Severity of Illness Influences the Efficacy of Enteral Feeding Route on Clinical Outcomes in Patients with Critical Illness



      Few trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial.


      To test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness.


      A 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes.


      One hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study.


      Patients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as “less severe” and “more severe,” with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20.

      Main outcome measures

      Daily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin.

      Statistical analyses performed

      Two-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes.


      Among less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group.


      To optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jeejeebhoy K.N.
        Enteral nutrition versus parenteral nutrition—The risks and benefits.
        Nat Clin Pract Gastroenterol Hepatol. 2007; 4: 260-265
        • Abou-Assi S.G.
        • Khurana V.
        • Schubert M.L.
        Gastric and postpyloric total enteral nutrition.
        Curr Treat Options Gastroenterol. 2005; 8: 145-152
        • Mazaki T.
        • Ebisawa K.
        Enteral versus parenteral nutrition after gastrointestinal surgery: A systematic review and meta-analysis of randomized controlled trials in the English literature.
        J Gastrointes Surg. 2008; 12: 739-755
        • Marik P.E.
        • Zaloga G.P.
        Gastric versus post-pyloric feeding: A systematic review.
        Crit Care. 2003; 7: R46-R51
        • Neumann D.A.
        • DeLegge M.H.
        Gastric versus small-bowel tube feeding in the intensive care unit: A prospective comparison of efficacy.
        Crit Care Med. 2002; 30: 1436-1438
        • Kortbeek J.B.
        • Haigh P.I.
        • Doig C.
        Duodenal versus gastric feeding in ventilated blunt trauma patients: A randomized controlled trial.
        J Trauma. 1999; 46: 992-998
        • Kearns P.J.
        • Chin D.
        • Muller L.
        • et al.
        The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: A randomized clinical trial.
        Crit Care Med. 2000; 28: 1742-1746
        • Multz A.S.
        • Chalfin D.B.
        • Samson I.M.
        • et al.
        A “Closed” medical intensive care unit (MICU) improves resource utilization when compared with an “Open” MICU.
        Am J Respir Crit Care Med. 1998; 157: 1468-1473
        • Ledeboer M.
        • Masclee Ad A.M.
        • Biemond I.
        • et al.
        Effect of intragastric or intraduodenal administration of a polymeric diet on gallbladder motility, small-bowel transit time, and hormone release.
        Am J Gastroenterol. 1998; 93: 2089-2096
        • Heyland D.K.
        • Dhaliwal R.
        • Drover J.W.
        • et al.
        Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients.
        JPEN J Parenter Enteral Nutr. 2003; 27: 355-373
        • McClave S.A.
        • Martindale R.G.
        • Vanek V.W.
        • et al.
        Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
        JPEN J Parenter Enteral Nutr. 2009; 33: 277-316
        • Knaus W.A.
        • Draper E.A.
        APACHE II: A severity of disease classification system.
        Crit Care Med. 1985; 13: 818-829
        • Gursel G.
        • Demirtas S.
        Value of APACHE II, SOFA and CPIS scores in predicting prognosis in patients with ventilator-associated pneumonia.
        Respiration. 2006; 73: 503-508
        • Sahu S.K.
        • Gupta A.
        • Sachan P.K.
        • Bahl D.V.
        Outcome of secondary peritonitis based on APACHE II score.
        (Internet Journal of Surgery website) (Published 2008. Accessed March 15, 2011)
        • Komatsu S.
        • Shimomatsuya T.
        • Nakajima M.
        • et al.
        Prognostic factors and scoring system for survival in colonic perforation.
        Hepatogastroenterol. 2005; 52: 761-764
        • Chen S.C.
        • Chan K.S.
        • Chao W.N.
        • et al.
        Clinical outcomes and prognostic factors for patients with Vibrio vulnificus infections requiring intensive care: A 10-yr retrospective study.
        Crit Care Med. 2010; 38: 1984-1990
        • Dunham C.M.
        • Frankenfield D.
