PEG

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[0:16] Guys and welcome to Speech Talk. I'm Emily. And I'm Eva. This week we're going to be talking the world of enteral nutrition. The bonus point question is what does the PEG acronym stand for? Drumroll. It is percutaneous endoscopic gastrostomy and I have to use over articulation to get that out. Yeah and I couldn't spell that if my life depended on it. Yeah, way too many letters. Like my little hangman guy in hangman would be dead. Fully hangin'. I use like one vowel and get confused. Yeah, well, if you would use E, it would show up like a hundred times in there. So this week we read the absolutely thrilling paper by Ravnamay Azar et al.

[1:09] Percutaneous endoscopic gastrostomy. Indications, technique, complications, and management. And as far as I'm concerned, this article is like its own 101 course on pegs. It covers all the steps from considering peg tube eligibility to post-procedural complications. So, Emily, tell us why we're talking about pegs today. So, pegs have become one of the most common alternatives for feeding for people who, for whatever reason, aren't eating orally. And while we're certainly not GIs, not cheap GIs, people ask us whether pegs should be placed and ask us to deal with them once they've been placed and generally seem to think we're experts on internal feeding. All right. Yeah. So we have to maintain that really fine line between having an opinion and not being qualified to have an opinion because we don't have that degree. And we thought it'd be helpful to review some key points about PEGTUBE with you guys.

[2:14] So here, the article talks about patients who may be appropriate for a two placements, people who have degenerative diseases like ALS, people who have a head injury, etc., etc., and if the patient and their family want to pursue that alternative nutrition. Yeah. So what are the main pros of PEGS? They've been shown to really effectively manage weight. So if people aren't eating for whatever reason and they need to maintain their weight, PEG tubes are a really good option. It stimulates the gut and it doesn't have the same risks that TPN has with administering nutrition through your veins. Also the cost, like there's a big cough differential between TPN and PEG tube. But cons, so the biggest being infection and internal organ damage from the tube. When people think about getting a peg tube placed, a lot of times they're considering it for a really long period. They're like, my mother can't eat anymore. She has dementia. Why don't we just put in a peg tube? And peg tubes are fantastic. Like all of your systems are working. But say you had a traumatic face injury and just literally can't get food down. Being able to maintain weight and nutrition by a peg tube is fantastic while you're rehabilitating.

[3:32] But their lowest infection risk period is short after a certain amount of time just becomes like a tube that can go into your body that can be prone to get dirty and has its own issues so like infections really are a problem they they have to be monitored anyways not to bring up sad things like infections from tubes that go from outside your body to into them. But we're going to move away from the article for a second and talk about contraindications and misconceptions that we see because, as we've said clearly throughout this episode, we are not GIs, but we do have a take on the situation. So let's take a look at one of the main things, which is folks with cognitive impairments. My hardest niche is that my, my cog people, it's like so hard, but people with cognitive impairments for specifically talking about maybe a, a, a bad TBI.

[4:33] Someone who's impulsive or someone with dementia who gets really confused, like they could pull their tubes. Yeah. I have this lady who she has dementia. She does not remember what her peg tube is for or her colostomy bag. And she's always yelling from her room. She's like, hey, help. And you go in, she's like, I gotta get this count off. I gotta get it off. And you're like, what's going on? She's like, there's this thing. I gotta do it. Help me take this off. She said, do you have scissors? I need to get this off. And I'm like, oh my God, please do not take off your colostomy or pull that tube.

[5:09] It's a huge problem. We have to get abdominal binders for her that are velcros that she like can't get into them easily but she's the main thing is that she never remembers what it is and she then always finds it and then is just completely distressed by it oh my god that's terrible yeah it's really bad and on the you know the next thing that we see a lot of with our.

