Follow Your Gut: Challenges in Nutritional Therapy During the COVID-19 Pandemic

Dear Editor:

We have read with great interest the article entitled “Donning a New Approach to the Practice of Gastroenterology: Perspectives from the COVID-19 Pandemic Epicenter” by Dr Sethi et al.¹ Their review comprehensively discussed the different implications of coronavirus disease 2019 (COVID-19) to the gastrointestinal (GI) practice from the repurposing of endoscopy units and GI services to the care of patients with preexisting GI diseases and even to the emotional and leadership aspects of the pandemic. We are particularly interested in their discussion of enteral nutrition and access, because we also receive referrals for percutaneous endoscopic gastrostomy (PEG) placements even in this time of pandemic. As gastroenterologists, aside from providing nutritional access, we also encounter several challenges in the nutritional therapy of our patients. We aim to highlight these nutritional dilemmas while also providing evidence-based recommendations.

Despite the viral effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the GI tract, enteral nutrition is still the preferred method of nutrition therapy for patients with COVID-19 because of its multiple benefits in the gut. It supports the structural and functional integrity of the gut, thereby modulating systemic immunity, attenuating disease severity, and favorably affecting patient outcomes.² However, the presence of GI symptoms such as anorexia, nausea, vomiting, or diarrhea in some patients with COVID-19 complicates this challenge to feed the patient.

There are several routes where feeding can be administered. If nutritional requirements are not met orally, enteral nutrition via a nasogastric tube (NGT) is recommended. If still unable to reach targets and if all strategies to maximize enteral nutrition intolerance have been attempted, nasojejunal tube (NJT) feeding or parenteral nutrition should be considered.³ In the context of the pandemic, placement of these tubes is not without risks. Placement of enteral access such as an NGT or NJT is an aerosol-generating procedure; hence, proper personal protective equipment should be used.⁴ Its placement should prioritize the safety of both the patient and the healthcare workers. A large-bore NGT may be used because it has less risk of tube occlusion during feeding, but it should be replaced with a more pliable tube of smaller diameter within 5–7 days to improve patient comfort and reduce morbidity.⁵

Consensus guidelines suggest that patients who are likely to require enteral nutrition for >30 days should be considered for placement of a PEG tube.⁶ However, the timing of PEG tube insertion during the pandemic is a dilemma in itself because of the risk of aerosolization. We agree with Dr Sethi and colleagues in their proposal to delay the PEG tube insertion until the patient has shown clinical improvement and a probable chance of discharge. Therefore, enteral nutrition via NGT should be continued while waiting for the appropriate time to do the procedure.

Another challenge in the nutritional therapy is the proning maneuvers done to patients with COVID-19. Historically, there is apprehension to feed patients in prone position in view of the relatively flat body position and increase in abdominal pressure of these patients, thereby with risk of aspiration. However, studies have shown that enteral feeding in the prone position is safe and is not associated with increased risk of pulmonary or GI complications.⁷ It is recommended to keep the head of the bed elevated or in a reverse Trendelenburg position to at least 10°–25°.³ We also suggest to hold feeding temporarily for 1 hour when shifting positions to further decrease aspiration risks.

The most challenging issue in the nutritional therapy of these patients probably is the problem of GI intolerance. Reported in up to 60% of critically ill patients, it is important for clinicians to understand its etiology to ensure enteral nutrition delivery can be optimized and not inadvertently halted.⁸ For COVID-19 patients, it is usually due to multifactorial reasons that include the disease severity, multiple sedative drugs, and prone positioning. We hypothesize that it could also be aggravated by the effects of the SARS-CoV-2 infection in the GI tract. GI intolerance can manifest as nausea, vomiting, diarrhea, or abdominal distention.³ Measurement of gastric residual volume is controversial because nutrition societies have different views. Nevertheless, there are several methods that can be done to address GI intolerance. Prokinetics can be administered. Enteral feeding rate can be reduced. Semi-elemental formula can be used. Finally, parenteral nutrition or post-pyloric feeding should be considered with persistent GI intolerance.

In conclusion, we recognize that there could be potential challenges in the nutrition therapy of our patients. Fortunately, there are several solutions for these dilemmas, and by giving due priority to patient’s nutrition, we can improve clinical outcomes. As they say, “follow your gut as it is always right.”