The placement of a feeding tube in the gastrointestinal tract opens the possibility of drug delivery through this via, also reducing the risk of administration of injectable dosage forms.

1. ENTERAL FEEDING TUBE
FOR DRUG ADMINISTRATION
Surya Amal
Presented For Pharmacy Department
University of Darussalam Gontor - Indonesia

2. Overview
1. The important reason to choice the route of enteral feeding (p2)
2. The possibility of drug delivery through this route (p5)
3. Choice of feeding tube for drug administration (p6)
4. Indications for enteral tube feeding (p7)
5. Complications of enteral tube feeding (p8)
6. Routes and types of feeding tubes (p9 – p19)
7. Characteristics of the tubing material (p20 – p21)
8. Technique of flushing (p22 – p23)
9. How to choice of medication formulation ? (p25)
10. Preparing medication for administration (p26 – p31)
11. Medications not suitable for administration via enteral tubes (p32)
12. Ethical issues of enteral tube feeding (p33)

3. The important reason to choice this route
“When patients are unable to be
fed orally, enteral or parenteral
nutrition is recommended.”

4. Enteral Nutrition (EN)
“Enteral Nutrition (EN) offers some advantages over
parenteral nutrition as the decrease in hospitalization
time, reduced clinical complications, greater
convenience, improvement in bowel function,
maintenance of the structure and function of the
gastrointestinal mucosa, and less possibility of bacteria
translocation.”
Presoti et al., J Gen Pract 2013, 1:2

5. Drug administration via enteral feeding tubes
The placement of a feeding
tube in the gastrointestinal
tract opens the possibility
of drug delivery through
this via, also reducing the
risk of administration of
injectable dosage forms.

6. Choice of feeding tube for drug administration
 Use of enteral feeding tubes for drug
administration is increasing.
 Sizes of feeding tubes are decreasing.
 The range of healthcare professionals
involved in drug administration via enteral
feeding tubes is increasing.
 Collation of all available information is
necessary.

7. Indication for feeding Examples
Unconscious patient Head injury, ventilated patient
Swallowing disorder Post-CVA, multiple sclerosis, motor
neurone disease.
Physiological anorexia Liver disease (particularly with ascites)
Upper GI obstruction Oesophageal stricture.
Partial intestinal failure Postoperative ileus (see section 5.0),
inflammatory bowel disease, short
bowel syndrome.
Increased nutritional
requirements
Cystic fibrosis, renal disease.
Psychological problems Severe depression or anorexia nervosa.
Indications for enteral tube feeding
GI, gastrointestinal; CVA, cerebrovascular accident.
Source : Nightingale, J. et al. 2003

8. Type Complication
Insertion Nasal damage, intracranial insertion,
pharyngeal/oesophageal pouch perforation,
bronchial placement, variceal bleeding.
PEG/PEJ insertions Bleeding, intestinal/colonic perforation
Post insertion trauma Discomfort, erosions, fistulae, and strictures.
Displacement Tube falls out, bronchial administration of
feed.
Reflux Oesophagitis, aspiration.
GI intolerance Nausea, bloating, pain, diarrhoea.
Metabolic Refeeding syndrome, hyperglycaemia, fluid
overload, electrolyte disturbance
PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous endoscopic
jejunostomy; GI, gastrointestinal. (Source : Nightingale, J. et al. 2003)
Complications of enteral tube feeding

9. Types of feeding tubes
 Ensure that you know the type,
size and position of the enteral
feeding tube before administration
of medication via the tube.
 The exit site of the tube may
affect drug pharmacokinetics or
side-effect profile.

10. Routes of Feeding

11. Nasogastric tube (NGT)
This feeding tube
is inserted via the
nose and exits in
the stomach.
In adults these
tubes are usually
90–100 cm long.