[5:33] COG patients is combative care, making, you know, the administration of the bolus difficult. We just got this young guy, TBI by a car crash. He similarly does not remember what the PEG tube is. And I'm always like, it's a tube in your stomach for eating. It's a tube in your stomach for eating. Which one? He finds super weird. He's always like, a tube? My stomach? And I'm like, yeah, it's weird. Don't think about it too much. But he does not like getting the bolus push and he's always fighting the administration and so then you have to like have people try to like hold his hand so they can do the bolus and he's like yelling and it's it's like a really distressing event to attend if you're like in the room and you're watching like three people try to calm this kid who like cannot remember what's happening to him and why people are like pushing things through a tube into his stomach It's like, I mean, he is weirdly enough otherwise a really good candidate because he's young and really healthy, but does not change the fact that, like, it comes with some difficulties for him. Oh, man, that's terrible. I wonder, like, for him, too, like, what's the benefit of having a bolus feed versus a continuous feed at night if it's, like, traumatic? Yeah, you know what?

[6:51] I'm a follow-up on that and be like, look, he just does not like the continuous. I think it's because he also has a lot of impulsivity difficulties, and he wiggles around at night. So he needs the supervision to make sure he's getting the bolus feed? Yeah, and so when he sees or can feel the tube, he gets agitated. And I wonder if maybe seeing the continuous feed tube would be more of a visual stimulus. But I think it might be something that the family might look to consider if, you know, when he goes home, they find that he's decreased agitation in his own place because also like being in a sniff is very disarming yeah it is, Moving on from Eva's sad story. I know, fuck the sad stories. Hashtag healthcare. Having a PEG tube doesn't automatically eliminate aspiration. I've had people who, I mean, part of PEG tube care is making sure your patients are always elevated at that 45 degree angle. So they're not getting reflux, GERD, and aspirating their stomach contents from the nutritional supplement. Through the peg. We're professionals.

[8:05] So it is, I mean, it is important that we're educating patients. Like if you have a patient who is constantly coughing, choking, and aspirating on food and liquid, and they're like, well, why don't we just tube them up? Well, Sally, your problem is not necessarily solved.

[8:24] I love that. Tube them up. I watched a dude potentially aspirating the penetration aspiration line we don't quite yet know on just a giant chunk of phlegm today at lunch it was gross uh and it's just one of those things you're like that just came from his respiratory system like dude's got a cold it's germ's got some post-nasal drip it's building up in his throat like you can have that with a pig that just because you're not eating doesn't mean stuff isn't going down oh yeah you still got allergies to environment, making boogers. You've got stuff still in your throat.

[9:03] And then another issue is the inhibition of appetite. So for people who are no longer doing any oral intake, this is not really a concern. But for people who are doing oral intake and we want to be increasing the amount of oral intake, we need to make sure that We're really working with our teams, you know, with dietitians and, you know, family, the CNAs who are like really involved with mealtimes around, hey, what is the optimal feeding schedule by a PEG so that we can promote appetite and subsequently oral intake? It kind of like leads us into this next little topic thing with goals. If we're not trying to inhibit their appetite, then we have to make sure that we're giving them.

[9:57] As much time and opportunities to eat as they can because there's no swallow exercise quite like eating and swallowing. You've said it. There's no swallow exercise like eating. I love that. It truly is. And people with peg tubes, they can still residually swallow. They're still practicing swallowing their saliva just because they're not eating and drinking. They're still swallowing happening so they can be strengthening. So we want to make sure that even if you have someone here, your part B is there. Case load's low. Got some part Bs. We're checking out our two people first because we want them eating and drinking.

[10:43] Yes. And I think so many people think just turning over your med Bs is really scammy. But I have truly gone through, back when I was doing more long-term care, gone through Part B lists for PEG tubes, and some of them had gotten flagged in an audit, actually, for having indications that there was oral swallowing, but had been on a PEG for a really long time. And I went and I saw them, and I had both the patients, and the first guy could get some puree down, and so we were able to basically get him to a pleasure feed for a puree, which is great, because if you are bed-bound on a PEG tube, and you've been living this way for years turns out a little chocolate pudding really can brighten the day and the other guy could eat full meals oh my gosh who did anybody know about this oh i hate those stories i was just like oh my god dude if i had been left in this room and was being given no food orally not even like.

[11:46] Thin liquids and it turns out like i had been able to eat but like my documentation fell through the cracks i would just be so livid and so i was just like yeah so it really is go through those lists of who's on the tomb um and just go see what's up your caseload is long go ahead and be like you know what i'm gonna go see if betsy can sneakily actually get stuff down oh yeah and with uh instrumentals too because sometimes our people are on peg tubes because they're like bad aspirators so they're good well they're good bees to pick up you might irritate your dor.

