CARDIAC NURSING

Development and evaluation of standardized protocol to prevent

nasoenteral tube obstruction in cardiac patients requiring enteral
nutrition with restricted fluid volumes
Claudia ST Matsuba MSN, RN
Nurse in Intensive Care Unit, Federal University of São Paulo, Hospital do Coração/Associação do Sanatório Sı́rio, São Paulo,
Brazil

Maria GR De Gutiérrez PhD, RN

Advisor of the Study, Assistant Professor, Nursing Department, Federal University of São Paulo, São Paulo, Brazil

Iveth Y Whitaker PhD, RN

Co-Advisor of the Study, Assistant Professor, Nursing Department, Federal University of São Paulo, São Paulo, Brazil

Submitted for publication: 2 November 2005

Accepted for publication: 8 July 2006

Correspondence: E R R E Z M G R & W H I T A K E R I Y ( 2 0 0 7 ) Journal of

M A T S U B A C S T , D E G U T I É
Claudia S.T. Matsuba Clinical Nursing 16, 1872–1877
Rua Antonio Loureiro Development and evaluation of standardized protocol to prevent nasoenteral tube
594 ap.73-D
obstruction in cardiac patients requiring enteral nutrition with restricted fluid volumes
São Paulo
Aims and objectives. This study sought to assess the impact of a standardized
Brazil
Telephone: þ55 11 5565 2502
protocol to maintain nasoenteral tube (NET) patency in patients requiring fluid
E-mail: csmatsuba@uol.com.br restriction and identify factors associated with tube patency.
Background. Nasoenteral tube obstruction may interrupt nutritional support and
prohibit drug administration. Balancing NET patency in the context of fluid
restriction can be a challenge.
Design and methods. The impact of the standardized protocol was assessed by using
a quasi-experimental design and an historical control.
Results. Sixty patients receiving nasoenteral feeding as part of their clinical man-
agement were enrolled in the study. Nasoenteral obstruction was 8Æ3%, showing a
reduction from the 17Æ4% observed in the baseline data collection. A key factor
associated with tube obstruction was sounding of an infusion pump alarm reflecting
the tube patency issues.
Conclusions. While mindful of the limitations of probability sampling, the imple-
mentation of a standardized protocol accompanied by staff training reduced the
rates of NET obstruction.
Relevance to clinical practice. On the basis of these findings, we conclude that it is
possible to maintain the patency of small bore tubes, even in the presence of fluid
restriction, with a standardized protocol to guide clinical management.

Key words: enteral nutrition, gastrointestinal intubation, heart disease, nurses,