12. Sit the patient upright with the head level. Slide the tube gently
backwards along the floor of the clearer nostril until visible at the
back of the pharynx (10–15 cm).
Check nasal patency by ‘‘sniff’’ with each nostril occluded in turn.
The clearer nostril can be sprayed with lignocaine to minimise
discomfort.
Lubricate the tube externally with gel/water and internally with
water if a guide wire is present. Check the guidewire moves freely.
Mark the tube at a distance equal to that from the
xiphisternum to the nose via the earlobe (50–60 cm).
Explain the procedure to the patient.
Placing a Nasogastric Tube

13. Document tube insertion in the patient’s notes.
Check position of the tube before use (this does not usually require
an x ray)
Once in place, remove any guidewire and secure carefully.
If there is difficulty passing the tube, ask the patient to tilt their
head forwards or turn it to one side.
Withdraw the tube at any stage if the patient is distressed,
coughing, or cyanosed.
Repeat the water swallow/advance until the preset mark on the
tube reaches the nostril.
If the patient is cooperative, ask them to take a mouthful of water
and then advance the tube 5–10 cm as they swallow.
Cont … …

14. Nasoduodenal tube (NDT)
The nasoduodenal tube
feeding tube is inserted
in the same manner as
the NG tube but is
allowed to pass into the
duodenum, usually with
assistance, either
endoscopic or
radiological. This is used
to overcome the
problems associated
with gastric stasis. It is
also referred to as
‘postpyloric’.

15. Nasojejunal tube (NJT)
Nasojejunal tubes
are usually inserted
endoscopically or
radiologically to
ensure that they
are in the correct
position in the
jejunum. These
tubes are prone to
blockage owing to
their length, usually
more than 150 cm

16. Percutaneous gastrostomy
Percutaneous
gastrostomy tubes are
inserted into the stomach
via the abdominal wall,
most commonly
endoscopically
(percutaneous
endoscopic gastrostomy,
PEG).

17. A permanent tract (stoma) forms after 3 weeks. The device is held in
place with an internal balloon or bumper and an external fixator.
Percutaneous gastrostomy
Cont…….

18. Percutaneous jejunostomy
The percutaneous jejunostomy tube is inserted into the jejunum via the
abdominal wall, endoscopically (percutaneous endoscopic jejunostomy,
PEJ), radiologically or surgically. They are held in place either externally
with stitches or internally with a flange or Dacron cuff.

19. Percutaneous gastrojejunostomy
The percutaneous gastrojejunostomy tube is inserted into the
stomach via the abdominal wall and the exit of the feeding tube is
placed into the jejunum, most commonly endoscopically
(percutaneous endoscopic gastrojejunostomy, PEGJ).

20. o Enteral feeding tubes are composed of
polyvinylchloride (PVC), polyurethane (PUR), silicone or
latex.
o The external diameter of the feeding tube is expressed
using the French (Fr) unit where each ‘French’ is
equivalent to 0.33 mm.
Nasoenteric tubes are used for short- to medium-
term feeding (days to weeks).
Ostomy tubes are used for long-term feeding
(months to years).
Characteristics of the tubing material

21. Endoscope

22. Flushing enteral feeding tubes
Tube flushing is the single most effective action in
prolonging the life of any enteral feeding tube.
Enteral feeding tubes require regular, effective
flushing to prevent tube blockage.

23. Technique of Air Flushing
1. Pre-fill a 50 mL syringe with 30 mL of air.
2. Attach the syringe to the appropriate port of the patient’s
nasogastric feeding tube.
3. Ensure that any other ports are closed and airtight.
4. Ensure that there is an airtight connection between the
syringe and the enteral tube and administer the flush.
5. Listen for any evidence of the air venting into the mouth or
upper oesophagus; such venting may suggest misplacement of
the tube tip in the upper oesophagus or rupture of the tube.
6. Attempt to aspirate with a 50 mL syringe. This will reduce the
likelihood of the inner lumen of the enteral feeding tube
collapsing under vacuum.

24. Technique Water flushing
1. Prepare a flush of water (according to local guidelines) in a 50
mL syringe and label if necessary. Place it in a clean tray.
2. Stop or suspend enteral feeding.
3. Ensure that any other ports are closed and airtight.
4. Attach the syringe to a port of the patient’s enteral feeding
tube. Ensure that there is an airtight connection between the
syringe and the enteral tube.
5. Using a pulsatile flushing action, administer the flush.
6. Positioning the patient in a semi-recumbent position can help
to prevent regurgitation and possible pulmonary aspiration
from gastric flush and or drug residual.
7. Administer the drug and flush; cap off, or connect further
enteral feeding depending on the patient’s requirements.

25. How to Choice of medication
formulation ?
1. Solutions or soluble tablets are the
formulations of choice.
2. Do not assume that liquid formulation will
be suitable.
3. Do not crush tablets or open capsules
unless an alternative formulation or drug is
unavailable.

