Journal of Parenteral and Enteral
`Nutrition
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`http://pen.sagepub.com/
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`A New Nasal Bridle for Securing Nasoenteral Feeding Tubes
`Jeffrey A. Meer
` 1989 13: 331JPEN J Parenter Enteral Nutr
`
`DOI: 10.1177/0148607189013003331
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`A New Nasal Bridle for Securing Nasoenteral Feeding Tubes
`
`JEFFREY A. MEER, M.D., F.A.C.P.
`
`From the Department of Medicine, Sinai Hospital of Detroit, Detroit, MI
`
`ABSTRACT. A newly designed nasal bridle and rationale for
`its clinical use are described. Previous nasal bridles have been
`shown to reduce the 40 to 60% incidence of dislodgement of
`nasoenteral feeding tubes. Nasal bridles, however, are still not
`routinely used in nasoenteral feeding of patients who dislodge
`their feeding tubes. Instead, percutaneous gastrostomies and
`parenteral nutrition are increasingly being used in these pa-
`
`tients who may otherwise be fed adequately with a secured
`nasoenteral tube. The newly designed nasal bridle described
`herein has the advantages of easy and rapid placement. Use of
`this bridle can promote safer and more effective enteral feeding
`while avoiding the complications and cost of parenteral nutri-
`tional and gastrostomies. (Journal of Parenteral and Enteral
`Nutrition 13:331-334, 1989)
`
`Nasoenteral feeding tube dislodgement is a common
`occurrence in hospitalized patients. Studies have dem-
`onstrated the incidence of this problem to range from 40
`to 60%.1-5 Repeated dislodgement of feeding tubes has
`several undesirable results: (1) feeding is delayed while
`awaiting proper replacement of the feeding tube; (2) there
`is an increased risk of aspiration of feeding solutions if
`the tube is partially dislodged; (3) physician and nursing
`staff time and effort is wasted in replacing the tube and
`in repeating endoscopic placement, fluoroscopy, or ab-
`dominal x-rays to confirm proper replacement of the
`tube; (4) there is an unnecessary increase in the use of
`more invasive forms of nutritional support such as gas-
`trostomy or parenteral nutrition; (5) tube feeding solu-
`tion is wasted; (6) hospital stays are prolonged, and (7)
`there is increased medicolegal liability as a result of the
`above complications. It is apparent that the current
`means for securing nasoenteral feeding tubes is inade-
`quate. One means for securing feeding tubes is with the
`use of the &dquo;nasal bridle&dquo;. This device was originally
`described in 1980 by McGuirt and Strout as a length of
`material looped around the patient’s nasal septum and
`then secured to the feeding tube.’ Their paper described
`the use of this device in over 100 postoperative head and
`neck cancer patients. They demonstrated the effective-
`ness and safety of the nasal bridle as there were no
`episodes of feeding tube removal or complications seen
`in these patients. Subsequent studies have further dem-
`onstrated the effectiveness and safety of the nasal bri-
`dle.7,8 Additionally, a bridle &dquo;anchor&dquo; has been described
`as a means for increasing the effectiveness of the bridle.’
`It is a segment of tubing cemented around the feeding
`tube at the attachment site to the bridle. By tying the
`bridle to the tube at each end of this &dquo;anchor&dquo;, slippage
`of the junction can be minimized.
`It is surprising then, considering the high incidence of
`feeding tube dislodgement, that nasal bridles are used
`
`infrequently in most hospitals. There are probably sev-
`eral reasons for this, mostly related to problems related
`to the currently used materials and techniques used for
`bridle assembly. These problems will be discussed later.
`In this paper, a new feeding tube bridle and techniques
`for insertion of the device are described which will avoid
`the problems associated with current bridle use. Several
`cases are described in which the newly designed nasal
`bridle provided an effective solution to the problem of
`recurrent feeding tube dislodgement.
`
`DESCRIPTION OF THE DEVICE
`
`The bridle system used in the following patients con-
`sists of an eight French polyurethane tube, 65 cm in
`length whose tips can be attached together by plugging
`the rounded tip of the bridle into the opposite hollow
`end of the bridle tube. (Meer Bridle System8, manufac-
`tured by ENtech, Inc., Lebanon NJ)
`The bridle is secured to the feeding tube with a 4 cm
`width strip of adhesive-backed polyurethane tape which
`is positioned within the patient’s nasal passageway. The
`polyurethane tape is a transparent, thin flap similar to
`the material currently used to cover intravenous catheter
`sites (eg, OpSite‘&dquo;, Smith & Nephew Inc, Columbia, S.C.).
