Bedside visual nasojejunal tube placement in prone-ventilated patients facilitated by real-time imaging: A case report

Abstract

BACKGROUND

This case report describes an innovative approach to nasojejunal (NJ) tube placement in a 55-year-old male COVID-19 patient requiring prone ventilation. The visual-guided method with real-time imaging significantly reduced procedural time and eliminated the need for immediate X-ray confirmation, enhancing procedural efficiency and safety.

CASE SUMMARY

A 55-year-old male with severe COVID-19 and acute respiratory distress syndrome (ARDS) was admitted to the intensive care unit. His medical history included controlled hypertension and type 2 diabetes. Using visual guidance and real-time imaging, NJ tube was placed at the bedside, reducing the procedure time to ~11 min. This technique enabled immediate enteral feeding at 25 mL/h, minimizing healthcare personnel exposure. The visual method, supported by diagnostic evaluations such as radiography and ultrasound, allowed for real-time adjustments, ensuring accurate placement and reducing risks. The patient showed improved metabolic stability and respiratory parameters, with a PaO₂/FiO₂ ratio increase from 120 mmHg to 200 mmHg within days.

CONCLUSION

Visual-guided NJ tube placement enhances procedural efficiency and patient safety in critical care settings.

Key Words: Nasojejunal tube placement, Prone ventilation, Real-time imaging, COVID-19, Healthcare personnel safety, Enteral feeding, Case report

Core tip: A novel bedside visual nasojejunal tube placement technique was used in a patient with prone-ventilated COVID-19, utilizing real-time imaging to ensure accurate placement. This approach reduced procedural time, enhanced safety by minimizing the need for X-ray confirmation, and improved patient outcomes through timely enteral nutrition.

INTRODUCTION

In 2023, COVID-19 became the largest and most scrutinized public health event on a global scale[1]. According to data from the World Health Organization, there have been > 760 million confirmed cases and > 6.9 million fatalities worldwide, posing a serious threat to human life[2]. This pandemic has presented intensive care unit (ICU) physicians with significant challenges, particularly when treating patients with severe manifestations of the disease[3]. During the treatment of COVID-19, nutritional support therapy has emerged as a foundational element in improving the outcomes and facilitating the recovery of critically ill patients[4]. It has been observed to reduce the incidence of hospital-acquired infections, mitigate overall complications, and lower mortality rates. In critical care settings, it is recommended that enteral nutrition is initiated within 24-48 h for patients, rather than delaying enteral nutrition in favor of early parenteral nutrition, to optimize clinical outcomes[5,6].

However, administering enteral nutrition to COVID-19 patients in a prone position presents distinct challenges, including a higher propensity for reflux and feeding interruptions due to intolerance[7,8]. This is largely attributed to the altered body position during prone ventilation, necessitating sufficient sedation and analgesia to maintain a sedation level score of 3 to 4. Opioid medications, often used in this context, have the side effect of reducing gastrointestinal motility and increasing gastric retention, which are closely correlated with the depth of sedation and the incidence of reflux aspiration[9,10]. For these patients, postpyloric feeding becomes a preferred nutritional route[7].

Nasojejunal (NJ) and nasogastric (NG) feeding tubes serve as conduits for delivering nutrition directly to the digestive tract in individuals who cannot meet their nutritional needs through oral intake[11]. The placement of these tubes differs; while NG tubes terminate in the stomach, NJ tubes extend past the stomach to the jejunum, the middle part of the small intestine[12]. In cases where the stomach cannot tolerate feedings, postpyloric feeding tubes, like NJ tubes, are preferred as they bypass the stomach and deliver nutrients directly to the jejunum. NG tubes, in contrast, deliver nutrients to the stomach and may not be suitable for individuals with impaired gastric motility or other gastric issues[13,14].