26. Preparing Medications for Administration
Soluble Tablets :
1. Dissolve the required number of tablets in a suitable
volume of sterile potable water.
2. If the whole tablet dose is to be administered, rinse
out the vessel in which the tablet was dissolved with
sterile potable water, draw up into the same syringe
used to administer the dose, and administer this
residue to ensure the full dose is given.
3. If only a part dose is to be administered, ensure the
resulting solution from the dissolved tablet is well
suspended by continually agitating the solution.
Administer the dose IMMEDIATELY.

27. Preparing Medications for Administration
Tablets :
1. Crush the tablet in a tablet crusher .
2. Mix the resultant powder with an appropriate volume
of sterile potable water.
3. If the whole tablet dose is to be administered, rinse out
the vessel in which the tablet was dissolved with sterile
potable water, draw up into the same syringe used to
administer the dose, and administer this residue to
ensure the full dose is given.
4. If only a part dose is to be administered, ensure the
resulting solution from the dissolved tablet is well
suspended by continually agitating the solution.
Administer the dose IMMEDIATELY

28. Preparing Medications for Administration
Capsules :
1. Carefully open the capsule and allow its contents to fall into a
suitable container .
2. Disperse this powder with an appropriate volume of sterile
potable water .
3. If the whole tablet dose is to be administered, rinse out the vessel
in which the tablet was dissolved with sterile potable water, draw
up into the same syringe used to administer the dose, and
administer this residue to ensure the full dose is given.
4. If only a part dose is to be administered, ensure the resulting
solution from the dissolved tablet is well suspended by
continually agitating the solution. Administer the dose
IMMEDIATELY

29. Preparing Medications for Administration
Liquids (including injectable products) :
1. Shake the bottle well (for at least 15 seconds).
2. Draw up the required volume for the dose.
3. Thick liquids should be diluted with 2 to 3 times the
volume with sterile potable water. This makes them
less likely to “clog” in the tube.
Do NOT flush enteral tubes with the same syringe used to administer the dose as
enteral syringes have a “dead-space” which is accounted for on the graduations.

30. Acarbose
FOR EXAMPLE OF DRUG REVIEW
Source : White, R and Bradnam, V. 2007

31. 1. Stop the enteral feed.
2. Flush the enteral feeding tube with the recommended volume of
water.
3. Place the tablet in the barrel of an appropriate size and type of
syringe.
4. Draw 10 mL of water into the syringe and allow the tablet to
disperse, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10 mL of water into the syringe and also flush this
via the feeding tube (this will rinse the syringe and ensure that the
total dose is administered).
7. Finally, flush with the recommended volume of water.
8. Re-start the feed immediately.
Intragastric administration procedure for acarbose
FOR EXAMPLE

32. Medications NOT Suitable for Administration
via Enteral Tubes :
 Enteric coated medications (denoted e/c on
packaging, label or in the BNF.)
 Modified Release medications (denoted CR,
MR, SR, XL, LA, OnceWeekly on packaging,
label or in the BNF.).
 Cytotoxic medications.
 Hormones.
 Tablets designed for administration sub-
lingually, buccally, or that should be
chewed.

33. Ethical Issues
ETF should never be started without consideration of all related
ethical issues and must be in a patient’s best interests (grade C =
requiring evidence from category IV in the absence of directly
applicable clinical studies).
ETF is considered to be a medical treatment in law. Starting,
stopping, or withholding such treatment is therefore a medical
decision which is always made taking the wishes of the patient
into account.
In cases where a patient cannot express a wish regarding ETF, the
doctor must make decisions on ETF in the patient’s best interest.
Consulting widely with all carers and family is essential.
Category IV—Evidence obtained from expert committee reports
or opinions or clinical experiences of respected authorities.

34. References
1. White, R and Bradnam, V. 2007. Handbook of Drug
Administration via Enteral Feeding Tubes.
Pharmaceutical Press, London –UK.
2. Nightingale, J. et al. 2003. Guidelines for enteral feeding
in adult hospital patients. Gut 2003;52(Suppl VII):vii1–
vii12
3. Presoti et al., 2013. Prescription of Drugs to be
Administered through Feeding Tubes in a Brazilian
Hospital: Profile and Qualification. J Gen Pract 2013, 1:2
4. Sutherland, A. 2009. Guideline On Administration of
Medication Via Feeding Tubes. NHS. PICU Consultant
Group.