`This material is resistant to loosening by nasal secre-
`tions, does not irritate mucous membranes and seems to
`adhere indefinitely to the feeding tube and bridle. One
`bridle system has the nasoenteral feeding tube preat-
`tached (Fig. 1) for simultaneous placement of the bridle
`and feeding tube (ENtube/Meer Bridle System ENtech,
`Inc.) whereas another system has a bridle alone (Fig. 2)
`which can be placed separately and then attached to the
`feeding tube with the polyurethane tape.
`
`INSERTION OF THE BRIDLE
`
`Excellent detailed descriptions for insertion of jury-
`rigged bridles are available. (7, 8, 9) The following pro-
`cedure is suggested for the insertion of the ne«T1~--de-
`signed bridle systems. Materials used for insertion of the
`bridle are listed in Table I.
`
`Reprint requests: 28625 Northwestern Hwy, Suite 200, Southfield,
`MI 48034.
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`331
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`332
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`FIG. 1. Nasal bridle attached to feeding tube with polyurethane tape
`
`6. While an assistant illuminates the oropharynx with
`a flashlight, depress the patient’s tongue and then extract
`both ends of the bridle through the mouth using the
`McGill forceps (Fig. 3). Plug the blunt tip of the bridle
`into the opposite hollow tip securely (Fig. 4) and then
`pull slowly on one end of the bridle as indicated in Fig.
`5.
`
`7. Attach the bridle to the feeding tube by wrapping
`the polyurethane tape around the two tubes. Then ad-
`vance the feeding tube with the attached bridle until the
`adhesive tape is completely inside the nasal passageway.
`The bridle is now looped around the nasal septum. (The
`loop that this forms should be loose enough so that
`pressure will not be constantly placed on the posterior
`aspect of the nasal septum as this may result in ulcera-
`
`FIG. 2. Nasal bridle.
`
`TABLE I
`Materials used for insertion of the bridle
`
`Procedure
`
`1. The patient should be NPO at least 8 hr prior to
`placement of a bridle.
`2. The patient should be in a sitting position or lying
`in bed with the head of the bed elevated at least 45° in
`order to minimize the risk of emesis. Explain the proce-
`dure to the patient.
`3. Pass the nasoenteral tube through one nostril and
`confirm its position as desired in the usual manner. (If
`the preattached nasoenteral length feeding tube bridle is
`used, tip placement in the small bowel should first be
`confirmed as the tube is advanced until the bridle/feeding
`tube junction is just outside of the nasal columnella then
`this junction is advanced into the nasal passageway as
`the bridle is placed.)
`4. In many patients bridle placement is better tolerated
`with the use of local anesthesia. Spray the oropharynx
`with topical anesthetic such as 10% lidocaine or Ceta-
`caine. One may also apply topical viscous xylocaine to
`both nasal passageways gently using the cotton-tipped
`applicator.
`5. Pass one end of bridle through the same nostril as
`the feeding tube and the other end of the bridle tube
`through the other nostril. If using the preattached bridle,
`one limb of the bridle may be passed simultaneously with
`the feeding tube through one nostril.
`
`FIG. 3. Bridle and feeding tube placed in ipsilateral nasal passageway
`with one tip of bridle extracted through mouth.
`
`FIG. 4. Tips of bridle interconnected.
`
`FiG. 5. Pull in direction of arrow to loop bridle around nasal septum.
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`tion of the latter. The loop should not, however, be large
`enough to allow the patient to place a small finger within
`it.) Tie the bridle at the nasal collumnella with 3-0 silk.
`Cut off excess tubing from the bridle as indicated in Fig
`6.
`
`8. The feeding tube is now securely in place with the
`bridle. The entire device may be completely removed by
`cutting the silk suture off and slowly sliding the nasoen-
`teral tube out. The bridle will slide out right along with
`the feeding tube.
`
`CASE SUMMARIES
`
`The case summaries described in Table II illustrate
`some uses of the new nasal bridle and will serve as
`examples in the subsequent &dquo;Discussion&dquo; section.