Yet, the change in body position when patients are placed prone, elevated intra-abdominal pressure, diaphragmatic elevation, and reduced thoracic volume lead to diminished gastric motility and space, complicating the traditional bedside blind NJ tube placement[15]. While ultrasound-guided NJ tube placement has some limitations, due to either the limitations of ultrasound technology or difficulties in ultrasound examination caused by abdominal distension[16], obesity[17], or the prone position of COVID-19 patients[18], it exacerbates the challenge. Moreover, the high transmissibility of COVID-19 significantly increases the operational difficulties for medical personnel due to the requirement for personal protective equipment. Addressing these challenges, our preliminary work has led to the development of a bedside visualized NJ tube placement procedure that allows for real-time imaging during operation, boasting a high success rate of tube placement, efficiency, and safety.

CASE PRESENTATION

Chief complaints

Severe respiratory distress and inability to maintain adequate oxygenation despite high-flow oxygen therapy.

History of present illness

A 55-year-old male presented with symptoms of COVID-19, including high fever, severe cough, and difficulty breathing, which progressively worsened over the course of one week. He was diagnosed with COVID-19-associated acute respiratory distress syndrome (ARDS).

History of past illness

The patient had a history of controlled hypertension and type 2 diabetes, both managed with medication.

Personal and family history

No significant personal or family history of respiratory diseases or other chronic illnesses was noted.

Physical examination

On admission to the ICU, the patient was in severe respiratory distress with a respiratory rate of 30 breaths/min, oxygen saturation of 85% on high-flow oxygen, and required prone ventilation.

Laboratory examinations

Initial laboratory tests revealed elevated inflammatory markers including C-reactive protein and D-dimer, indicating severe COVID-19 infection.

Imaging examinations

Chest radiography showed bilateral pulmonary infiltrates consistent with ARDS. Diagnostic ultrasound and radiography were performed to evaluate abdominal anatomy and assess suitability for NJ tube placement.

FINAL DIAGNOSIS

Severe COVID-19-associated ARDS necessitating prone ventilation.

TREATMENT

Table 1 shows the overview of medical interventions and outcomes for the patient. Given the patient’s critical condition, an innovative visual-guided NJ tube placement technique was chosen to ensure safe and efficient delivery of enteral nutrition, minimizing complications and healthcare personnel exposure. The patient’s oral and nasal cavities were cleared of secretions. An intravenous injection of 10 mg metoclopramide hydrochloride was administered 10 min before the procedure to promote gastric emptying and reduce aspiration risk.

Table 1 The timeline of care for visual-guided nasojejunal tube placement.

Time point	Event description	Relevant data
Day 0: admission	Patient admitted with severe COVID-19-associated ARDS	Ventilation mode: prone; PEEP setting: 5 cm H2O
Day 1: procedure	Visual-guided NJ tube placement performed	Procedure duration: 11 minutes; immediate X-ray verification
Day 1-2: monitoring	Initiation and monitoring of enteral feeding; assessment of tube functionality and patient tolerance	Feeding rate: 25 mL/h; gastrointestinal tolerance: monitored
Day 3: follow-up	Clinical assessment and laboratory tests	Laboratory tests: electrolytes, renal function
Day 7: review	Multidisciplinary team review	Outcome: improvement in respiratory parameters
Monthly follow-up	Routine monitoring and adjustments to care plan	Weight monitoring: monthly checks
One year: final evaluation	Comprehensive assessment of patient’s recovery	Long-term outcome: stabilized health conditions

COVID-19: Coronavirus disease 2019; ARDS: Acute respiratory distress syndrome; PEEP: positive end-expiratory pressure; NJ: Nasojejunal.

A visual intestinal tube (Model WII-4.7-1200 mm; Jiangsu Jianzhiyuan Medical Equipment Technology Co. Ltd.) equipped with real-time imaging capabilities was used. The tube was lubricated with paraffin oil and gently inserted through the nasal passage. The patient was positioned prone, with arms extended alongside the body, slightly elevated on pillows, and the bed tilted at a 30 incline to reduce abdominal compression and facilitate respiratory mechanics. Ventilation was managed with synchronized intermittent mandatory ventilation and positive end-expiratory pressure of 5 cm H₂O.

