Mortality associated with nasogastric tube feeding was highBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7036.973 (Published 13 April 1996) Cite this as: BMJ 1996;312:973
- H D Duncan,
- E Walters,
- D B A Silk
- Gastroenterology research fellow Research dietitian Consultant gastroenterologist Central Middlesex Hospital NHS Trust, London NW10 7NS
EDITOR,—B Norton and colleagues suggest that percutaneous endoscopic gastrostomy feeding is superior to nasogastric tube feeding in patients with dysphagic stroke.1 Since their conclusions are likely to have a considerable impact on clinical practice we wish to raise several concerns about the study.
Firstly, we are concerned that decisions about providing nutritional support to these patients were not made for two weeks after admission. As it is stated that intravenous fluid was the patients' sole nutritional intake before they entered the study, their nutritional status may have deteriorated considerably before nutritional support was started.2 Furthermore, the patients were then fed with starter regimens. Such practice has not been shown to offer any advantages over the institution of full feeding from day 1, and, indeed, the use of starter regimens has been shown to reduce nutritional intake significantly.3
Another of our concerns is that the resiting of inappropriately removed nasogastric feeding tubes was delayed (range 1-10 days, median 5). This delay will almost certainly have led to an inappropriate reduction in the patients' nutritional intake.
The mortality of 57% in the group fed nasogastrically is higher than that reported in other studies (0% to 11%).4 5 The fact that three patients in the group receiving percutaneous endoscopic gastrostomy feeding regained their ability to swallow while none in the group fed nasogastrically did so suggests that, despite the use of standard scoring systems, the patients in the two groups may not have been comparable neurologically.
Finally, we question the practical and clinical importance of the differences in discharge rates between patients with a percutaneous endoscopic gastrostomy and those fed by a nasogastric tube. The differences may simply represent a bias by community services to accept only patients with a percutaneous endoscopic gastrostomy. As the paper shows, patients with a percutaneous endoscopic gastrostomy are often easier to manage and feed and require less nursing time than those fed by a nasogastric tube, and thus we are sympathetic to the preference of wards and nursing homes for a patient with dysphagia to have a percutaneous endoscopic gastrostomy.
In our opinion, the authors' conclusion that percutaneous endoscopic gastrostomy tube feeding is superior to nasogastric tube feeding in patients with dysphagic stroke is premature and a larger comparison of the two methods is indicated. At the moment, the data suggest to us that at a relatively late stage after dysphagic stroke percutaneous endoscopic gastrostomy feeding is superior to rather inadequately managed nasogastric tube feeding.
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