Gastroesophageal Reflux in Intubated Patients Receiving Enteral Nutrition: Effect of Supine and Semirecumbent Positions

Abstract

The incidence of gastroesophageal reflux (GER) in critically ill patients as well as the effect of a nasogastric tube (NGT) and body position as risk factors for GER were determined. Seventy patients with orotracheal intubation receiving enteral nutrition through a NGT for more than 48 hours were prospectively studied with two randomly assigned body positions: supine or semirecumbent. Detection of GER was achieved by scintigraphy after labeling gastric contents with 500 microCi of technetium-99m sulfur colloid administered through the NGT. In 50 patients scintigraphy was performed after subjects had remained in the randomized position for 2 hours with the NGT pinched. Twenty additional patients were studied after the NGT had been removed. In 50 patients with NGT, GER was present in 74% (37 of 50) and was higher in the supine position (81%, 21 of 26) than in the semirecumbent position (67%, 16 of 24), but this difference was not statistically significant (p = .26). In 20 patients without NGT, the incidence of GER was 35% (7 of 20) and it was also higher in the supine (50%, 6 of 12) than in the semirecumbent position (12%, 1 of 8, p = .16). There was a statistically significant difference between GER in patients with and without NGT (74% vs 35%, p = .0002). These data show that there is a high incidence of GER in patients with orotracheal intubation and NGT. The presence of a NGT is a risk factor for GER. Semirecumbency does not prevent GER, but there is less incidence than in the supine position.

A Nursing Clinical Decision Support System and Potential Predictors of Head-of-Bed Position for Patients Receiving Mechanical Ventilation

“…4,5 Additionally, lower head-of-bed (HOB) elevations have been associated with higher rates of aspiration. [6][7][8][9][10][11] Despite the evidence that HOB elevation (30º-45º) helps prevent aspiration in patients receiving mechanical ventilation, the intervention is underused. [11][12][13] tion due to interpretation error by a nurse.…”

Gastro-oesophageal reflux in mechanically ventilated patients: effects of an oesophageal balloon

“…One of the most commonly recognised risk factors for VAP is the bacterial colonisation of the gastric content with subsequent gastrooesophageal reflux (GOR) and aspiration into the airways [6,7]. The GOR has been found to be enhanced in mechanically ventilated patients maintained in the supine body position and in patients carrying a nasogastric tube (NGT), because these factors appear to increase the permeability of the lower oesophageal sphincter [8][9][10].Several groups find it reasonable and clinically relevant to further investigate new potential preventive measures, which are applicable to conventional clinical settings, have little or no impact on selecting resistant microorganisms, and are economically viable. In this regard, several mechanical preventive measures have been evaluated, including intermittent [11] or continuous [12] subglotic aspiration, avoidance of NGT [10], small-bore NGT [13,14], and semi-recumbent body positioning [9].…”

“…The GOR has been found to be enhanced in mechanically ventilated patients maintained in the supine body position and in patients carrying a nasogastric tube (NGT), because these factors appear to increase the permeability of the lower oesophageal sphincter [8][9][10].…”

“…In this regard, several mechanical preventive measures have been evaluated, including intermittent [11] or continuous [12] subglotic aspiration, avoidance of NGT [10], small-bore NGT [13,14], and semi-recumbent body positioning [9]. In 1992, the supine body position and the duration of the time spent in the supine position were associated with an increased risk of aspirating the gastric content into the airways [9].…”

“…One of the most commonly recognised risk factors for VAP is the bacterial colonisation of the gastric content with subsequent gastrooesophageal reflux (GOR) and aspiration into the airways [6,7]. The GOR has been found to be enhanced in mechanically ventilated patients maintained in the supine body position and in patients carrying a nasogastric tube (NGT), because these factors appear to increase the permeability of the lower oesophageal sphincter [8][9][10].…”