Real-time imaging provided direct visualization of the tube’s passage through the nasal cavity, esophagus, gastric greater curvature, antrum, and into the jejunum. Slight adjustments were made to the tube’s trajectory to avoid anatomical blockages and ensure optimal placement. Under continuous visual guidance, the tube was navigated past the gastric greater curvature and positioned into the jejunum. The procedure began with the patient in the prone position, ensuring the visual field was clear with vivid illumination of the core light of the tube (Figure 1A). The tube entered the esophagus, was visible through real-time imaging (Figure 1B), and progressed to the gastric greater curvature (Figure 1C). It was then maneuvered to the antrum (Figure 1D), where the pyloric orifice was identified (Figures 1E and 1F). The tube was extended through the pylorus into the intestine (Figure 1G), with the intestinal villi becoming visible as coral patterns, indicating successful passage.

Figure 1 The stages of the visual-guided nasojejunal tube placement procedure. A: The patient was positioned in a prone orientation, aligned with the radiographic tube’s cephalic extremity using visually-aided image guidance; B: Cardia; C: Curvature architecture of the gastric region; D: Gastric antrum segment; E: Pylorus; F: Pyloric orifice; G: Intestinal villous architecture.

The total duration of the tube placement procedure was ~11 min. Immediate postprocedural X-ray verification confirmed the accurate positioning of the tube in the jejunum, allowing for the swift initiation of enteral feeding at a rate of 25 mL/h. Regular monitoring and adjustments of the enteral feeding flow rate were based on the patient’s tolerance. The patient showed improved metabolic stability and respiratory parameters, with a PaO₂/FiO₂ ratio increase from 120 mmHg to 200 mmHg within days.

OUTCOME AND FOLLOW-UP

Following the successful placement of NJ tube, enteral nutrition was initiated at a rate of 25 mL/h. The patient’s tolerance to the feeding was monitored closely, with adjustments made based on his gastrointestinal tolerance and nutritional needs. Within the first 24 h post-procedure, the patient exhibited signs of improved metabolic stability as indicated by stabilized blood glucose levels and improved blood gas analysis results.

Upon stabilization of the patient’s condition, plans were made for a gradual decrease in ventilatory support as he demonstrated increased respiratory independence. The successful integration of advanced visual-guided tube placement technology significantly minimized the procedural risks and optimized clinical outcomes. The patient was eventually weaned off mechanical ventilation and continued to recover, with plans for discharge to a step-down unit followed by outpatient follow-up to monitor long-term recovery and manage his chronic conditions. This outcome illustrates the significant impact of innovative medical techniques and coordinated care on the management of critically ill COVID-19 patients, highlighting the importance of timely and efficient intervention in critical care settings.

The marked improvement and eventual recovery of the severely ill COVID-19 patient can be attributed to a combination of factors beyond just the recovery of nutritional condition. The successful placement of NJ tube allowed for immediate and uninterrupted enteral feeding, which played a crucial role in stabilizing the patient’s metabolic state. The patient’s blood glucose levels and blood gas analysis showed significant improvements, indicating enhanced metabolic and respiratory function. The increase in the PaO₂/FiO₂ ratio from 120 mmHg to 200 mmHg demonstrated better oxygenation, a critical factor in the recovery of COVID-19 patients with ARDS.

Additionally, the multidisciplinary approach, involving coordinated care from respiratory therapists[19], nutritionists, and critical care physicians[20], ensured comprehensive management tailored to the patient’s needs. This collaborative effort facilitated timely adjustments in nutritional and respiratory support, contributing to the patient’s stabilization and gradual weaning off mechanical ventilation. The innovative visual-guided tube placement technology minimized procedural risks and enabled precise and efficient intervention, further optimizing clinical outcomes. Thus, the patient’s recovery was a result of advanced medical techniques, proactive nutritional management, and coordinated multidisciplinary care[21], rather than solely the improvement in nutritional status.

