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Syringe Force on Clogged Feeding Tubes

Many people think feeding tubes are merely used to deliver nutrition (i.e., feeding formula), however, they deliver life-sustaining medications too – it’s no wonder they tend to clog. At Actuated Medical, Inc., we developed the TubeClear System to keep enteral therapy (medication, nutrition and hydration) being delivered as prescribed.

 

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Article Summary

  • Forces required to do air flushes via enteral syringe in feeding tubes with no clog, 1-layer, and 2-layers of feeding formula mixtures were measured.
  • Feeding tube clogs, or material build-up on the walls (i.e., 1-layer clogs), may begin forming before becoming noticeably difficult to flush.
  • 2-layer clogs required a force that was nearly 5.5 times of the “No Clog” feeding tubes, which was noticeable when flushed by hand.
  • The TubeClear System should be used when caregivers notice higher forces during air or water flushes to maintain full patency of feeding tubes.

We have demonstrated that compared to flushing with water alone, the TubeClear System can remove residue “sludge” from feeding tube interior walls with greater efficacy.[1] However, the question remains – How does one know when material build-up is adhering to the interior feeding tube wall if fluids can still be introduced into the feeding tube?

For patients using feeding pumps, most pump alarms will sound an alert when the flow rate falls below the predesignated flow rate.[2] However, for those using gravity or syringe feedings, clinicians flush the feeding tube with a syringe to confirm patency (open or unobstructed). These water flushes may require increased force if materials are building up on the inner tube walls. In cases of fully clogged feeding tubes, the water may blow backward toward the clinician due to increased syringe resistance. Note that using excessive force on a syringe (often called power flushing) is generally not recommended as it may cause a rupture to the patient’s feeding tube.[3]

Measuring Flushing Force

Our engineers investigated the amount of force (Newtons [N]) required to be applied to a syringe plunger when attempting to introduce air into non-clogged and partially clogged feeding tubes. In vitro produced clogs were created with a mixture of feeding formula and fiber within 14Fr NG feeding tubes (Cardinal Health, Dublin, OH). Three (3) different feeding tube conditions were tested, N=15 trials, with n=5 trials/feeding tube condition: 1) No clog (lacking all material), 2) 1-layer of clog mixture on feeding tube walls, and 3) 2-layers of clog mixture on feeding tube walls (see Figure 2). To create the single layer, the clog mixture was introduced into feeding tubes (N=10) and dried at 55°C for three (3) hours.  To create the two-layer clog buildup, a second clog layer was introduced into a subset of the same feeding tubes (N=5) and dried at 55°C for three (3) hours. To measure the force, a 60-cc syringe was filled with air to the 50-cc mark, and the plunger was depressed to the 10-cc mark using a Shimpo model 100XY force gauge (ELECTROMATIC Equipment Co., Inc., Cedarhurst, NY) (see Figure 1). A n = 5 trials were performed for each feeding tube condition.

Figure 1: Testing set-up.

Figure 2: A rendering of the cross-section of the clog types. The grey circle represents the feeding tube wall, and clog material is represented in shades of orange.

The peak force (measured in Newtons [N]) required to push air via the syringe through a non-clogged feeding tube averaged 7.6±0.1N, compared to 14.3±0.5N and 41.0±1.7N, for the one and two layered partially clogged feeding tubes, respectively (see Figure 3).

While these measurements demonstrate an increasing amount of required force, what does that feel like in practice?

Figure 3: Syringe Force testing summary. 
Blue Bar= No clog, Orange Bar= Single layer of clog mixture, Gray Bar= Double layer of clog mixture. n=5 trials/performed for each feeding tube condition. Error bars= standard error of the mean. Two-way ANOVA, Tukey’s Multiple comparison test, different variables =p<0.01.

Feeling the Force

There are many publications discussing preventative means to feeding tube clog formation and multiple ways to remove clogs;[4-5] however, the question as to how one can determine if a feeding tube is fully patent does not appear to have been addressed.

Some feeding tube clogs appear to form quickly, while others occur gradually over time, leading clinicians and care takers to be uncertain to the state of patency of a feeding tube at any particular time. We aimed to quantify the amount of required force to introduce air into feeding tubes with the various levels of clogging- with the end goal to correlate those values with a subjective “feel,” as such, initial tests were conducted without a force gauge. Videos demonstrate how easily (or not) air could be introduced into feeding tubes of the various conditions.

A

B

C

Figure 4: Syringe resistance against each feeding tube condition. A) No clog. B) 1 layer. C) 2 layers (note: looping GIF animation may look like the plunger “snaps” back, but this is the beginning of the animation).

