Unplanned removal of feeding tubes consumes resources and exposes patients to an increased risk of complications. Some of these complications are potentially fatal and mainly occur at the time of reinsertion of the nasoenteral tube itself. These complications can be averted by preventing dislodgement of the tube. Several methods of securing nasoenteral tubes have been developed over time. A range of adhesive tapes, septal sutures, nasal bridles and even football helmets (1) have been used to anchor nasoenteral tubes. There is increasing evidence showing that nasal bridles are effective at preventing tube dislodgement and may hence reduce complication rates.
Nasal bridles have been described since 1989 (2). A bridle is a length of material that enters one naris, loops around the nasal septum and exits the opposite naris. Today, there are two main techniques of creating a bridle. The ends of spare material are passed through each naris, retrieved through the oropharynx and tied to form a loop. The loop is then pulled from one of the naris, shortened and the ends tied again to form the bridle. This technique requires a physician to safely insert the bridle. The other technique makes use of the Applied Medical Technology (AMT) bridle© (Pro-Care Ltd, UK), a device that uses a magnetic retrieval system to aid the formation of the bridle around the nasal septum (3). It has been shown to be a simple, fast system that does not require specialized equipment and can be safely performed by nurses at the bedside (3).
Despite the advent of this simple device, bridling is still generally used only for high-risk patients or those in whom replacing the tube is deemed to be dangerous. Its limited use is likely due to a perceived increased risk of posterior epistaxis, stimulation of microbial growth that may promote sinusitis, major septal injury and patient discomfort. We conducted a systematic review to evaluate the efficacy and complication rate of nasal bridle compared to conventional methods.
Materials and methods
We searched for published and unpublished articles in June 2014 in seven electronic databases (MEDLINE, EMBASE, CINAHL, SCOPUS, the Cochrane Library, ProQuest Dissertations and Theses Global and Australasian Medical Index). The terms used were “nasal”, “bridle”, “loop”, “nasoenteral”, “nasogastric”, “nasojejunal”, “tube”, “secure” and “retain”. We searched for ongoing trials on Clinicaltrials.gov, WHO trial register and Cochrane DARE. We hand searched three journals (Critical Care Medicine, Journal of Parenteral and Enteral Nutrition and Nutrition in Clinical Practice) from 2004 to 2014, including articles only published online. We also hand searched abstracts from three conferences: Digestive Disease Week (2004–2014), American College of Gastroenterology Annual Scientific Meeting (2004–2014) and Clinical Nutrition Week (2010–2014). We contacted the manufacturer AMT and experts for relevant articles and ongoing research. We then searched the reference lists of the studies. If full texts of identified studies could not be readily obtained from online libraries, librarians, editors and identified contact person of relevant journals, publishers, manufacturers and authors were contacted for a copy of the missing articles. We also conducted a thorough search on the search engine Google for potentially available texts of the missing articles online.
Two reviewers independently screened titles and abstracts against the inclusion criteria. Any disagreements were resolved by discussion. Full texts of citations that met or could potentially meet the inclusion criteria were retrieved. These full texts were independently reviewed by two reviewers and discrepancies were resolved by consensus. Studies were included if they were systematic reviews, randomized controlled trials and comparative studies that compared nasal bridles with one or more other method of securing nasoenteral tubes. We excluded case reports, narrative reviews, editorial, letters, expert opinions and comments. Case series were included if direct comparisons were made before and after bridling. Case series were otherwise excluded. No restriction on age, language, year of publication or methodology quality were imposed.
Two reviewers independently appraised the quality of the study by using the validated Cochrane Collaboration’s tool for assessing risk of bias. Any discrepancies were resolved by consensus. For each included study, data extraction was conducted by one reviewer and verified by another. Discrepancies were resolved by consensus. The outcomes evaluated were rate of tube dislodgement, rate of tube replacement, tube dwelling time, quantified enteral nutrition, cost, complications including emotional distress, and PEG-related morbidity and mortality. Extracted data was entered into a form that included characteristics of the study and outcomes measured. This form was initially trialed on ten random included studies. Relevant changes were made. The form was then deployed for all studies.
Results of search
During the primary search, 2,750 titles and abstracts were screened, and 53 potential studies were identified based on the inclusion and exclusion criteria. Of these 53 studies, 15 were included in this study and the full texts of two could not be obtained. Six potential further studies were identified from the secondary search. After reviewing the full texts against the inclusion criteria, three were included and one excluded. The full texts of the other two studies could not be sourced. Of the missing texts, two are from discontinued journals, one is an abstract from a 1980 conference and one is from a European journal.
Characteristics of included study
A total of eighteen studies were included in this review (Tables 1,2). Only two of these were randomized controlled trials (4,5). One was a meta-analysis (6) and one was a systematic review (7). Each study was reviewed for risk of bias (Table 3). Data from >1,038 patients were included. One study (8) did not report the number of patients included in the study. Five studies (3-5,9,10) compared nasal bridles to adhesive tape while only two (11,12) compared bridling to septal sutures. Nine studies (8,13-20) did not specify which method was used for the control group or before nasal bridling was deployed. The meta-analysis (6) compared bridling to adhesive tape only. The systematic review (7) aimed to include any article that compared at least two methods of securing nasoenteral tubes. Only one (8) of the included eighteen studies was conducted in a pediatric cohort.
