Effect of intragastric versus small intestinal delivery of enteral nutrition on the incidence of pneumonia in critically ill patients: a complementary meta-analysis

Critical Care, Jul 2014

Wan-Jie Gu, Jing-Chen Liu

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Effect of intragastric versus small intestinal delivery of enteral nutrition on the incidence of pneumonia in critically ill patients: a complementary meta-analysis

Critical Care Effect of intragastric versus small intestinal delivery of enteral nutrition on the incidence of pneumonia in critically ill patients: a complementary meta-analysis Wan-Jie Gu 0 Jing-Chen Liu 0 0 Department of Anaesthesiology, the First Affiliated Hospital, Guangxi Medical University , Nanning 530021, Guangxi , China As intensive care specialists with a long-time interest in the relative pros and cons of intragastric and small intestinal delivery of enteral nutrition in critically ill patients, we greatly enjoyed reading the excellent metaanalysis performed by Deane and colleagues based on randomized clinical trials (RCTs) [1]. The analysis demonstrated small bowel feeding was associated with a reduced risk of pneumonia (relative risk (RR) 0.75; 95% CI 0.60 to 0.93; P = 0.01). The authors concluded that use of small intestinal feeding may reduce the incidence of ICU-acquired pneumonia. Although this result has significant clinical implications, one important issue should be addressed. Based on the same articles used by Deane and colleagues [1], we performed a complementary meta-analysis to reappraise the effect of intragastric versus small intestinal delivery of enteral nutrition on the incidence of pneumonia. The data extracted from the 12 RCTs were stratified by population (trauma versus non-trauma population). It was shown that small bowel feeding was associated with a reduction in the incidence of pneumonia in trauma (four RCTs; RR 0.67; 95% CI 0.52 to 0.87; P = 0.003; references [2-5] in the article by Deane and colleagues), but no reduction in non-trauma population (eight RCTs; RR 0.86; 95% CI 0.58 to 1.26; P = 0.43; references [6-13] in the article by Deane and colleagues) (Figure 1). What is noteworthy is that the rate of pneumonia reported in the trauma population was approximately two to three times higher than that in the non-trauma population (trauma versus non-trauma population: 132/293 (45.1%) versus 131/683 (19.2%)). This potentially further limits the generalizability of the conclusions from the study of Deane and colleagues. - Adam M Deane, Rupinder Dhaliwal, Andrew Day, Emma J Ridley, Andrew R Davies and Daren K Heyland In response to our systematic review [1] it has been suggested that the reduction in pneumonia observed with small intestinal delivery occurs only in patients following trauma. Following traumatic injury, patients are at risk of developing enteral feed intolerance [2], and it is intuitive that these patients will have greater capacity to benefit from small intestinal feeding [3]. Furthermore, injuries frequently demand that patients remain without head elevation, positioning that increases the risk of developing pneumonia [4]. There is, therefore, a strong biological plausibility that this population will benefit from small intestinal feeding to a greater extent than other populations. However, inferences about subgroup effects in systematic reviews should be made cautiously, as comparisons must be consistent between and within studies [5]. Several of the studies included by Gu and Liu as nontrauma population were studies performed in mixed medical/surgical ICUs. Indeed, several of these studies 2014 Gu and Liu; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Figure 1 The 12 studies reporting the incidence of pneumonia used for the complementary meta-analysis. RR, relative risk (small bowel feeding versus gastric feeding). actually included a proportion of patients following traumatic injuries. On detailed analysis of demographic data from the Montecalvo (reference [30] in our study), Davies 2012 (reference [21] in our study), Davies 2002 (reference [32] in our study) and White (reference [18] in our study) studies (Figure 1), 39%, 37%, 27% and 8%, respectively, of enrolled patients were admitted following trauma and were included in the complementary meta-analysis but were grouped in the non-trauma population. While this complementary meta-analysis is of interest, it may be explained by differences between studies and/ or by chance. Accordingly, we suggest that further analysis, using individual patient data meta-analysis, is required before the observation by Gu and Liu can be considered hypothesis generating. 1. Deane AM , Rupinder D , Day AG , Ridley EJ , Davies AR , Heyland DK : Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis . Crit Care 2013 , 17 : R125 . 2. Gungabissoon U , Hacquoil K , Bains C , Irizarry M , Dukes G , Williamson R , Deane AM , Heyland DK : Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness . JPEN J Parenter Enteral Nutr 2014 , [Epub ahead of print]. 3. Chapman MJ , Nguyen NQ , Deane AM : Gastrointestinal dysmotility: clinical consequences and management of the critically ill patient . Gastroenterol Clin North Am 2011 , 40 : 725 - 739 . 4. Metheny NA , Stewart BJ , McClave SA : Relationship between feeding tube site and respiratory outcomes . JPEN J Parenter Enteral Nutr 2011 , 35 : 346 - 355 . 5. Sun X , Ioannidis JP , Agoritsas T , Alba AC , Guyatt G : How to use a subgroup analysis: users' guide to the medical literature . JAMA 2014 , 311 : 405 - 411 .


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Wan-Jie Gu, Jing-Chen Liu. Effect of intragastric versus small intestinal delivery of enteral nutrition on the incidence of pneumonia in critically ill patients: a complementary meta-analysis, Critical Care, 2014, 450, DOI: 10.1186/cc13978