nursing, nursing care

1872  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
doi: 10.1111/j.1365-2702.2006.01793.x
Cardiac nursing
Introduction
Enteral nutrition therapy (ENT) is a resource frequently
used in intensive care units (ICUs) to maintain an optimal
nutritional status or to support feeding of a patient who is
unable to ingest food orally. This approach has been
adopted due to advantages such as shortened hospitaliza-
tion period and decreased complications and hospital
costs.
In view of the technological advances, equipment for this
therapy requires strict quality control from the enteral
solution to the devices used for its administration. Despite
this strict approach, nasoenteral feeding tube obstruction is a
problem that may be worsened by several factors, such as
different types of enteral solutions, tube quality, drugs
administered through this route, methods of administration
and reflux caused by delayed gastric emptying.
Nasoenteral tube (NET) obstruction may require tube
replacement, involving discomfort for the patient, increased
nursing time and additional costs, including materials and
radiography (Metheny & Titler 2001, Kesek et al. 2002). A
further potential complication of the tube replacement is the
inadvertent positioning in the respiratory tract (Huerta &
Puri 2000, Stroud et al. 2003). Therefore, it is critical to
implement strategies to maintain tube patency, particularly in
those patients where there is a need to observe a fluid
restriction.
A previous study carried out with cardiac patients
hospitalized in ICU and submitted to ENT showed a
17Æ4% tube obstruction incidence and the main cause was
simultaneous drugs administration (Matsuba et al. 2001).
These findings are supported by literature, that reports
enteral formulae agglutination when in contact with solu-
tions whose pH is £4Æ6 during more than 35 seconds
(Hofstetter & Allen 1992) and the immediate formation of
a gelatinous mass after the enteral formulae come in
contact with certain medications (Merino et al. 1999,
Montejo et al. 2001).
Another aspect observed by Matsuba et al. (2001) was that
the nursing team did not use a standardized procedure to
maintain nasoenteral feeding tube patency. This potentially
caused the high obstruction rates observed.
On the basis of these findings, we have developed,
implemented and evaluated the outcomes of a standardized
procedure to maintain nasoenteral feeding tube patency in
cardiac patients whose clinical conditions require strict fluid
control, to confirm whether or not the implementation of that
protocol might contribute to a reduction in that 17Æ4%
obstruction rate (Matsuba et al. 2001).
Thus, the objectives of this study were:
 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Development and evaluation of standardized protocol
1 To develop a standardized protocol to maintain nasoen-
teral feeding tube patency in cardiac patients requiring
enteral nutrition with restricted fluid volumes.
2 To evaluate the implementation of such protocol using
tube obstruction rate as an outcome measure.
3 To identify a possible association between this complica-
tion and the following variables: enteral solution formu-
lation; changes in enteral solution infusion; difficulties in
tube drug administration; and pharmaceutical drug
preparations.
Methods
This intervention study using a quasi-experimental design
and an historical control was carried out at the ICU and
Coronary Care Unit of a private Cardiology hospital in São
Paulo City, Brazil.
The inclusion criteria were: patients with ENT prescription
through an 8-French nasoenteral feeding tube administered
by a continuous, rotating peristaltic pump-assisted infusion
system, presence of heart disease, fluid restriction, age P 18 -
years and written approval of the patient or someone legally
capable and responsible.
Sixty patients (61Æ6 % male and 38Æ4% female) met the
inclusion criteria and represented 83Æ3% of patients who
received ENT during the study period. After approval of
the project by the Research Ethics Committees of both the
Hospital and the Federal University of São Paulo, data were
collected from January to July 2002 by seven research
assistants, who were trained in the standardized procedures.
Comparative baseline data were obtained in a previous
assessment of tube obstruction in patients undergoing ENT
during six months before the implementation of the protocol
to be tested (Matsuba et al. 2001). These data were used to
establish a six-month period for data collection with a
convenience sample.
Matsuba et al. (2001) showed that there were different
routines for NET care in the ICUs where data were collected.
To develop the protocol for this research, these routines were
analysed along with literature data on the subject and the
researchers proposed the protocol presented in Table 1.
Before data collection, all members of the nursing staff
(n ¼ 137) from the units where the study was carried out
were instructed about the implementation of the feeding tube
patency maintenance protocol. Instructions were provided
during 40–60-minute classes and the techniques were
demonstrated in simulated situations.
Data collected were electronically processed using EXCEL 
and STATA  (version 7Æ0) programs. Fisher’s exact test was
used to determine if there are associations between the NET
1873
CST Matsuba et al.