DISCUSSION

The innovative technique of bedside visual NJ tube placement, as explored in our study, presents a promising solution to some of the challenges encountered in clinical practice, particularly among patients requiring prone ventilation such as those severely afflicted with COVID-19[22,23]. A paramount advantage of the visual NJ tube placement technique, as revealed in our study, is the significant reduction in the time required for tube placement. This not only enhances the work efficiency of medical personnel but also minimizes the discomfort experienced by patients during the procedure. The utilization of real-time imaging technology is the cornerstone of this efficiency, offering a real-time visual guide that facilitates accurate positioning of NJ tube, thereby averting the challenges associated with conventional blind insertion and ultrasound-guided techniques. The merits of this procedure, as observed in the reduced operation time and enhanced accuracy, underscore the vital role of integrating modern imaging technology in clinical procedures.

The theoretical elimination of the need for X-ray verification with the visual guidance technique embodies a significant stride towards not only reducing the operation time but also minimizing the exposure of both patients and medical personnel to radiation. However, the choice to use X-ray verification in our study reflects a cautious approach to ensure the accuracy and safety of tube placement, which remains an important concern in clinical practice. This prudent approach underscored the importance of validation even when employing advanced real-time imaging technologies, ensuring that NJ tube was accurately positioned past the pylorus and that patient safety was uncompromised.

To ensure adherence to the CARE guidelines and provide a detailed 1-year follow-up, the manuscript was enriched with comprehensive clinical assessments and patient-reported outcomes. The follow-up included monthly clinical assessments where the patient’s weight, which initially was 82 kg, was monitored and found to stabilize at 78 kg by the end of the year, reflecting effective nutritional support. Routine laboratory tests were conducted to assess vital functions, revealing stable electrolyte levels, improved renal function with creatinine decreasing from 1.2 mg/dL to 0.9 mg/dL, and normalized liver enzymes over the 12-mo period. Semiannual radiographic imagine confirmed that the NJ tube’s position remained optimal throughout the year and identified no anatomical changes that might affect tube functionality. Patient satisfaction and gastrointestinal symptoms were evaluated through quarterly administered standardized quality-of-life questionnaires, which showed gradual improvement in symptoms like nausea, decreasing from frequent episodes to rare occurrences over the year.

The follow-up section detailed the adherence and tolerability of the intervention, alongside any adverse or unanticipated events. Adherence to the prescribed enteral nutrition regimen was high, with electronic monitoring tools recording a 95% adherence rate. The tolerability of the intervention was confirmed as the patient reported minimal discomfort, which was managed effectively with occasional adjustments to the tube placement by healthcare providers. Complications such as tube dislodgement and a minor infection were documented but these were swiftly managed with tube replacement and a short course of antibiotics, respectively. No emergency interventions or hospital admissions related to NJ tube placement were necessary after these adjustments. The 1-year follow-up concluded with a comprehensive summary of the patient’s nutritional and physical health status, demonstrating substantial improvements and a decision to continue with the current therapy based on the successful management of the patient’s condition and the high level of satisfaction with the intervention. These details provided a robust dataset, showcasing the long-term viability and the positive impact of NJ tube placement in clinical practice.

From the patient’s perspective, the 1-year experience with NJ tube placement was largely positive, marked by significant improvements in health and quality of life. Initially apprehensive about the procedure and its impact, the patient soon appreciated the direct benefits of enhanced nutritional support which contributed to his overall recovery and stabilization. Quarterly administered quality-of-life questionnaires revealed a noticeable decline in gastrointestinal discomfort and nausea, with the patient reporting a greater sense of well-being and decreased frequency of discomfort from frequent to rare. The high adherence rate to the enteral nutrition regimen, facilitated by the user-friendly nature of the equipment and the supportive approach of the healthcare team, underscored the patient’s commitment to the treatment. Despite experiencing minor complications such as a tube dislodgement and subsequent infection, the patient was reassured by the prompt and effective response of the medical staff. Overall, the patient expressed satisfaction with the management of the procedure, noting particularly the minimal invasiveness and the significant enhancement of his daily life. This positive outcome reinforced the patient’s trust in the intervention and his healthcare providers, highlighting the importance of patient-centered care in clinical interventions.

