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Jonathan Benjamin Wilfong
Fletcher Allen Heath Care
March 18, 2014
Jonathan Benjamin Wilfong
Fletcher Allen Heath Care
March 18, 2014
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
 39 y/o W w a history of schizophrenia
 s/p 19-day ICU course for influenza pneumonia
and secondary MRSA pneumonia
 resolving AKI and hypoxic respiratory failure
 Laryngeal and esophageal paralysis post-
extubation impairs speech and swallow
 16 kg weight loss in the last month
 NG tube in place for last 14 days
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
 “Malnourished or at risk of malnutrition and have
1) inadequate or unsafe oral intake, and a
functional, 2) accessible gastrointestinal tract.”
 Long or unpredictable duration
 Preferred route for feeding of indeterminate
duration in patients with dysphagia?
 Risks and rates of complication associated with
each intervention?
Should we use PEG or NG tube, why or
why not?
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
Percutaneous endoscopic gastrostomy
versus nasogastric tube feeding for
adults with swallowing disturbances
(Review)
Gomes Jr CAR, Lustosa SAS, Matos D, Andriolo RB,
Waisberg DR, Waisberg J
March 14, 2012 Cochrane Database Systematic Review
 Systematic review of the literature
 RCTs comparing NG tube to PEG
 Dysphagia as indication
 Adults, all primary diagnoses included
 Study bias assessment
 Measures of Treatment Effect
◦ Risk Ratio for dichotomous variables
◦ Mean Difference w CI for continuous variables
◦ Heterogeneity of studies, I2
◦ Sensitivity analysis based on intention to treat
 474 records identified
◦ 456 not comparing interventions
 18 assessed
◦ 3 inappropriate study design (Retrospective)
 9 included in meta-analysis
 PEG
◦ n = 345
◦ Mean age = 56
 NG
◦ n = 341
◦ Mean age = 65
 Follow-up time: 4 weeks – 6 months
 Included diagnoses:
◦ Cancer, Neurological, ENT, Stroke, VAP
 Primary: Intervention failure
 Secondary
◦ Nutritional status
◦ Mortality
◦ Adverse events
◦ Time on Enteral Nutrition
◦ Quality of life
◦ Length of stay
◦ Cost
TF route
Treatment Failure (n = 314)
◦ PEG 12.7%
◦ NG 39.87%
◦ RR 0.24 (0.8-0.76), p = 0.01
◦ I2
= 0.68 (corrected by sub-group of PEG)
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup
Defined as any event leading to failure to introduce the tube,
recurrent displacement, and treatment interruption
Mortality (n = 584)
◦ PEG: 37.24%
◦ NG: 35.71%
◦ RR 0.96 (0.64-1.44), p = 0.84
◦ I2
= 0.38
Complications (n = 503)
◦ PEG 42.0%
◦ NG 42.68%
◦ RR 1.00 (0.93-1.11), p = 0.93
◦ I2
= 0.0
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup
Defined as complication not due to other studied factors. i.e
aspiration, hemorrhage, fistula, wound infection, etc.
Pneumonia (n = 585)
◦ PEG 32.53%
◦ NG 39.25%
◦ RR 0.84 (0.61-1.14), p = 0.26
◦ I2
= .61
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup
Survival
◦ Means Difference 4.30 (3.28-5.32), p < 0.00001
◦ Favoring PEG
Clarification of Terms
I2
: likelihood the difference is due to study heterogeneity
Relative Risk: ratio of the probability of an event occurring in an
exposed group to the probability of the event occurring in a
comparison, non-exposed group
Means Difference: the "average" or "mean", formally the expected
value, of the absolute difference of two random variables
TF route
TF route
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
 Lower rate of treatment failure in PEG
 Benefit in neurological disease
 Trend toward increased risk for PNA in NG
 Higher mortality in NG group
◦ MD 4.3 years
 No significant difference in complication rate
 No significant difference in proximal clinical
endpoints noted (i.e. nutrition)
 Adequately powered for primary outcome
 Overall limited bias, high-quality data
 Clinically relevant outcomes
 Generalizable given patient population
 Concealment bias
 Significant heterogeneity for most outcomes
 Small patient numbers
 Under-powered for subgroup analysis
 High loss-to-follow-up
 No association of event rates over time
1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions
 Lower risk of treatment failure in PEG
◦ Significant for neurological diseases
 No difference in complications
 Increased risk of pneumonia in NGT?