Nasoenteral tube dislodgement
Eight studies reported a significant decrease in nasoenteral tube dislodgement with bridling than with conventional methods (3,4,9,10,13,14,17,18,). Similarly, two studies (5,9) reported that nasal bridling significantly decreased the rate of tube replacement. A meta-analysis of five studies by Bechtold et al. reported dislodged tubes in 14% of the patients in the bridle group compared to 40% in the adhesive tape group (OR 0.16, 95% CI: 0.10–0.27, P<0.01) (6).
Carey et al. compared the weight required to dislodge nasogastric tubes secured with anterior septal sutures and nasal bridles in cadaveric sheep (11). If secured by a septal suture, the nasogastric tube would sustain a weight of 4.5 kg, distort at 5 kg, and snap with a 5.5 kg weight. Bridled tubes were consistently intact up to a weight of 15.5 kg. At 16 kg, the nasogastric tube itself snapped, leaving the bridle intact. No damage to the septum was observed.
Four studies reported nasoenteral tubes secured with nasal bridles remaining in situ for significantly longer than conventional methods (3,4,14,20). One study compared nasal bridles to septal sutures and did not find a statistically significant difference in tube dwelling time (12).
Delivery of targeted nutrition
Five studies (4,5,15,16,18) evaluated the effect of nasal bridling on the proportion of prescribed feed delivered to patients via nasoenteral tubes. All five studies reported that feed delivery significantly increased with the use of bridles.
Only two studies evaluated the impact of nasal bridling on cost. Beavan et al. found mean cost per patient was higher in the bridle group (£426 vs. £338) (5). This was attributed to the use the AMT bridle© (Pro-Care Ltd, UK) which cost £76 each and an estimated £5.20 increment per extra percent of prescribed feed delivered. However, Seder and Janczyk estimated they saved $4038 over the 3-month study period (10). They fashioned nasal bridles themselves using 8-Fr red rubber catheter and, later, 1/8-inch umbilical tape. The bridles cost only $6 per patient. The $4,038 savings was calculated by estimating how many replacements were avoided. This was an estimated 16 nasoenteral tube replacements during the study period. Two of these sixteen would have likely required fluoroscopy which costs $875 each.
Five studies (3,5,17,19,20) reported a higher incidence of self-limiting episodes of epistaxis with bridling, mostly due to insertion of the bridle itself. Seven studies evaluated the incidence of nasal ulceration and other superficial complications. Three (4,10,13) reported a higher incidence in the bridle group, three (5,8,9) observed no significant difference with either method and the last was a meta-analysis (6) of 4 studies. The later meta-analysis found 13% of patients with nasal bridles had skin complications compared to 3% of the adhesive tape group (OR 4.27, 95% CI: 1.79–10.23, P<0.01). Seder et Janczyk observed that nasal ulceration was secondary to using 8-Fr rubber catheter and no further incidence was documented when the rubber catheter was substituted by 1/8-inch umbilical tape (10).
No study reported any significant injury secondary to a dislodged tube attached to a bridle. Two studies (4,9) compared the incidence of sinusitis and both reported two cases of sinusitis with conventional methods and none in the bridle group.
Pain and distress
Only two studies assessed the impact of nasal bridling on pain or distress. Beavan et al. (5) reported 19 of 43 (44%) patients in the bridle arm and 16 of 41 (39%) patients in the control group found the insertion of NGT distressing. In the same study, 12 (28%) and 17 (41%) in the bridled and control group respectively experienced day-to-day discomfort. Al-Khudari et al. (12) observed that overall pain did not differ significantly between bridling and septal sutures. However, up to 9 days post tube insertion, pain secondary to the securing method itself was significantly less with bridling (P<0.05) but was not statistically different after 10 days (P=0.7).
Mortality and morbidity post-acute stroke
Two studies (16,19) reported 30 day-mortality post PEG insertion fell after routine bridling was introduced. On the other hand, Beavan et al. concluded that, in a cohort of patients with severe dysphagia post acute stroke, the outcomes were similarly poor in both the conventional and bridled arms (5).
We conducted this systematic review to evaluate the effectiveness and complications of securing nasoenteral tubes using nasal bridles. We found that nasal bridling was associated with a lower rate of tube dislodgement, higher percentage of targeted feed received, decreased use of imaging and, potentially, decreased costs and distress to the patient compared to conventional methods of securing nasogastric tubes. However, there was a higher incidence of minor nasal complications but no significant increase in major complications such as posterior epistaxis, sinusitis or substantial trauma to the septum. Overall, we found that the nasal bridle is a safe and effective method of securing nasoenteral tubes.