As expected, the feeding tube without a clog (No Clog) could be flushed with air without experiencing any major resistance. However, the feeding tube with a single layer of clog mixture appears to flush almost as easily as the “No Clog” feeding tube, but the required force as measured by the force gauge was nearly double. This finding suggests that feeding tube clogs, or material build-up on the walls, may begin forming before becoming noticeable to clinicians or caretakers. Further research is required to elucidate this finding.

Attempts to flush air into feeding tubes with a double layer of clog mixture proved the most difficult, requiring additional force as the syringe plunger pushed backwards towards the Operator (see Figure 4c) due to the partial blockage. These simulated clogs required a force that was nearly 5.5 times that of the “No Clog” feeding tubes.

From Bench to Bedside

Using the TubeClear System proactively can remove material build-up from feeding tube inner walls enabling enteral therapy (i.e., medication, nutrition and hydration) to be delivered as prescribed.[1] Based on the results presented here, we recommend using the TubeClear System on a patient’s feeding tube as soon as the clinician notices a change in the required pressure to administer fluid or air during routine syringe flushing, as this may be indicative of material build-up on the inner walls of the tube.

How often do you notice a change in the required force during routine flushes? Let us know! Find us on Twitter and Facebook or send us an email at info@tubeclear.com.

References:

  1. Actuated Medical, Inc. Internal Test Report Doc. No. 1100791569-001.
  2. Cardinal Health, Dublin, OH. https://www.cardinalhealth.com/content/dam/corp/web/documents/patient-recovery/Literature/kangaroo-connect-enteral-feeding-pump-operator-manual.pdf. Accessed 9/27/19.
  3. Richards, S., Walsh, K. (2016), Feeding Tube Irrigation: Performing. Nursing Practice and Skill. https://www.ebscohost.com/assets-sample-content/Feeding_Tube_Irrigation_Performing_-_NSP.pdf. Accessed 9/27/19.
  4. Boullata, J. I., Carrera, A. L., Harvey, L. , Escuro, A. A., Hudson, L. , Mays, A. , McGinnis, C. , Wessel, J. J., Bajpai, S. , Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L. , Martin, K. , Pompeii‐Wolfe, C. , Sullivan, J. , Wood, A. , Malone, A. , Guenter, P. and , (2017), ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of Parenteral and Enteral Nutrition, 41: 15-103 0148607116673053. doi:1177/0148607116673053.
  5. Lord, L.M. (2018), Enteral Access Devices: Types, Function, Care, and Challenges. Nutrition in Clinical Practice, 33(1): 16-38. doi: 10.1002/ncp.10019.

Proactive Use of the TubeClear System Assists Optimum Therapy Delivery

Enteral access devices (EADs;  feeding tubes) provide vital nutrition, medication, and hydration to more than seven million patients annually [1].  Interruptions to the delivery of enteral therapy has been found to increase the patient’s caloric deficit and their hospital length of stay[2], greatly increasing the overall cost of care.

The TubeClear System, a device developed to clear clogged or sluggish feeding tubes to restore or maintain their patency, could help prevent interruptions to delivery of enteral therapy when used proactively.  A recent bench test found promising results.[3]

Bench studies suggest that, when used correctly and proactively (i.e. before a feeding tube becomes completed clogged), the TubeClear System is 145.6% more effective at removing built-up material along the walls of the feeding tube than the standard practice of flushing a tube with water. As material builds up along the inside walls of the feeding tube, it can gradually restrict the flow of nutrition. 

Actuated Medical, Inc. (AMI) tested the use of the TubeClear System on partially clogged feeding tubes.  For this test, 22 feeding tubes were used; the patency of 11 tubes was maintained with the standard practice of water flushing, and the patency of the other 11 tubes was maintained with the TubeClear system.  A weight was recorded for each empty feeding tube before it was clogged.  The clog contents included a combination of feeding formula and fiber supplements, to simulate types of clogs observed in a clinical setting, and clogged feeding tubes were then dried to ensure consistency between the tubes. Each clogged tube was weighed and received a water flush. 

For the first 11 feeding tubes, only water was used for clearing the tube.  After treatment, they were weighed again.  On average, flushing the partial clog with water increased the weight of the feeding tube by 68.5%, indicating that the moisture may have been absorbed by the build-up.

The second 11 feeding tubes were treated with the TubeClear System after the initial water flush.  On average, those feeding tubes decreased in weight by 77.1%, suggesting more of the occlusion material was removed than the tubes treated with water alone. 