 PEG associated with longer survival

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TF route

  • 1. Jonathan Benjamin Wilfong Fletcher Allen Heath Care March 18, 2014
  • 2. Jonathan Benjamin Wilfong Fletcher Allen Heath Care March 18, 2014
  • 3. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 4. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 5.  39 y/o W w a history of schizophrenia  s/p 19-day ICU course for influenza pneumonia and secondary MRSA pneumonia  resolving AKI and hypoxic respiratory failure  Laryngeal and esophageal paralysis post- extubation impairs speech and swallow  16 kg weight loss in the last month  NG tube in place for last 14 days
  • 6. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 7.  “Malnourished or at risk of malnutrition and have 1) inadequate or unsafe oral intake, and a functional, 2) accessible gastrointestinal tract.”  Long or unpredictable duration
  • 8.  Preferred route for feeding of indeterminate duration in patients with dysphagia?  Risks and rates of complication associated with each intervention? Should we use PEG or NG tube, why or why not?
  • 9. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 10. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances (Review) Gomes Jr CAR, Lustosa SAS, Matos D, Andriolo RB, Waisberg DR, Waisberg J March 14, 2012 Cochrane Database Systematic Review
  • 11.  Systematic review of the literature  RCTs comparing NG tube to PEG  Dysphagia as indication  Adults, all primary diagnoses included  Study bias assessment  Measures of Treatment Effect ◦ Risk Ratio for dichotomous variables ◦ Mean Difference w CI for continuous variables ◦ Heterogeneity of studies, I2 ◦ Sensitivity analysis based on intention to treat
  • 12.  474 records identified ◦ 456 not comparing interventions  18 assessed ◦ 3 inappropriate study design (Retrospective)  9 included in meta-analysis
  • 13.  PEG ◦ n = 345 ◦ Mean age = 56  NG ◦ n = 341 ◦ Mean age = 65  Follow-up time: 4 weeks – 6 months  Included diagnoses: ◦ Cancer, Neurological, ENT, Stroke, VAP
  • 14.  Primary: Intervention failure  Secondary ◦ Nutritional status ◦ Mortality ◦ Adverse events ◦ Time on Enteral Nutrition ◦ Quality of life ◦ Length of stay ◦ Cost
  • 16. Treatment Failure (n = 314) ◦ PEG 12.7% ◦ NG 39.87% ◦ RR 0.24 (0.8-0.76), p = 0.01 ◦ I2 = 0.68 (corrected by sub-group of PEG) ◦ ITT: RR 0.51 (0.31- 0.83) ◦ Statistically significant only in neurological subgroup Defined as any event leading to failure to introduce the tube, recurrent displacement, and treatment interruption
  • 17. Mortality (n = 584) ◦ PEG: 37.24% ◦ NG: 35.71% ◦ RR 0.96 (0.64-1.44), p = 0.84 ◦ I2 = 0.38
  • 18. Complications (n = 503) ◦ PEG 42.0% ◦ NG 42.68% ◦ RR 1.00 (0.93-1.11), p = 0.93 ◦ I2 = 0.0 ◦ ITT: RR 0.51 (0.31- 0.83) ◦ Statistically significant only in neurological subgroup Defined as complication not due to other studied factors. i.e aspiration, hemorrhage, fistula, wound infection, etc.
  • 19. Pneumonia (n = 585) ◦ PEG 32.53% ◦ NG 39.25% ◦ RR 0.84 (0.61-1.14), p = 0.26 ◦ I2 = .61 ◦ ITT: RR 0.51 (0.31- 0.83) ◦ Statistically significant only in neurological subgroup
  • 20. Survival ◦ Means Difference 4.30 (3.28-5.32), p < 0.00001 ◦ Favoring PEG Clarification of Terms I2 : likelihood the difference is due to study heterogeneity Relative Risk: ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a comparison, non-exposed group Means Difference: the "average" or "mean", formally the expected value, of the absolute difference of two random variables
  • 23. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 24.  Lower rate of treatment failure in PEG  Benefit in neurological disease  Trend toward increased risk for PNA in NG  Higher mortality in NG group ◦ MD 4.3 years  No significant difference in complication rate  No significant difference in proximal clinical endpoints noted (i.e. nutrition)
  • 25.  Adequately powered for primary outcome  Overall limited bias, high-quality data  Clinically relevant outcomes  Generalizable given patient population
  • 26.  Concealment bias  Significant heterogeneity for most outcomes  Small patient numbers  Under-powered for subgroup analysis  High loss-to-follow-up  No association of event rates over time
  • 27. 1 The encounter 2 The clinical problem 3 The evidence 4 Discussion 5 Conclusions
  • 28.  Lower risk of treatment failure in PEG ◦ Significant for neurological diseases  No difference in complications  Increased risk of pneumonia in NGT?  PEG associated with longer survival