, and OG tubing may come with weighted tips, radiopaque indicators, stylets, and/or magnets to help with placement. Common pediatric tube size for feeding is a 6–8 Fr and for adults a 12–14 Fr.
Gastric Decompression Devices
Similar to the temporary feeding devices, there are NG and OG tubes used for decompression and lavage. These devices are larger than feeding tubes: 8–10 Fr for children and 12–14 Fr for adults. Decompression devices are divided into single and double lumen tubes. Single lumen tubes, such as the Levin tube, are used more frequently in the emergency department or intensive care unit for intermittent decompression. Single lumen tubes should not be placed on continuous suction because they can adhere to the stomach wall and cause tissue damage. A double lumen tube is the preferred decompression device because it has both a large lumen for suction or irrigation and a small lumen (typically blue in color) that vents the large lumen. This small lumen serves as a pop‐off valve for the device to prevent excessive suctioning. There are two common types of double lumen tubes: Salem