These results suggest that the TubeClear System is more effective at clearing partial clogs than the standard practice of flushing with water alone.  AMI recommends using the TubeClear System at least once per week for optimum therapy delivery.  If the flow within the feeding tube is sluggish in the meantime, indicated by a feeding pump alarm or when it’s difficult to flush with water or administer medication, it is appropriate to use the TubeClear System more frequently, as needed.


[1] Botoman VA, Kirtland SH, Moss RL. “A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition”, JPEN J Parenter Enteral Nutr. 1994;18(2):154-158.

[2] Peev, M. P., Yeh, D. D., Quraishi, S. A., Osler, P. , Chang, Y. , Gillis, E. , Albano, C. E., Darak, S. and Velmahos, G. C. (2015), Causes and Consequences of Interrupted Enteral Nutrition. Journal of Parenteral and Enteral Nutrition, 39: 21-27. doi:10.1177/0148607114526887

[3] Source: Actuated Medical, Inc. Internal Test Report Doc. No. 1100791569-000.

TubeClear System Clears Clogged Tubes: Various Compounds

Small bore feeding tubes are used to provide essential nutrition and medication to patients at risk of malnutrition and dehydration due to an inability to ingest orally (1).

Clogging is one of the most frequent mechanical complications of feeding tubes (2,3). Tubes are more likely to become clogged when powdered, crushed, acidic, or alkaline medications or ground feeding formulas containing particulates are delivered through the small inner lumen, or when tubes are not routinely flushed following feedings (2). Reported clogging rates vary, ranging from 9-35% (1, 2).

Attempts to clear clogged feeding tubes using various techniques are time-consuming and often result with tube replacement still being required. Also, many of the current methods only work on certain types of clogs. For example, most enzyme treatments are only applicable to protein (feeding formula) based clogs. Among common emergency room medical procedures, patients rank nasoenteral (NE), (nasogastric [NG]) tube insertion to be one of the most painful (4, 5, 6). Replacing a feeding tube may cause additional patient safety risks, associated medical costs, and additional pain and discomfort to the patient. The most common way to place NE (NG) feeding tubes, is blind insertion at patient bedside, and has a reported 0.5-15% malposition rate (3). Malposition into the trachea may cause pneumothoraxes and possibly death. Several methods exist for verifying accurate tube placement, the most reliable being radiography (3). However, this exposes patients to additional radiation and medical costs.

Taking into account nursing time, tube replacement, radiographs and other miscellaneous costs, the capability to clear a clogged feeding tube while it remains in the patient, could represent substantial savings to a medical facility not to mention reduced pain and discomfort to the patient. For patients outside the hospital, a clogged feeding tube often results in transportation and admission costs to the payer and anxiety to the patient.

The TubeClear System was developed to efficiently and effectively clear clogged feeding tubes while the tube remains in the patient (7). It is currently FDA cleared to unclog 10-18 Fr NE, NG, gastrostomy (G [including percutaneous endoscopic gastrostomy, PEG tubes]) and jejunostomy (J) feeding tubes in adults at bedside while the tube remains in the patient. The TubeClear System is also CE marked. The TubeClear System is comprised of a reusable Control Box to which a single-use Clearing Stem is attached. The Clearing Stem is inserted into the patient’s feeding tube by the licensed healthcare practitioner. The Clearing Stem moves backward and forward, and the tip works against the clog to mechanically disrupt and clear the feeding tube.

+ FDA Cleared for clearing occlusions / clogs in Feeding and Decompression Tubes in adult patients that have a Tube size of 6 to 18 Fr.

 

References:
1. Ireton-Jones C, DeLegge M. Handbook of Home Nutrition Support. Sudburry, MA: Jones and Bartlett; 2007
2. Beyer PL, Matarese LE, Gottschlich MM. Complications of enteral nutrition. 1998.
3. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505-8524.
4. Singer AJ, Richman PB, Kowalska A, Thode HC, Jr. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33(6):652-658.
5. Bae KH, Jeong IS. [Pain perception of nurses and pain expression of patients in critical care units]. J Korean Acad Nurs. 2014;44(4):437-445.
6. Penrod J, Morse JM, Wilson S. Comforting strategies used during nasogastric tube insertion. J Clin Nurs. 1999;8(1):31-38.
7. TubeClear System- Clears Clogged Feeding Tubes. 2015;http://www.tubeclear.com/

 

TubeClear System Clears Clogged Tubes: NE, G, J Tubes

Individuals unable to ingest nutrition and/or medication orally for various causes, often become dependent on enteral nutrition as a life-saving mechanism (1). However, due to daily administration of feeding formula and/or medication, as well as other unknown causes, these medically needed feeding tubes may become clogged, up to 35% of the time (1, 2).