Table 1 Nasoenteral tube patency maintenance protocol
Flushing with 10-ml Flushing with 5-ml
filtered water filtered water
Flushing every six hours Before drug or complement
administration
After drug or complement Before enteral solution
administration infusion beginning
Immediately after enteral
solution interruption
obstruction and each one of the following variables: enteral
solution formulation (high osmolality and high calorie
density), changes in enteral solution infusion (flow velocity
reduction by nurse, temporary discontinuation and enteral
solution flow reduction identified by pump alarm sound),
difficulties in drug administration (in dilution or in the
flushing of the feeding tube) and pharmaceutical drug
preparation (in tablets, coated pills, powder). A level of
significance of p < 0Æ05 was adopted.
Results
Of the 60 patients participating in the study, 44 (73Æ3%)
underwent medical treatment and 16 (26Æ7%) underwent
surgical treatment, mainly because of heart failure and heart
valve surgery, respectively. The average age of subjects was
73 years (SD ¼ 13), with almost half aged older than
60 years. The main indication for introducing ENT was
orotracheal intubation (56Æ7%). Other less frequent indica-
tions were: dysphagia (13Æ3%), anorexia (10Æ0%) and oral
supplement (10Æ0%).
The feeding tube had a predominantly gastric location,
daily confirmed by abdominal radiography (56 patients –
93Æ3%) and its permanence ranged mostly from 2 to 7 days,
similar to the use of enteral solution duration, as observed in
58Æ3% and 60Æ0% of the patients, respectively. The NET
obstruction incidence during the follow-up period was 8Æ3%
(five patients) and only changes in enteral solution infusion
and difficulties in drug administration presented a statistically
significant association with the occurrence of obstruction.
Regarding the changes in enteral solution infusion, Table 2
shows that, among the variables considered, only enteral
solution flow reduction identified by pump alarm sound was
significantly associated with NET obstruction (p ¼ 0Æ006).
The sample sizes (55 subjects with no obstruction and five
with it) allowed a test power of 77% for this finding.
As for the difficulties in drug administration shown in
Table 3, only difficulties in feeding tube flushing were
observed in three out of five patients with an obstructed
tube. Thus, this variable was highly associated with this event
and, therefore, considered a predictive factor of NET
obstruction (p < 0Æ001), a result assured by a test power of
95%.
No association was observed among NET obstruction,
enteral solution formulation and pharmaceutical drug pre-
paration (Table 4).
Discussion
The results of the present study showed an 8Æ3% rate of NET
obstruction in the sample studied, demonstrating a reduction
in the 17Æ4% rate previously found (Matsuba et al. 2001).
The reduction of almost a half (47Æ7%) in rates of NET
obstruction may be related to the result of the protocol
implementation and staff training. This rate compares
favourably with previously reported data in literature for it
corresponds to the lowest third of rates observed in those
studies that ranged from 4Æ0 to 35Æ0% (Marcuard & Stegall

Table 2 Distribution of cardiac patients

Feeding tube obstruction
Changes in enteral according to alterations in solution infusion
solution infusion No (n %) Yes (n %) Total (n %) p and nasoenteral tube obstruction,
São Paulo, 2002
Flow velocity reduction by nurse
No 38 (69Æ1) 4 (80Æ0) 42 (70Æ0) >0Æ999
Yes 17 (30Æ9) 1 (20Æ0) 18 (30Æ0)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)
Temporary discontinuation
No 22 (40Æ0) 3 (60Æ0) 25 (41Æ7) 0Æ640
Yes 33 (60Æ0) 2 (40Æ0) 35 (58Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)
Enteral solution flow reduction identified by pump alarm sound
No 55 (100Æ0) 3 (60Æ0) 58 (96Æ7) 0Æ006
Yes 0 (0Æ0) 2 (40Æ0) 2 (3Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)

1874  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
Cardiac nursing Development and evaluation of standardized protocol

Table 3 Distribution of cardiac patients

Feeding tube obstruction
according to difficulties in medication Difficulties in drug
administration and nasoenteral tube administration No (n %) Yes (n %) Total (n %) p
obstruction, São Paulo, 2002
In the dilution
No 46 (83Æ6) 3 (60Æ0) 49 (81Æ7) 0Æ224
Yes 9 (16Æ4) 2 (40Æ0) 11 (18Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)
In the flushing of the feeding tube
No 55 (100Æ0) 2 (40Æ0) 57 (95Æ0) <0Æ001
Yes 0 (0Æ0) 3 (60Æ0) 3 (5Æ0)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)

