Considerations before switching from Nasogastric (Ryles) to PEG Tube feeding

PEG tube (percutaneous endoscopic gastrostomy)  is a feeding tube that is surgically placed in the stomach to enable feeding directly. It is usually recommended if a feeding tube needs to be placed on a patient for long term basis. Examples are in case of stroke/ ALS patients who could no longer swallow, and illness/physical injury that affects the throat’s ability to swallow.

Whereas nagoastric (NG) tube is inserted via the nose which goes straight to the stomach. The entry point to the nose is secured with micropore tape. Unlike PEG tube, it is not surgically placed and can be removed and changed anytime, provided it is after 3 hours (ideally it is 4 hours) from the last feed/ meal. Those who only require feeding tube on short term basis (eg few days, weeks or months) would usually be given a NG tube.

PEG vs NG for Alzheimer’s/ dementia patients who could not eat

It is now more than 2 years since my mother, who have Alzheimer’s have been fitted with a NG feeding tube. My mom have a lot of phlegm and secretion issues which requires constant phlegm suction. So a few specialists who are currently seeing my mom was recommending that she changed from a nasogastric tube to a PEG tube as it would likely reduce the secretions and phlegm as there is no friction that causes irritation to her mucus membrane surrounding her nasal and digestive cavity.

However, the gastrologist who is seeing my mother have a different opinion. I wish to share her advice in this post. She said that when a PEG tube is placed, it would require 2 doctors to manage the procedure- one to do endoscopy to pass a camera tube to the stomach, while a surgeon would need to make the incision to place the PEG tube. She mentioned she does not conduct surgery but she can pass the endoscopy tube. This means she is very familiar with the procedures and after the PEG placements, patients would be placed under her… hence she is familar with the benefits as well as the possible complication from this procedure.

There are some things shared by the gastrologist before considering a PEG tube placement:

1. A PEG tube may not necessary solve the secretion and phlegm issue

If the secretions are mainly due to friction between the NG tube brushing against the mucus membrane of the nasal and digestive passageway, then yes, changing to a PEG tube may help to reduce the secretions tremendously.

However, the reason my mom require a feeding tube in the first place was because she had lost her swallowing reflex. Ie she was not able to swallow on her own and would choke on fluids and liquids. Not only that she can no longer swallow water or food, she also could not swallow her secretions nor spit them out. And that means, these secretions would form and would accumulate anyway because she was not doing anything to get rid of it. If it is not being suctioned out, these secretions would move into her lungs resulting in aspiration pneunomia.

Hence in such scenario, placing a PEG tube may just reduce the risk slightly but not significant enough to warrant an operation because there is also another huge concern….

2. Meddling with the wound on the PEG tube area- DANGER

The main concern my mom’s doctor have is the fact my mom may displace the PEG tube….. if the PEG tube is displaced (either by movement or them tugging at the tube), the opening of the PEG tube may move upwards to the epidermis or adipose layer of the stomach instead of on the opening the stomach.

So imagine when the end which was supposed to go to the stomach got dislodged into the upper layer of the stomach tissue. When you put in the feed via the other end, instead of the food going to the stomach, it spread into the layers within the stomach tissue. This is very dangerous because it can lead to blood sepsis which can be fatal. And worst is especially if they cannot tell us what is wrong or if they don’t feel well…

For cases like a stroke or ALS patient would know that they cannot rub, tug, pull or rub at the area when it is uncomfortable or painful. They would try to communicate to their caregivers if they experience discomfort, itching or pain. In cases of Alzheimer’s or dementia, they are not able to understand the danger, and even if they could still do when we tell them, after about 5 minutes they would forget.

Actually I am grateful because as the option of PEG was being suggested by other doctors (before I saw the gastrologist)

4. When they cannot tell if anything is wrong… before it is too late

If our loved one or the patient cannot tell us what is wrong… whether it is due to loss of speech due to stroke or neurological degeneration (like in cases of motor neurone disease like ALS) or Alzheimers (they lose their cognitive ability to verbalise their thoughts and feelings)…… then we would not know if anything is wrong.

In my mom’s case, she is no longer able to tell me what is wrong. A PEG tube area is essentially a wound and would itch, be in pain or risk possible infection. I have seen my mom trying to tug at her NG tube which fortunately did not come off as I’ve figured out a way to secure the tube to her nose using 3 layers of taping.

I’ve been told by a nurse that with a PEG tube, it would require daily change of dressing as it is essentially a wound area. When it is healing, wounds generally would itch…. and I have absolutely no doubt that my mom would be scratching the area. There was a suggestion to tie her hands but it is not something that I could bring myself to do. Covering the area may not work as well because if the area is covered for protection, heat and moisture may accumulate causing more discomfort (however in understand in cases of infant or toddlers on feeding tube, they do use a covering to protect the area).

4. Age and other underlying illness and physical condition

If the patient is already elderly, their skin may thin out and healing may be difficult. For the case of my mom, I’ve noticed that whenever she has a wound (caused by her scratching herself or after the nurse take blood), it would take a long time to heal than average.

Aside from that, medical conditions such as diabetes where wounds does not heal easily and can lead to sepsis (blood infection) if not well managed as well as other conditions that doctors may have concern about… these have to be taken into consideration.

Conclusion

The above are based on the advice of the doctor, as well as my personal observation in caring for my mom. Sometimes when we spend time with the person we care for a lot, we would be familiar with their actions and habits. For example it is logical to transition a patient from NG tube to PEG tube when they have been on it for few years. However, at times, we may know the patient, who is our loved one the best.

Usually PEG would be considered for someone who is younger and more active as later it can be changed to a Mickey tube which is small and inconspicuous that it can remain hidden in clothing. However in cases of a person with Alzheimers/dementia where they are more active and may meddle with the tube or scratch the area as the wound is healing, further consideration would be required.

 

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