D Albert Barrocas, MD, FACS, Medical Advisor, Nutritional Support Service, Pendleton Memorial Methodist Hospital
`Clinical Associate Professor, Department of Surgery, Tulane University School of Medicine, Adjunct Associate Professor'
`Department of Nutrition, Tulane University School of Public Health and Tropical Medicine; Charles Jastram, RPh, Clin'.
`ical Pharmacist, Nutritional Support Service, Pendleton Memorial Methodist Hospital; Clare St. Romain, RD, Clinical
`Dietitian, Nutritional Support Service, Pendleton Memorial Methodist Hospital, New Orleans, Louisiana 7CJ 27
`
`The Bridle: Increasing
`the Use of Nasoenteric Feedings
`
`A new technique for the anchoring of nasoenteric tube feedings
`is presented. The silicone rubber nasopharyngeal sling has in(cid:173)
`creased the number of patients who can be nutritionally sup(cid:173)
`ported through the gastrointestinal route, without the probabil(cid:173)
`ity of tube dislodgement. The sling, known as the bridle, has
`proven to be easily inserted and safe for prolonged periods of
`time. By permitting more patients to be tube fed and allowing
`their nutritional support to be rendered at home, the cost of this
`type of support can be decreased.
`
`Figure 1: Materials for inserting the bridle.
`
`INTRODUCTION
`Recent studies have indicated a great number of nutrition(cid:173)
`al deficiencies may be found in hospitalized patients today.I
`The assessment of various nutritional abnormalities and ~heir
`treatment with parenteral nutrition has significantly reduced
`the morbidity and mortality in these patients. 2 Metabolic ab(cid:173)
`normalities and catheter sepsis are associated complications
`of parenteral nutrition. 3 Intravenous nutritional support is
`expensive and should be reserved for patients without suffi.
`cient gastrointestinal function to meet their nutritional re(cid:173)
`quirements.
`Proper techniques for administration of liquid formulas
`through nasoenteric tubes have been developed over the past
`decade.4•5 Use of the gastrointestinal tract is the safest, most
`economic and effective method of feeding a patient. The fact
`that a patient cannot or will not eat is not a reason to exclude
`the enteral route completely from consideration in nutrition(cid:173)
`al support.6
`The development of continuous pump feedings with lac(cid:173)
`tose-free formula liquids has eliminated the majority of prob(cid:173)
`lems associated with bolus feedings such as cramping, diar(cid:173)
`rhea, distention, and dumping syndrome.7 The soft, small(cid:173)
`bore feeding tubes with weighted tips have greatly enhanced
`tube placement and patient comfort and tolerance. 8 The ma(cid:173)
`jor problem encountered with these tubes is their ease of dis(cid:173)
`placement. Many tubes have been removed by disoriented
`or confused patients; coughing and gagging can also displace
`these tubes. The aforementioned often will lead to the tem(cid:173)
`porary or permanent termination of feeding. Until recently,
`the alternatives available for such patients were parenteral
`nutrition at higher cost and risks or a surgical procedure for
`the placement of an ostomy for feeding purposes. 9
`
`Figure 2: Silicone rubber tubing ends introduced into each nostril.
`
`8 NUTRITIONAL SUPPORT SERVICES, Volume 2, Number 8, August 1982
`
`Figure 3: Both ends retrieved with forceps from the hypopharynx
`and brought out through the mouth.
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`The development of a nasopharyngeal sling for anchoring
`termed the bridle by Luther and Armstrong, 10 has al(cid:173)
`nasoenteric nutritional support to be used with less
`of tube displacement. The bridle has increased the
`of patients managed through the enteral route.
`TECHNIQUE
`The technique was first described in 1981.10 Since that time,
`i(we have used it with slight modifications. A minimal amount
`~ofequipment(an 18" length of small base silicone rubbertub(cid:173)
`::;ing, a' McGill or ~imilar forceps, and 00 silk suture) is neces:
`fsary to create the bridle (Figure 1 ).
`.
`After a thorough explanation of the procedure, the patient
`is allowed to sit up or the head of the bed is raised to 45°. The
`t nostrils are checked for patency to establish which to use for
`.,:inserting the feeding tube. Both nostrils are lubricated with
`topical anesthetic. The hypopharynx is sprayed with a top(cid:173)
`ical anesthetic to decrease gagging. One end of the silicone
`rubber tube is placed in one nostril gently pushing the tube
`tip down and back. The other end of the tube is placed in the
`'opposite nasal passage in the same manner (Figure 2). When
`each limb has been advanced approximately 8", the patient
`js asked to open his mouth. Both ends of the tubing should
`••.• be visible in the hypopharynx. The two free ends are grasped
`with the forceps, pulled out through the mouth (Figure 3),
`and sutured together (Figure 4). The loop of tubing across the
`columella is then pulled gently, bringing the tied ends of the
`
`tube back to the nasopharynx and eventually to the posterior
`aspect of the nasal septum (Figure 5). One side of the loop is
`then advanced through one nasal passage while the other side
`is pulled, bringing the sutured ends through the nasal passage
`(Figure 6). Next, the tied ends are cut and the tubing is tied
`to itself allowing enough room between the loop and the sep(cid:173)
`tum to prevent pressure necrosis (Figure 7). Silk ties are placed
`in front and back of the knot to prevent slippage (Figure 8).