`
`DISCUSSION
`
`The above cases illustrate several points with regard
`to the indications for the use of nasal bridles and their
`drawbacks. First of all, each of these patients had suf-
`fered some recent neurological insult and for this reason
`they were unable to swallow adequately and were period-
`ically confused such that they inadvertently might dis-
`lodge their feeding tubes. Patients P.S. and D.B. regained
`the ability to tolerate oral feeding as their neurological
`status improved, whereas it eventually became apparent
`that S.C. and M.P. would not regain the ability to eat. It
`was difficult to determine initially, however, which pa-
`tients would regain the ability to eat so that nasoenteral
`tube feeding was an appropriate short-term solution for
`maintaining nutrition without the risk or cost of paren-
`teral nutrition or gastrostomy. These are the patients
`who are also very likely to dislodge their feeding tubes
`and are, therefore, appropriate patients for use of the
`
`FIG. 6. Bridle and feeding tube in place.
`
`333
`
`nasal bridle. Some of these patients will not regain the
`ability to tolerate oral feeding and in these patients it is
`probably more appropriate to place a feeding gastros-
`tomy. It is, however, usually not possible to determine
`which patients will or will not recover their ability to
`take oral feeding and it is appropriate to use a nasoen-
`teral feeding tube secured with a bridle for a period of 2
`to 6 weeks until this can be determined with more
`certainty. Since PEG (percutaneous endoscopic gastros-
`tomy) tubes can be placed relatively easily in many
`patients, there may be a tendency to place PEG’S initially
`in these patients. Placement of PEG tubes, however, is
`costly and may occasionally result in significant compli-
`cations.lo, 11, 12 Such complications have included local
`infections, fistulae, peritonitis and, rarely, death due to
`sepsis or respiratory failure. Parenteral nutrition, too, is
`both costly and may lead to significant complications
`such as pneumothorax, catheter sepsis and subclavian
`vein thrombosis. It is therefore generally accepted that
`&dquo;when the gut works, use it.&dquo; As illustrated in some of
`these cases, many of these patients do not need to be
`exposed to the increased morbidity of this procedure as
`they will regain their ability to take oral feeding within
`a few weeks.
`Another group of patients in whom bridle use has been
`shown to be useful is in postoperative head and neck
`cancer patients.’ Replacement of a dislodged feeding tube
`in these patients is quite hazardous due to the risk of
`disrupting fresh suture lines when the tube is passed.
`In view of the high incidence of nasoenteral feeding
`tube dislodgement, one would expect bridles to be used
`frequently. This, however, has not been the case in most
`hospitals. The following are four basic reasons for the
`reluctance to use bridles along with a discussion on how
`the new bridle and the above technique for bridle place-
`ment avoids these problems:
`1. The procedure for placing the currently used jury-
`rigged bridles is time-consuming, tedious, cumbersome
`and can be quite difficult in an uncooperative patient.
`Insertion time for the new bridles, however, is much less
`because: (1) the interconnecting tips eliminate the time-
`consuming and technically difficult step of tying the tips
`of the bridle together after they have been extracted from
`the mouth. (2) preconnection of the bridle to the feeding
`tube eliminates another time-consuming step. Alterna-
`tively, the use of adhesive polyurethane tape is quicker
`than suture material for securing the feeding tube to the
`bridle, (3) the availability of a bridle kit decreases the
`time required to gather supplies, (4) adequately anesthe-
`
`TABLE II
`Case summaries
`
`
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`334
`
`tizing the oropharynx and nasal choanae will enhance
`patient compliance during the procedure and allows the
`procedure to progress without patient interference.
`In the above cases, the time required for insertion of
`the bridles varied from 10 min to as long as 35 min. In
`the author’s experience, bridle placement rarely takes
`more than 15 min. If one calculates the amount of time
`required to replace a feeding tube two or three times, it
`will be obvious that the use of bridles will save a sub-
`stantial amount of time and effort for physician and
`nursing staff over the long run. If the tube tip must be
`placed in the small bowel via fluoroscopy or endoscopy
`and confirmed by x-ray even greater amounts of time
`will be saved.
`2. Another reason that bridles are not yet commonly
`used is that there is concern over potential complications
`of the bridle (eg, fracture or ulceration of the nasal
`septum) and patient discomfort during insertion of the
`bridle (eg, gagging). Although fracture of the nasal sep-
`tum has never been reported with bridle use, it is reason-
`able to be concerned about this complication especially
`in elderly, osteoporotic patients. It is likely, however,
`that it is not the strength of the bridle that secures the
`feeding tube but rather the immediate discomfort created
`when the patient pulls even gently on the feeding tube
`bridle that actually prevents tube dislodgement. For this
`reason, it is unlikely that one will have to secure most
`bridles with more than a couple loops of 3-0 suture.