Table 4 Distribution of cardiac patients

Feeding tube obstruction
according to the pharmaceutical drug Pharmaceutical drug
preparation and nasoenteral tube obstruc- preparation No (n %) Yes (n %) Total (n %) p
tion, São Paulo, 2002
Tablets
No 18 (32Æ7) 1 (20Æ0) 19 (31Æ7) 0Æ999
Yes 37 (67Æ3) 4 (80Æ0) 41 (68Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)
Coated pills
No 49 (89Æ1) 3 (60Æ0) 52 (86Æ7) 0Æ128
Yes 6 (10Æ9) 2 (40Æ0) 8 (13Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)
Powder
No 54 (98Æ2) 4 (80Æ0) 58 (96Æ7) >0Æ999
Yes 1 (1Æ8) 1 (20Æ0) 2 (3Æ3)
Total 55 (100Æ0) 5 (100Æ0) 60 (100Æ0)

1990, Sriram et al. 1997, Alves et al. 1999, Thomson et al.
2000, Pancorbo-Hidalgo et al. 2001). These results represent
an important improvement in nursing care for nutritional
support of cardiac patients under fluid restriction, for they
offer a possibility to use less water volume to maintain small-
bore tube patency.
Regarding the causes of NET obstruction, the change in
enteral solution infusion (specifically enteral solution flow
reduction identified by infusion pump alarm sound) was the
observed event in two out of the five patients whose NET was
obstructed.
Several papers show the importance of using infusion
pumps both to reduce gastric and intestinal discomfort and to
assure the maintenance of prescribed volume and dripping
accuracy (Mateo 1996, Jones & Guenter 1997, Stroud et al.
2003). Enteral solution administration with no infusion
pump use may lead to dripping inaccuracy, causing up to
50% flow reduction, even using administration maximum
velocity, exposing patients to the enteral tube obstruction risk
(Krupp & Heximer 1998, Montejo et al. 2001).
The second variable associated with tube obstruction was
the difficulty in drug administration, evidenced by the
resistance found in the feeding tube flushing, suggesting that
this event can be one of the first obstruction signs. Although
protocols are checked to avoid enteral tube obstruction and
nurses follow an enteral tube flushing routine, a great variety
in practice is seen that can contribute to the tube obstruction
occurrence.
Enteral tube flushing with filtered water is one of the
procedures used by nursing staff to maintain tube patency.
Two aspects related to NET flushing must be considered: the
volume of fluid and when it should be performed.
As for fluid volume, we observed in our clinical practice a
lack of definition on the appropriate volume to maintain
patency of enteral tubes according to their different bores.
Although 20–30 ml of water is widely described in tube
patency maintenance literature (Sriram et al. 1997, Krupp &
Heximer 1998, Beckwith & Feddema 2004, Reising & Neal
2005), in this study, we decided to use 5–10 ml of filtered
water volumes, even between drug administrations, as
recommended by Varella et al. (1997) and Thomson et al.
(2000) and all the patients were using 8-French bore tubes.
The 8Æ3 % obstruction rate obtained represented a good
performance, when compared with the findings of Pancorbo-