Clogged feeding tubes often result in the interruption of a patient’s nutrition and medication regimens, representing a burden to both caregivers and patients. Attempts to clear clogged feeding tubes using various techniques are time-consuming and as a result cause delays in feeding, hydration, and medications which can have negative effects on overall patient health and healing (3). Often, these tube clearing methods fail and the tube requires replacement, exposing patients to both additional radiation from placement confirmation (x-rays) and increased medical costs. Notably, among common medical procedures, patients rank nasoenteral (NE), (nasogastric [NG]) tube insertion to be one of the most painful (4, 5, 6). The most common way to place NE (NG) feeding tubes, is blind insertion, and has a reported 0.5-16% malposition rate (7). Malposition into the trachea may cause pneumothoraxes and possibly death, though several methods exist for verifying accurate placement, the most reliable is radiography (7). Replacing clogged gastrostomy (G) and jejunostomy (J) feeding tubes may require additional endoscopic guidance or surgical procedures depending on tube type.

The TubeClear System, an FDA-cleared and CE marked medical device, was developed to clear clogged feeding tubes at bedside while the tube remains in the patient. The system comprises of a reusable Control Box that actuates a single-use Clearing Stem. The Clearing Stem inserts into the feeding tube and the backward and forward movement of the Clearing Stem acts to mechanically disrupt and clear the clogged feeding tube (8). It is currently FDA cleared to unclog 6-18 Fr NE, NG, G (including percutaneous endoscopic gastrostomy, [PEG tubes]) and J tubes while the tube remains in the patient.

+ FDA Cleared for clearing occlusions / clogs in Feeding and Decompression Tubes in adult patients that have a Tube size of 6 to 18 Fr.

Using the TubeClear System to Clear Clogged G-tubes.


Benchtop Study evaluated at AMI with Levin 18 Fr, 14 inch long gastrostomy tubes. Half of the occlusions were made from 2:1 ratio of coagulated protein and ground medication (Medication Clog). Half of the occlusions were made from 1:1 ratio of feeding formula and fiber (Feeding Formula Clog).

Using the TubeClear System to Clear Clogged NE tubes.

Benchtop Study evaluated at AMI with Levin 10F Fr, 55 inch long nasoenteral (Entriflex) tubes. Half of the occlusions were made from 2:1 ratio of coagulated protein and ground medication (Medication Clog). Half of the occlusions were made from 1:1 ratio of feeding formula and fiber (Feeding Formula Clog).

References:
1. Ireton-Jones C, DeLegge M. Handbook of Home Nutrition Support. Sudburry, MA: Jones and Bartlett; 2007
2. Beyer PL, Matarese LE, Gottschlich MM. Complications of enteral nutrition. 1998.
3. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J. 2002;78(918):198-204.
4. Singer AJ, Richman PB, Kowalska A, Thode HC, Jr. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33(6):652-658.
5. Bae KH, Jeong IS. [Pain perception of nurses and pain expression of patients in critical care units]. J Korean Acad Nurs. 2014;44(4):437-445.
6. Penrod J, Morse JM, Wilson S. Comforting strategies used during nasogastric tube insertion. J Clin Nurs. 1999;8(1):31-38.
7. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505-8524.
8. TubeClear System- Clears Clogged Feeding Tubes. 2015;http://www.tubeclear.com/

TubeClear System Clears Clogged Tubes at Bedside: Clinical Case Study

Feeding tubes are used to deliver enteral nutrition to patients that are unable to ingest nutrients and medications orally and therefore are at risk of malnutrition and dehydration (1).

Unfortunately, the long and narrow inner lumens of small bore feeding tubes used to deliver enteral nutrition and medication to patients often clog for various reasons including, delivery of high viscosity medications, by chemical reactions between feeding formula and medication, or by inadequate tube maintenance (2,3). Clogged feeding tubes can cause patients to go extended periods without nutrition and medication, and attempts to unclog tubes strain

valuable nursing resources. Traditional methods to clear clogged feeding tubes are often unsuccessful, potentially leading to tube replacement, and patient discomfort (2,3,4).

The TubeClear System, an FDA-cleared and CE marked medical device, was developed to clear clogged feeding tubes at bedside while the tube remains in the patient. The system comprises of a reusable Control Box that actuates a single-use Clearing Stem. The Clearing Stem inserts into the feeding tube and the backward and forward motion of the Clearing Stem Tip acts to mechanically disrupt and clear the clogged materials from the feeding tube (5).

