References

Australasian Society of Enteral and Parenteral Nutrition. Nutrition management for critically and acutely unwell hospitalised patients with COVID-19 in Australia and New Zealand. V1. 2020. https://tinyurl.com/re2g2t4 (accessed 14 April 2020)

British Association for Parenteral and Enteral Nutrition (BAPEN). COVID-19 and enteral tube feeding safety. 2020. https://tinyurl.com/vj3ezds (ccessed 14 April 2020)

British Dietetic Association. Critical Care Specialist Group guidance on management of nutrition and dietetic services during the COVID-19 pandemic. 2020a. https://tinyurl.com/reacaba (accessed 14 April 2020)

British Dietetic Association. Critical Care Specialist Group COVID-19 best practice guidance: enteral feeding in prone position. 2020b. https://tinyurl.com/uvb282a (accessed 14 April 2020)

Linn D, Beckett R, Foellinger K. Administration of enteral nutrition to adult patients in the prone position. Intensive Crit Care Nurs. 2015; 31:(1)38-43 https://doi.org/10.1016/j.iccn.2014.07.002

Managing Adult Malnutrition in the Community Expert Panel. Malnutrition pathway. Managing malnutrition in COPD. 2020. https://tinyurl.com/tpwrph3 (accessed 14 April 2020)

Public Health England, NHS England, Health Education England. Making every contact count (MECC) consensus statement. 2016. https://tinyurl.com/ydhs9oxx (accessed 14 April 2020)

Public Health England. COVID-19 personal protective equipment (PPE). 2020. https://tinyurl.com/to3l2ey (accessed 14 April 2020)

World Health Organization. Coronavirus. 2020. https://tinyurl.com/tduna3z (accessed 14 April 2020)

Providing nutritional support for the patient with COVID-19

23 April 2020
Focus
02 April 2020
Volume 29 · Issue 8

COVID-19 is an infectious disease caused by a newly discovered coronavirus (World Health Organization (WHO), 2020).

Most people who it affects will experience mild-to-moderate respiratory symptoms and should recover. However, as we are sadly aware, some people will experience severe respiratory symptoms and many will be admitted to hospital very ill, in respiratory failure, needing specialised support and care.

Because COVID-19 is such a new disease, it is not possible to write specific nutritional guidance for these patients, so the best way is to manage their nutrition as you would treat any patient with severe respiratory disease.

The British Dietetic Association (BDA) (2020a) has developed useful and pragmatic guidance for dietitians to follow. However, what about the nursing staff who will be caring for these patients? How can we ensure that our patients continue to be well nourished during this time of isolation?

Oral nutrition support

In these challenging times, with reduced staffing due to staff sickness or self-isolation, lack of mealtime volunteers and visitors bringing snacks, we have to be aware that vulnerable patients may well be at increased risk of both malnutrition and dehydration. Therefore it is worth considering an ‘Every Contact Counts’ scenario. (Public Health England (PHE) et al, 2016). Put simply, every health professional who has an encounter with a patient should offer them a drink or snack, which in turn can improve both their nutrition and hydration status and will lead to a quicker and uncomplicated recovery. After all, the Every Contact Counts model is all about improving people's health—this is just as important when they are sick as when they are well. This should not just be nurses—doctors, allied health professionals, phlebotomists and so on, can all contribute too. Talk to the patient's family/carer on the phone and find out what the patient likes and dislikes. Ensure that their food and drink is within easy reach. It is also important to acknowledge that some patients may well have swallowing difficulties due to existing conditions such as stroke or Parkinson's, so making sure that they receive the correct texture diet is essential. There are also some excellent resources in the Malnutrition Pathway guidance Managing Malnutrition in COPD (Managing Adult Malnutrition in the Community Expert Panel, 2020).

‘Nasogastric tube placement is an aerosol-generating procedure and, as such, full PPE should be worn for both COVID-19-positive and COVID-19-suspected patients’

Enteral nutrition support

Patients with COVID-19 pneumonia who develop respiratory failure, shock or multi-organ failure will require intensive care management with mechanical ventilation and other interventions to support the other organs (Australasian Society of Enteral and Parenteral Nutritions (AuSPEN), 2020). Guidelines for nutrition support in adult critically ill patients recommend enteral nutrition over parenteral nutrition as the preferred route of feeding (Linn et al, 2015). Therefore, these patients will be fed either nasogastrically or nasojejunally.

A lot of experiential evidence so far has shown that patients with COVID-19 pneumonia can develop acute respiratory distress syndrome (ARDS). Consensus from health professionals from both the UK and internationally has shown that nursing these patients in the prone position is the most effective way to treat them. However, this is going to cause concerns if they have fine-bore nasogastric (NG) tubes present. Although there appears to be little evidence that enterally feeding prone patients carries an increased risk of aspiration of the feed, the British Dietetic Association Critical Care Specialist Group has developed guidance for the care of these patients (BDA, 2020b). This guidance, along with that of the British Association for Parenteral and Enteral Nutrition (BAPEN) (2020) can be summarised as follows:

  • NG tube insertion should occur only when the patient is in the supine position. X-ray MUST be used to confirm position as nursing patients in either the prone or supine position prior to placement exposes the patient to the risk of aspirating stomach contents into the lungs and thus increasing the risk of a false pH reading if the tube is in the lung
  • Feeding should be ceased an hour before proning (placing the patient in the prone position). Ensure insulin infusion is ceased simultaneously
  • NG tube should be aspirated immediately before proning and the contents discarded
  • The bed should be placed in the reverse Trendelenburg position (with the head elevated by 30 degrees) unless contraindicated
  • Recheck the position of the NG tube prior to feeding—ie position at the nostril, ensure that it is not curled at the back of the throat. If safe to do so, reconnect and continue enteral feeding
  • Cease feeding an hour before ‘deproning’ (placing the patient back into the supine position). Ensure insulin infusion is ceased simultaneously
  • Aspirate NG tube before deproning and discard contents
  • Recheck NG position as before and, if it is safe to do so, continue enteral feeding
  • Feed should be given through an enteral feeding pump and should not be administered at a higher rate than 60-85 ml per hour.

    • Placing NG feeding tubes and use of personal protective equipment

    There has been a lot of discussion around whether placing a NG feeding tube is an aerosol-generating procedure (AGP). However, the latest guidance from PHE (updated 12 April 2020) states that one of the procedures that generates an aerosol is the generation of sputum, which, arguably, is what a cough does. Those of us who pass NG tubes regularly know that patients nearly always cough when we pass the tube. Furthermore, COVID-19 patients in hospital are in an environment where aerosols are produced due to suction, continuous positive airway pressure (CPAP), mechanical ventilation or chest physiotherapy.

    BAPEN has therefore written a position statement based on expert opinion and guidance from other authorities such as the BDA, which states that NG tube placement is an AGP and, as such, full personal protective equipment (PPE) should be worn for both COVID-19-positive and COVID-19-suspected patients (BAPEN, 2020).

    Conclusion

    Providing nutrition and hydration is an essential part of care. As nurses we know that we play a huge part in ensuring that our patients receive what they need via the safest and most appropriate route for them. We are still learning as we go along during this pandemic, and no doubt guidance will change often. In the meantime, we will do what we can to keep our patients safe.