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 1875
CST Matsuba et al.
Hidalgo et al. (2001), whose rate was 12Æ5% using 10 and 12
French bore tubes and a 20–30 ml of filtered water flushing
protocol.
Regarding the appropriate moments to perform tube
flushing, this procedure should be carried out at regular
intervals to prevent or reduce the formula residue adherence
to the lumen, as well as before and after drug administration
in order to prevent drug-nutrient interactions (Lord 2003,
Beckwith & Feddema 2004).
During a study to evaluate enteral tube flushing standardi-
zation by nurses, Mateo (1996) observed a wide variety of
procedures and even a great percentage of nurses that did not
use any. Among the activities performed, this author reported
tube flushing before enteral solution infusion (29%), after
enteral solution infusion (43%) and between drug adminis-
trations (38%).
The protocol used in the present study (Table 1) estab-
lished a routine of flushing with 10 ml of filtered water every
six hours, along with 5 ml flushing before and 10 ml after
drugs administration or the enteral solution interruption and
restoration. This routine assured the tube cleaning during
the interval between procedures regarding the medications
and/or the beginning of infusion. We believe this was an
important issue to assure the low obstruction rate found.
Another aspect of enteral tube obstruction that must be
considered is related to the drugs prescribed to the patient in
oral regimen. It is known that several tube-administrated
drugs can represent an increased risk to its obstruction, due
both to their presentation form and possible incompatibility
to enteral formula. Beckwith and Feddema (2004) highlight
enteral drug administration difficulty because of obstruction
risk, drug effectiveness reduced by interactions and calorie
approach commitment to temporary suspension necessary for
some drugs.
Belknap et al. (1997) and Thomson et al. (2000)
observed that enteral tube obstruction caused by drugs
use can occur in 15% of patients. Another research carried
out in Brazil showed that out of 17Æ4% of patients
presenting NET obstruction, 87Æ5% had been prescribed
with tablets (Matsuba et al. 2001). Tablets, coated pills,
syrup and powder are the drugs presentation forms that can
cause more tube obstruction (Guenter et al. 1997, Thomson
et al. 2000). Tablets do not allow complete maceration and
proper dilution, as their coating characteristic is suitable for
gastric protection; coated pills were prepared to have a
longer action and even pulverized can be associated to
enteral solution waste and can cause obstruction; although
syrups are fluid, they have low pH with gelatinous mass
formation risk when contacting enteral formula; and
powder, when not diluted in enough water volumes, can
1876  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
cause fast tube obstruction (Krupp & Heximer 1998, Miller
& Miller 2000).
To avoid enteral tube obstruction by drug use, it is
recommended that a pharmacist participates and makes the
follow-up of protocols development for drug administration
by enteral tube to assure their effectiveness. In addition, it is
also recommended to implement a wide nursing staff training
program showing the protocol application importance and
including: all types of drug dilution; the need of temporary
enteral solution suspension; tube types; use of other routes
(oral, i.v., i.m. ways); drugs absorption sites; and the
evaluation of drugs action (Belknap et al. 1997, Thomson
et al. 2000, Reising & Neal 2005).
This study showed the need for a continuous monitoring in
patients undergoing enteral nutritional therapy and following
up a nursing protocol to reduce enteral tube obstruction
occurrence. It was also observed that tube obstructions can
be influenced by several factors that must be properly
addressed. The research also demonstrated that it is possible
to use a reduced water volume to maintain tube patency in
cardiac patients even using several drugs in it, which is an
important development in nutritional support area for
patients under strict fluid restriction.
Nevertheless, the absence of consensus found in tube
flushing literature shows that further clinical trials are
required to verify the relation between different tube bores
and the ideal volume of water, NET flushing frequency and
other variables related to patency maintenance of nasoenteral
feeding tube, to guarantee patients security and the nursing
practice effectiveness by using evidence-based protocols.
Conclusions
Comparing the rate of NET obstruction found in baseline
data (17Æ4%) and the 8Æ3% rate obtained after implementing
a protocol with standardized procedures to maintain tube
patency, there was a 47Æ7% reduction in occurrences of this
mechanical complication. Although this positive outcome
cannot be considered as evidence of the protocol effectiveness
due to the study design limitations, for it did not have a
control group and random sample, the 8Æ3% rate of NET
obstruction may be considered low when compared with the
4Æ0 to 35Æ0% rates found in literature. Among the variables
studied, only the enteral solution flow reduction and the
difficulty in irrigating the feeding tube showed a significant
association with the obstruction. The low obstruction rate
was achieved as a result of several factors, including the
elaboration of a specific tube patency maintenance protocol,
extensive nursing staff training, the equipment used in this
procedure and the strict protocol application. Another aspect
Cardiac nursing Development and evaluation of standardized protocol

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