Enteral feeding is associated with a lower complication rate, attenuated inflammatory responses and shorter recovery time (21-23). Villet et al. showed that, in intensive care patients, a higher proportion of delivered prescribed nutrition decreased infection rate, length of mechanical ventilation and length of stay in intensive care unit (24). Nasal bridling reduces tube dislodgement rates and, hence, increases the reliability of feeding via enteral tubes. This suggests that nasal bridling can improve complication rates and patient outcomes by ensuring sustained feeding of patients.
Reducing dislodgement rates also means a lower rate of tube replacement. This, in turn, decreases the exposure of individual patients to the procedural risks of enteral tube placement. The risk of complications from nasoenteral tube insertions has been reported to be as high as 20% (25). The most common are endotracheal intubation and aspiration pneumonia but intraperitoneal, intravascular, mediastinal and intracranial intubation have also been reported (25). All of these complications are potentially fatal and can be avoided by decreasing the risk of tube dislodgements with the routine use of nasal bridles.
A lower rate of nasoenteral tube replacement may also decrease patient and staff’s distress. Beavan et al. reported that distress or perceived distressed secondary to insertion and replacement of nasogastric tube was reported by nearly 40% of the patients or their nurse (5). Further, nearly 85% of patients included in the study had cognitive impairment and were unable to give consent for the procedure. This suggests a significant number of patients, particularly stroke patients, have a limited understanding of the need for enteral tube insertions and their replacement if dislodged. This may exacerbate the feeling of distress. Using nasal bridling to reduce the frequency of nasoenteral tube replacements may, hence, reduce distress of patients and contribute to a more positive patient experience.
The impact of bridling on cost was ambivalent. Seder and Janczyk (10) fashioned bridles themselves using rubber catheter or 1/8-inch umbilical tape which cost only $6 per patient, and potentially avoided 2 videofluoroscopy and 14 bedside replacements during the study period. This translated to an estimated total savings of $4,038. On the other hand, Beavan et al. reported higher costs in the bridle group (5). This was attributed to using the AMT bridle© (Pro-Care Ltd, UK) which cost £76 each and an additional £5.20 per extra percent of targeted nutrition delivered. This suggests that cost of implementing routine bridling depends on the population, frequency at which costly imaging are routinely performed for nasoenteral tube insertion such as videofluoroscopy and whether a device is used to fashion the bridle or it is done by a clinician using cheaper material.
Bridling was associated with a higher rate of minor nasal trauma but not major complications. The incidence of minor nasal trauma, such as minor epistaxis and mucosal ulceration, secondary to nasal bridles was inconsistent. Three out of six studies (5,8,9) did not observe more frequent minor nasal trauma with 1/8-inch umbilical tape bridles. This suggests that there may be other factors impacting on the incidence of these minor complications, such as ensuring the bridle is tension-free at the time of insertion and regular application of lubrication to reduce friction. Conversely, our review found no reported major complications, such as posterior epistaxis or septal injury, even if the nasoenteral tube was forcefully removed by patients. Despite a higher incidence of minor nasal complications, nasal bridles are overall safe devices for securing nasoenteral tubes.
It has been suggested that nasal bridling may reduce the rate of PEG insertion and its associated complications (16,19). Two studies (16,19) found that reliable feeding due to using nasal bridles allowed patients to recover their swallowing ability and, hence, avoid PEG insertion. However, the randomized controlled trial by Parks et al. demonstrated that, in a population of acute stroke patients with high risk dysphagia, there was no significant difference in the rate of PEG insertion between the bridled and conventional group (9). The evidence is not sufficiently robust to conclude whether or not bridling may prevent PEG placement but it suggests that nasal bridling may avoid PEG placement in patients with mild to moderate dysphagia.
Our study had several limitations. Only 50% of the included studies reported the method used in the control group. This limited our ability to perform sub-group analysis and, particularly, evaluate how nasal bridling compared to septal sutures alone. The quality of the studies varied with only two being randomized controlled trials, potentially resulting in selection bias and overestimation of intervention effect. Most studies only followed the patients until the tube was dislodged or intentionally removed. Consequently, inferences on long-term benefits of nasal bridling should be made with caution.
Lowering the rate of nasoenteral tube dislodgement using nasal bridles has considerable benefits, including reliable enteral feeding, shortening recovering time and lowering complication rates. However, nasal bridling is associated with a higher rate of minor complications, particularly self-limiting epistaxis and nasal septal ulceration. Nonetheless, the substantial benefits of sustained nutrition far outweigh the minor complications due to nasal bridles.
Optimal feeding due to bridling of nasoenteral tubes may also allow dysphagic patients more time to recover swallowing and, hence, avoid PEG insertion. Further randomized controlled trials are required to evaluate this potential benefit and its impact on PEG-related morbidity and mortality. Further research in the paediatric population is needed to evaluate whether nasal bridles are effective and, more importantly, at what age they can be safely inserted in children.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Lynch A, Tang CS, Jeganathan LS, Rockey JG. A systematic review of the effectiveness and complications of using nasal bridles to secure nasoenteral feeding tubes. Aust J Otolaryngol 2018;1:8.