        • Belzberg H.
        • et al.
        Gut failure-predictor of or contributor to mortality in mechanically ventilated blunt trauma patients?.
        J Trauma. 1994; 37: 30-34
        • Fanny P.
        • J Dimet J.
        • Martin-Lefevre L.
        • et al.
        Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: A prospective before–after study.
        JPEN J Parenter Enteral Nutr. 2010; 34: 125-130
        • McClave S.A.
        • DeMeo M.T.
        • DeLegge M.H.
        • et al.
        North American summit on aspiration in the critically ill patient: Consensus statement.
        JPEN J Parenter Enteral Nutr. 2002; 26: S80-S85
        • Lakshman K.
        • Blackburn G.L.
        Monitoring nutritional status in the critically ill adult.
        J Clin Monitor Comput. 1986; 2: 114-120
        • Montecalvo M.A.
        • Steger K.A.
        • Farber H.W.
        • et al.
        Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings.
        Crit Care Med. 1992; 20: 1377-1387
        • Nguyen N.Q.
        • Ng M.P.
        • Chapman M.
        • et al.
        The impact of admission diagnosis on gastric emptying in critically ill patients.
        Crit Care. 2007; 11: R16
        • Mentec H.
        • Dupont H.
        • Bocchetti M.
        • et al.
        Upper digestive intolerance during enteral nutrition in critically ill patients: Frequency, risk factors, and complications.
        Crit Care Med. 2001; 29: 1955-1961
        • Fennerty M.B.
        Pathophysiology of the upper gastrointestinal tract in the critically ill patient: Rationale for the therapeutic benefits of acid suppression.
        Crit Care Med. 2002; 30: S351-S355
        • Mutlu G.M.
        • Mutlu E.A.
        • Factor P.
        GI complications in patients receiving mechanical ventilation.
        Chest. 2001; 119: 1222-1241
        • Dive A.
        • Moulart M.
        • Jonard P.
        • et al.
        Gastroduodenal motility in mechanically ventilated critically ill patients: A manometric study.
        Crit Care Med. 1994; 22: 441-447
        • McClave S.A.
        • Snider H.L.
        • Lowen C.C.
        • et al.
        Use of residual volume as a marker for enteral feeding intolerance: Prospective blinded comparison with physical examination and radiographic findings.
        JPEN J Parenter Enteral Nutr. 1992; 16: 99-105
        • Metheny N.A.
        • Titler M.G.
        Assessing placement of feeding tubes.
        Am J Nurs. 2001; 101: 36-45
        • Gruenberg D.A.
        • Shelton W.
        • Rose S.L.
        • et al.
        Factors influencing length of stay in the intensive care unit.
        Am J Crit Care. 2006; 15: 502-509
        • Calder P.C.
        • Jackson A.A.
        Undernutrition, infection, and immune function.
        Nutr Res Rev. 1999; 12: 3-29
        • Briassoulis G.
        • Tsorva A.
        • Zavras N.
        • et al.
        Influence of an aggressive early enteral nutrition protocol on nitrogen balance in critically ill children.
        J Nutr Biochem. 2002; 13: 560-569
        • Singhi S.C.
        • Jayashree M.
        Dysharmony of hormonal functions in critically ill.
        Pediatr Crit Care Med. 2009; 10: 131-133


      H.-H. Huang is a doctoral degree candidate, Department of Life Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, Tainan City, Taiwan, and chief, Foodservice Management Division, Department of Food and Nutrition, Taipei Veterans General Hospital, Taipei City, Taiwan; at the time of the study, she was chief, Clinical Nutrition Division, Department of Nutrition, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.


      S.-J. Chang is a distinguished professor, Department of Life Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, Tainan City, Taiwan.


      C.-W. Hsu is an assistant professor, Medicine Department, School of Medicine, National Yang-Ming University, Taipei City, Taiwan, and a visiting doctor, Intensive Care Unit, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.


      T.-M. Chang is a professor of surgery and vice superintendent, Tungs' Taichung MetroHarbor Hospital, Taichung City, Taiwan.


      S.-P. Kang is a nurse, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.


      M.-Y. Liu is chief, Department of Nutrition, Tainan Sin-Lau Hospital, Tainan City, Taiwan.