`The excess tubing is cut and the bridle is completed (Figure
`9).
`The enteric tube is then inserted through the preselected
`nasal passage and, once .in place, anchored to the bridle by
`silk sutures and adhesive tape (Figures 10 and 11 ). Attempts
`at pulling the tube will result in gentle traction of the posteri(cid:173)
`or aspect of the nasopharynx. Serious dislodgement by cough(cid:173)
`ing, sneezing, or gagging is usually prevented by the fixed
`point of the tube.
`
`CARE
`The bridle and tube should be checked every eight hours.
`Tube position and bridle looseness should be noted. The ten(cid:173)
`dency towards crusting can be avoided by use of topical anti(cid:173)
`biotic ointments. The adhesive tape should be replaced if
`loose or wet.
`
`RESULTS
`To date, we have employed this technique in 10 patients
`over the past year with encouraging results. The bridle has
`
`Figure 4: Ends sutured.
`
`Figure 5: Sutured ends being pulled back to hypo, and nasopharynx.
`
`Figure 6: Sutured ends brought out through a nasal passage.
`
`Figure 7: Tube tied to itself after cutting suture connecting ends.
`
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`allowed tube placement for periods up to three months and
`has facilitated the early discharge of patients enterally sup(cid:173)
`ported at home wth further reduction in costs. One tube was
`pulled by a rather enterprising patient who managed to pull
`the tube distal to the anchoring suture in the bridle. Since
`institution of wrapping the tube and bridle with adhesive,
`this problem has not recurred.
`Luther (personal communication) and Luther and Arm(cid:173)
`strong (in preparation)6 have employed the bridle on well over
`500' patients and for as long as 11 months. Their rate of suc(cid:173)
`cess and satisfaction has been similar to ours. The use of the
`technique has, been extended to include nonfeeding tubes
`(i.e., nasogastric suction tubes) as well.
`SUMMARY
`Enteral nutrition has emerged as a safer, more economic
`and physiologic mode of nutritional support than the intra(cid:173)
`venous counterpart. In recent years, small, soft, pliable tubes
`for nasoenteric feedings have been developed, facilitating
`the use of the gastrointestinal tract in nutritional support.
`However, because of their increased flexibility, their dislodge(cid:173)
`ment, particularly in uncooperative patients, has precluded
`their use.
`The development of a nasopharyngeal anchoring sling
`known as the bridle has allowed for the increased use of the
`nasoenteric route of nutritional support. The technique is
`easily applied with minimal equipment. Results to date have
`
`been gratifying. The technique has resulted in reduced costs
`not only from the use of the enteral route, but also from th'
`facilitation of home enteral nutritional support.
`e
`Acknowledgments. The authors wish to express their appreciation to C
`0. Decker and Cindy C. Stevenson for preparation and editorial assistan ue
`and Allen Dufour for photography.
`re
`
`REFERENCES----------------
`0 1. Butterworth CE. The skeleton in the hospital closet. Nutr Toda)' PP
`4-8, March/ April 1974.
`·
`D 2, Blackburn CL, Bistrian BR, et al. Nutritional and metabolic assess.
`ment of the hospitalized patient. JPEN 1(1):11-22, 1977.
`D 3. Grant JP. Handbook of Total Parenteral Nutrition. Philadelphia: W.B.
`Saunders Co., 1980.
`D 4. Barrocas A. ABC's of tube feeding. La State Med Soc 130(4):83-86
`1978,
`'
`D 5. Rombeau JL, Barnt LR. Enteral nutrition therapy. Surg Clin North
`Am pp. 605-620, June 1981.
`D 6. Heymsfield SB, Bethel RA, et al. Enteral hyperalimentation: An al.
`ternative to central venous hyperalimentation. Ann Intern Med 90:63-71
`1979,
`'
`D 7. Shils ME, Bloch AS, Chernoff R. Liquid formulas for oral a,1d tube
`feedings. JPEN 1(2):89-96, 1977.
`D 8, Dobbie RP, Hoffmeister JA. Continuous pump-tube enteric hyperali(cid:173)
`mentation. Surg Gynecol Obstet 143:273-276, 1976.
`D 9. Torosian MH, Rombeau JL. Feeding by tube enterostomy. Surg Gy.
`necol Obstet 150:918-927, 1980.
`D 10. Luther RW, Armstrong CR. The bridle: A method of securing feed(cid:173)
`ing tubes, Poster Session Presentation, American Society of Parenteral and
`ffS-,j
`Enteral Nutrition, Clinical Congress, New Orleans, LA, 1981.
`
`Figure 8: Ties applied in front and back of knot to prevent slippage. Figure 9: Bridle completed after cutting excess tubing.
`
`Figure 10: Feeding tube inserted and secured to bridle by silk ties. Figure 11: Adhesive tape applied for reinforcement.
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