HINT: How are nasal bridles used to secure enteral tubes in home and community?
Connected Care Quick Hits are up to date and evidence based recommendations for the care of children with medical complexity & technology dependence, from hospital to home.
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SITUATION:
This QuickHit was developed to promote best practices for the securement of enteral tubes using nasal bridles in home and community.
BACKGROUND:
Many children with medical complexity rely on enteral feeding tubes to support nutrition, hydration, and/or medication administration in home and community. Nasal enteral tubes are commonly used and include nasogastric (NG), nasoduodenal (ND) and nasojejunal (NJ) tubes. Since these enteral tubes are inserted through a child’s nose, it is important to ensure that they are secured appropriately to prevent accidental dislodgements.
Nasal bridles are an alternative type of securement device for nasal enteral tubes that may be used in home and community, particularly for children that are at risk for frequent dislodgements, have skin sensitivities to adhesives (e.g., tape) and/or have a complex history of difficult tube use (e.g., difficult insertion, aspiration due to dislodgement).
Image taken from AMT website
ASSESSMENT:
The two main methods of securing nasal enteral tubes are tape and nasal bridle.
Tape: Preferred method of nasal enteral tube securement. Most cost effective and easily replaced. Hypoallergenic (i.e., Hypafix) and/or hydrocolloid (i.e., Duoderm) tapes are commonly used.
Nasal Bridle: Silicone device that is inserted through one nostril and is looped around a bone in the back of the nose and comes out through the other nostril. The device has a plastic clip to secure the enteral tube in place.
The type of securement device that is used will be determined by the child’s primary care provider. Nasal bridles are indicated in the following circumstances:
Risk of frequent nasal enteral tube dislodgement that cannot be managed by other strategies
Skin condition prohibiting use of tape securement (e.g., excoriation, burns, eczema, rash, skin adhesive allergy)
Complex history of difficult enteral tube use (e.g., difficult tube placement, aspiration due to dislodgement)
Skin treatment that compromises tape securement (e.g., Vaseline, face creams)
RECOMMENDATION:
Connected Care recommends that home and community providers confirm with family caregivers that there is a plan for changing nasal bridles at least every four weeks. An action plan for unexpected dislodgements or other issues with the nasal bridle and enteral tube is also required.
At the beginning of every shift, for the child's safety and comfort:
Assess the child’s skin integrity frequently and check that the clip is not causing any pressure, redness, sores or pain to the nares or surrounding areas. Skin barriers may be used to prevent skin breakdown.
Clean the clip with soap and water using a cloth or gauze daily. Gently remove any build up from the enteral tube or nose to keep the nare patent.
Confirm appropriate placement and securement of the nasal bridle. The clip should be about 0.5 cm away from the child’s nose. The nasal bridle is secured with knots beneath the enteral tube (not around the enteral tube to avoid pinching).
Confirm appropriate placement of the enteral tube prior to each use and at regular intervals if feeds are continuous.
For ND and NJ tubes, check placement by verifying the internal length (marking on enteral tube) and measuring the external length.
For NG tubes, check placement using pH testing of the gastric aspirate.
Ensure the nasal bridle opening tool remains with the child at all times in case there is a need to adjust or remove the device.
If the clip of the nasal bridle must be opened for adjustment or removal, place the side of the opening tool in the side of the clip and turn it slightly to open (as shown in the first image below). If an opening tool is not available, pull each side of the clip on the bridle away from each other in an upward and downward motion until it opens (as shown in the second image below).
Images taken from AMT website
Contact the child’s primary care provider and/or seek medical attention if the following signs or symptoms are noted:
Bloody nose
Visible sores
Increased or discoloured fluid coming out of the child’s nose
Reports of headache or pain in the nose
Tube or clip not in the original position
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