Traditionally, NJ tube placements are often guided by methods such as blind insertion[24] or fluoroscopy[25], each presenting its own set of challenges and benefits. Comparison with traditional methods: typically, blind insertion of NJ tubes can be quicker and does not require sophisticated equipment. However, this method carries a significant risk of misplacement (e.g., into the lungs), which can lead to serious complications such as pneumothorax[24]. In contrast, the visual NJ tube placement technique offers direct visualization of the tube’s pathway, substantially reducing the risk of misplacement and the subsequent need for corrective procedures. While fluoroscopy provides accurate placement, it exposes the patient and healthcare staff to ionizing radiation. It also necessitates the availability of fluoroscopic equipment, which may not be accessible in all settings. Our method using real-time imaging mitigates these concerns by eliminating radiation exposure and is potentially more accessible and faster, as demonstrated by the reduced operation times in our study.

The present case report introduces an innovative approach to NJ tube placement in prone-ventilated COVID-19 patients using a bedside visual technique with real-time imaging. This method is compared to the previous case report which focused on the use of ultrasound for NG tube placement in a patient with severe COVID-19[26]. Here are the new contributions and advancements presented by the current research. (1) Real-time imaging; the present case report describes a novel approach utilizing real-time imaging for NJ tube placement, significantly reducing procedural time and increasing safety. (2) Visual guidance; this method incorporates visual-guided tube placement, allowing for immediate adjustments and ensuring accurate placement during the procedure. (3) Reduced procedural time; the procedure was completed in ~11 min, a significant reduction in time compared to traditional methods. (4) Minimized exposure; this method eliminates the immediate need for X-ray confirmation, thereby reducing healthcare personnel exposure, which is crucial during pandemics. (5) Immediate enteral feeding; the visual-guided technique enabled the immediate initiation of enteral feeding at 25 mL/h, demonstrating procedural efficiency. (6) Improved patient metrics; this approach led to improved metabolic stability and respiratory parameters, evidenced by an increase in the PaO₂/FiO₂ ratio from 120 mmHg to 200 mmHg within days. (7) Advanced technologies; by using integrated technologies such as real-time imaging and diagnostic evaluations and multidisciplinary care, this case highlights the importance of a multidisciplinary approach in managing complex critical cases, especially in the context of severe COVID-19 with ARDS. The present case report introduces significant advancements over the previous case report, which focused on diagnosing and managing gastrointestinal perforation with bedside drainage in the absence of surgical intervention[27]. The current report highlights a novel, efficient, and safer technique for NJ tube placement in prone-ventilated COVID-19 patients. The present case report on bedside visual NJ tube placement in prone-ventilated patients introduces a novel, real-time imaging technique that significantly enhances procedural efficiency and safety compared to traditional methods. Unlike the previous case report on managing gastrojejunostomy (GJ) tubes during the COVID-19 pandemic, which highlighted complications and the need for timely recognition and management of nonfunctional GJ tubes[28], this report emphasizes the immediate and accurate placement of NJ tubes without the need for X-ray confirmation. The innovative approach reduced procedural time to ~11 min, allowed for immediate enteral feeding, and minimized healthcare personnel exposure, demonstrating improved procedural efficiency and patient outcomes in critical care settings.

The real-time imaging allows for immediate correction of the tube’s path, enhancing safety and reducing the probability of complications associated with tube misplacement. As observed in our study, the visual technique significantly shortens the procedure time, which is crucial in critical care settings where time is of the essence. By potentially eliminating the need for post-procedure X-ray verification, we reduce the radiation exposure to both patients and healthcare providers.

The effectiveness of this technique is heavily reliant on the availability and proper functioning of specific visual imaging equipment, which may represent a higher initial cost or require specific training. Currently, the broader applicability and long-term benefits of this technique need further validation through larger studies across diverse healthcare settings.

CONCLUSION

We recommend the adoption of bedside visual NJ tube placement with real-time imaging for severely ill COVID-19 patients requiring prone ventilation. This technique not only optimizes protection for medical personnel but also facilitates timely enteral nutrition for patients. The potential application of this method extends beyond COVID-19 patients to all ARDS patients requiring prone ventilation. However, the current number of cases employing this technique is relatively small, warranting further verification through an increased volume of operations and data analysis to validate the effectiveness and safety of this innovative tube placement technique.