The use of nasogastric (NG) and nasojejunal feeding tubes (NJ) has steadily increased over the past 20 years as they have become important approaches to providing adequate calories and hydration for children, older adults, and others who have temporary or long-term need for alternate pathways for nutrition.
Tube feeding can be an excellent option for any patient with a functional gastrointestinal tract, thereby avoiding intravenous hyperalimentation and its associated complications. Nasogastric and NJ feeding tubes are especially useful for nutritional supplementation for short-to-medium periods of time (<6 weeks) because they reduce the need for more invasive and expensive procedures, including surgical, endoscopic, or percutaneous gastrostomy or gastrojejunostomy.
After initial placement of a feeding tube, the main challenges are to maintain the tip of the feeding tube in a safe and effective position and to minimize inadvertent removal by the patient or staff. The target for tip position for an NG tube is generally within the gastric fundus, while the preferred tip position for an NJ tube is in at least the fourth portion of the duodenum to minimize the risk of fluid reflux into the stomach.
Historically, various types of taping and adhesive dressings were used to fix the feeding tube in position. Unfortunately, tube security with these dressings may be poor, and tubes are often inadvertently retracted into unsafe positions, such as in the esophagus for NG tubes or in the proximal duodenum or stomach for NJ tubes. They may also be prematurely removed entirely, necessitating a repeat placement. Replacing a feeding tube may require sedation or general anesthesia, especially in children, as well as additional radiation, particularly for NJ tube insertion where fluoroscopic guidance may be required.
The nasal bridle loop retention device (Applied Medical Technologies, Brecksville, Ohio) provides a more reliable method of securing a feeding tube for long periods of time.
Placing a nasal bridle requires neither imaging guidance nor sedation. The nasal bridle may be placed before or after the nasal tube; we prefer placing it after the NJ tube to prevent an unnecessary procedure if feeding tube insertion is unsuccessful. The child is placed in the supine position, and the procedure is performed as follows:
The nasal bridle loop retention system is technically easy to insert and usually takes less than 10 minutes, with most procedures completed in 5 minutes or less. Nasal bridle insertion is more invasive than securing an enteric feeding tube with tape or an adhesive product, and it does increase the cost of enteral feeding tube insertion.
However, the literature has shown that the incidence of dislodgement of taped NG tubes ranges from 43% to 82%. When NG tubes are secured with a bridle there is a 9-20% reduction in the incidence of dislodgement.1 The increased tube stability has several advantages, including significant cost reduction, shorter hospital stays, improved caloric intake, fewer radiographs for tube tip confirmation, and fewer complications. The improved tube security leads to a lower rate of untoward effects, including aspiration, as well as lower radiation exposure, more consistent delivery of calories, many fewer replacement procedures, and less escalation to more invasive procedures such as surgery, endoscopy, or percutaneous gastrostomy, gastrojejunostomy, and fundoplication.1 As is the case with any device, there are complications; the most common post-placement issues are epistaxis, nasal ulceration2,3 and skin injuries4 We have treated a child that developed pressure necrosis of the columella of the nasal septum (Figure 2).
The nasal bridle loop is an effective retention device for NG and NJ feeding tubes that reduces the frequency of tube malposition and loss. The improved tube security results in cost savings and reductions in potential complications and in the incidence of escalation to gastrostomy or gastrojejunostomy tube placement.
How We Do It | The Nasal Bridle: A Loop Retention Device. Appl Radiol.
Affiliations: Phoenix Children’s Hospital (Drs R Towbin, Schaefer, Aria); Cincinnati Children’s Hospital and Cincinnati College of Medicine (Dr A Towbin).