`Those patients who pull hard enough to break the sutures
`should probably have their tubes secured by other means
`or have PEG’s placed.
`The patient A.S. experienced a minor complication
`from his bridle as he developed a pressure ulcer on the
`nasal columnella. This is easily remedied by loosening
`the bridle loop slightly.
`With regard to patient discomfort during the proce-
`dure, as discussed previously, this problem can be mini-
`mized with adequate topical anesthesia and as expertise
`is gained with the procedure.
`3. Some people feel that a bridle looks uncomfortable
`or undignified but patient acceptance has never been a
`problem. When patients’ families understand the risks
`and benefits of bridles us the risks of repeated tube
`dislodgement or other invasive forms of feeding, they are
`usually agreeable to having the bridle used. It is certainly
`less uncomfortable and less undignified to place a bridle
`than to have feeding tubes replaced multiple times.
`4. Lastly, there are several technical problems with the
`current jury-rigged bridles. One is that when the feeding
`tube is secured to the bridle by the currently-used meth-
`ods, an adept patient can pull the feeding tube out by
`pulling on the tube proximal to the site at which it is
`secured to the bridle. This problem is avoided in the new
`bridle by securing the feeding tube to the bridle for a
`distance of at least 4 cm and by positioning this junction
`
`such that it is well within the nasal passageway. Another
`problem is that the feeding tube can slip through the
`sutures which secure it to the bridle and, at times, the
`feeding tube may become compressed and its lumen
`obstructed by the suture which ties the tube to the bridle.
`The new bridle avoids this problem by securing the
`feeding tube to the bridle with a strip of polyurethane
`tape such that obstruction of the tube lumen and slippage
`of the feeding tube is impossible.
`
`CONCLUSIONS
`
`Nasal bridles have been previously demonstrated to be
`safe, effective means for securing nasoenteral feeding
`tubes for patients who are likely to dislodge their feeding
`tubes and for postoperative head and neck cancer pa-
`tients in whom even a single episode of tube dislodgement
`constitutes a major problem due to difficulties with rein-
`serting nasoenteral tubes. With the use of adequate
`assistance and proper instruments, topical anesthetics
`and the newly designed bridle, one may avoid many of
`the shortcomings of the currently used jury-rigged bri-
`dles.
`
`ACKNOWLEDGMENTS
`
`The author wishes to thank Dr. Melvyn Rubenfire for
`his comments on the manuscript.
`
`REFERENCES
`
`1. Jeffers SL, Dorr LA, Meguid MM: Mechanical complications of
`enteral nutrition: prospective study of 109 consecutive patients
`(Abstr). Clin Res 32:233A, 1984
`2. Keohane PP, Attrill H, Jones BJM, et al: Limitations and draw-
`backs of fine bore nasogastric feeding tubes. Clin Nutr 2:85, 1983
`3. Vasquez R, Craig R, Slas T: Performance and acceptability of
`Entriflex feeding tube with hydromer lubricated lumen and mer-
`cury weight and placement stylet. Nutr Support Serv 7:9-11, 1981
`4. Crocker K, Krey S, Steffee W: Performance evaluation of a new
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`5. Meer J. Inadvertent dislodgement of nasoenteral feeding tubes:
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`6. McGuirt WF, Strout JJ: Securing of intermediate duration feeding
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`7. Barrocas A, Jastram C, St. Romain C: The bridle: increasing the
`use of nasoenteric feedings. Nutr Support Serv 2:8-10, 1982
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`9. Forlaw L, Chernoff R: Enteral delivery systems. IN Clinical Nu-
`trition Vol I: Enteral and Tube Feeding, Rombeau J, Caldwell M
`(ed). W.B. Saunders, Philadelphia, 1984, pp 231-233
`10. Torosian M, Rombeau J: Feeding by tube enterostomy. Surg Gy-
`necol Obstet 150:918-927, 1980
`11. Ponsky JL, Aszodi AA: Percutaneous endoscopic jejunostomy. Am
`J Gastroenterol 79:113-116, 1980
`12. Kirby DF, Craig RM, Tsang T, et al: Percutaneous endoscopic
`gastrostomies: a prospective evaluation and review of the literature.
`JPEN 10:155-159, 1986
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