COMMENTARY

Lung Injury and Feeding in the ICU

Greg Martin, MD

Disclosures

April 13, 2012

Initial Trophic vs Full Enteral Feeding in Patients With Acute Lung Injury: The EDEN Randomized Trial

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al
JAMA. 2012;307:795-803

Summary

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are common forms of respiratory failure in intensive care units,[1] and there is uncertainty about when and how to feed patients with these conditions.[2,3] A recent study by the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network found that antioxidant-supplemented enteral nutrition did not improve outcomes.

Participants were randomly assigned to receive either trophic or full enteral feeding for the first 6 days, after which a regular full-feeding protocol was used. They also were randomly assigned to receive either early or later enteral nutritional support. In total, 1000 patients were enrolled.

As expected, the full-feeding group received more enteral calories than the trophic-feeding group for the first 6 days (~1300 kcal/d vs 400 kcal/d; P < .001). There were no differences between the 2 groups in the duration of mechanical ventilation (number of ventilator-free days), 60-day mortality (23.2% vs 22.2%; P = .77), or infectious complications.

Despite receiving more prokinetic agents, the full-feeding group experienced more vomiting (2.2% vs 1.7% of feeding days; P = .05), elevated gastric residual volumes (4.9% vs. 2.2% of feeding days; P < .001), and constipation (3.1% vs 2.1%; P =.003). Glucose levels and insulin administration were greater in the full-feeding group during the first 6 days. The investigators concluded that a strategy of initial trophic enteral feeding for up to 6 days compared with full enteral feeding in patients with ALI did not improve clinical outcomes but was associated with less gastrointestinal intolerance.

Viewpoint

This large study is relatively definitive in showing that for patients with ALI, a delay in initiating enteral nutritional support for up to 6 days does not result in worse outcomes. In fact, it suggests that there may be benefits in terms of gastrointestinal symptoms.

Why this study differs from the pilot study, which found benefits for earlier enteral nutritional support, remains uncertain. Regardless, the trial was large and well conducted, and its findings take precedence over the earlier results.[4]

The practice of providing enteral nutrition should be the current standard of care in patients with ALI, with delays up to 6 days and even feeding via gastric tubes rather than the more time-consuming and costly postpyloric tubes. (Enteral nutrition in this current study was delivered via gastric tubes in more than 85% of the patients.) Of course, these results do not apply to patients who cannot receive enteral nutrition or those with severe nutritional deficits, as they were not included in this study.

Abstract

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