An in human case series was completed, documenting twelve cases in which TubeClear was used to clear clogged nasoenteral (NE) feeding tubes. All documented cases were completed by a single licensed healthcare practitioner and were 100% successfulwithout any issues reported by the practitioner and/or patients. The ability to quickly clear clogged feeding tubes while the tube remains in the patient will save healthcare resources, and ease the burden on patients and caregivers.

+ FDA Cleared for clearing occlusions / clogs in Feeding and Decompression Tubes in adult patients that have a Tube size of 6 to 18 Fr.

References:
1. Ireton-Jones C, DeLegge M. Handbook of Home Nutrition Support. Sudburry, MA: Jones and Bartlett; 2007
2. Beyer PL, Matarese LE, Gottschlich MM. Complications of enteral nutrition. 1998.
3. Metheny N, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res. 1988;37(3):165-169.
4. Smith R, Myers S. 2 devices that unclog feeding tubes. RN. 2005;68(1):36-41; quiz 42.
5. TubeClear System- Clears Clogged Feeding Tubes. 2015;http://www.tubeclear.com/

TubeClear System Clears Clogged NE Tubes: Benchtop Study

Small bore feeding tubes are used to provide essential nutrition and medication to patients at risk of malnutrition and dehydration due to an inability to ingest orally (1). Clogging is one of the most frequent mechanical complications of feeding tubes (2,3). Tubes are more likely to become clogged when powdered, crushed, acidic, or alkaline medications or ground feeding formulas containing particulates are delivered through the small inner lumen, or when tubes are not routinely flushed following feedings (2).

Clearing clogged feeding tubes creates hassles and frustration for practitioners and anxiety and discomfort for patients. The lapse in nutrition and medication regime may also negatively impact recovery (4). Standard techniques for clearing clogged feeding tubes in the past included enzymes, Coca-Cola®, and meat tenderizer. Today, commercially available manual brushes and stylets exist, in addition to enzymes or syringe water flushes (2,5,6). Attempts to clear clogged feeding tubes using these techniques are time-consuming and often result with tube replacement still required. Moreover, among other common medical procedures, patients rank Nasoenteral (NE, nasogastric [NG]) tube insertion to be one of the most painful (7,8,9).

The TubeClear System, an FDA-cleared and CE marked medical device, was developed to clear clogged feeding tubes at bedside while the tube remains in the patient. The system comprises of a reusable Control Box that actuates a single-use Clearing Stem. The Clearing Stem inserts into the feeding tube and the backward and forward movement of the Clearing Stem acts to mechanically disrupt the clog and clear the clogged feeding tube (10).

A bench study was conducted to test the efficacy of three different clog-clearing strategies on in-vitro clogged tubes. Of the three clog clearing strategies tested with artificially clogged tubes, warm water flushes and commercially available enzyme treatments took significantly longer to clear clogged feeding tubes, when compared to the TubeClear System.

  • FDA Cleared for clearing occlusions / clogs in Feeding and Decompression Tubes in adult patients that have a Tube size of 6 to 18 Fr.

Using TubeClear to Unclog Nasoenteral tubes that reside in the stomach.

Benchtop Study evaluated at AMI with Levin 14Fr, 48 inch long feeding tubes with in-vitro clogs. Occlusions were made from 1:1 ratio of feeding formula and fiber.

References:

  1. Ireton-Jones C, DeLegge M. Handbook of Home Nutrition Support. Sudburry, MA: Jones and Bartlett; 2007
  2. Beyer PL, Matarese LE, Gottschlich MM. Complications of enteral nutrition. 1998.
  3. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505-8524.
  4. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J. 2002;78(918):198-204.
  5. Metheny N, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res. 1988;37(3):165-169.
  6. Smith R, Myers S. 2 devices that unclog feeding tubes. RN. 2005;68(1):36-41; quiz 42.
  7. Singer AJ, Richman PB, Kowalska A, Thode HC, Jr. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33(6):652-658.
  8. Bae KH, Jeong IS. [Pain perception of nurses and pain expression of patients in critical care units]. J Korean Acad Nurs. 2014;44(4):437-445.
  9. Penrod J, Morse JM, Wilson S. Comforting strategies used during nasogastric tube insertion. J Clin Nurs. 1999;8(1):31-38.
  10. TubeClear System- Clears Clogged Feeding Tubes. 2015;http://www.tubeclear.com/