[12:26] They're like by the way i need a fees and they're like no not a piece another one we could never get those that's the third one this week uh i know we're just the devil for wanting instrumental exams, um okay but to that kind of general discussion finding out why people are on a peg tube and what is the criteria for coming off i think this is kind of a sneakier way that people slip through the cracks which is that they're on a peg tube maybe they're doing some oral nutrition um but, what people stopped paying attention to was like portions of meals weight um and so really making sure you understand why someone's on a peg it's like okay right now they have wounds and we need to make sure they're getting all the nutrition possible, in order to help their body heal. You're like, oh, okay, I understand that when the wounds heal, let's check back in. So maybe not a pickup right now, but, when those wounds don't need to be changed three times a day, we'll circle back up. And the other one being like.

[13:31] Sorry, I just feel like I'm going to hiccup and I'm trying to swallow it. I really shouldn't fight it, is weight. I hear a lot of people are like, oh, they're on peg tube for weight. I look at their weights and I'm like, they're pretty stable. They haven't been losing anything. Now that could be because they're on the peg tube. But like, find out what's that target weight they're trying to reach. Once they reach it, make sure they're coming off or weaning at minimum. Because as we've been trying to point out, peg tubes are great. They have their role, but they also are not risk-free. So we want to reduce possible risk in terms of overall health for our patients.

[14:07] Yeah. And make sure we're having conversations with patients too about how they feel about peg tubes and being on and being off. I have, if we're talking, when talking about like degenerate diseases, one like Parkinson's, where we know that, you know, they could pretty much be on speech forever, right? They can be doing exercises forever, but they're still going to have degradation. They have a peg tube and you do exercises now that their swallow is good, but maybe they don't want to get off. Maybe they like to have that peg tube for peace of mind. And that's an individual play. That's a really good Good point, Emily. I feel like I haven't had a lot of PEG tube patients who were their own responsible parties or POAs. And so a lot of the kind of advanced cognitive capacity for having a conversation like that, I haven't had a lot of patients that way, but I think that's a really good point that we can.

[15:07] In my experience, it's mostly been conversations with families and they're like, Nana's not eating. How do we get her food? Well, we heard about a pig tube. But to your point, in the case where a person is able to participate in their own medical decisions, getting in there and talking to them and be like, do you like this? How do you feel? That's patient-centered care, Emily. I love it. Way to go. Yeah, and to your point about Nana not eating, so I like this article too because they talk about dementia specifically and said that for people who had dementia, the peg tube was actually a contraindication. So like if someone has dementia and they're generally decreasing weight, it's likely that they are coming to an end of life event.

[15:55] And a peg tube isn't going to, it's going to not going to stray that it's, that ends up just being a hard conversation with family. Like, yeah, man, man, it's not eating. And this is kind of, this is kind of what your body does. It doesn't need food when you're getting older. You stop to need food. Your body is not regenerating cells like it used to. It doesn't need as much food. And if it's your body steadily declining, then pumping somebody with food who is absolutely confused is not going to improve their quality of life or just prolonging the inevitable. Yeah i've definitely had some um conversations with people um because.

[16:41] Kind of sounds weird to say but like death is kind of stigmatized and people who are nearing end of life and they're not eating and if when you know you're there you go in you check on them they're fine they're not like in pain they're not saying i'm hungry when food is in front of them they're not even always recognizing it and i think a lot of times the impression i've got from families is Nana is dying. And if I don't do everything I can, I'm killing her. And I just like to take a second to say, you're not killing Nana. Yeah. Take that weight off of you. Yeah. She's just slowly heading to the light, you know, like just she can float away. And I realize that that's a very emotionally charged conversation for families, but people really take on a lot of burden around, like, if I don't do all medical interventions possible.

[17:33] You know, I'm a bad family member or like, you know, she raised me. Who am I to not do everything I can for her? And I, I, for those, I actually like, I enjoy being a part of those conversations, not because I like having hard conversations, but I like to reassure family members in those moments. Like, no, you're perfect. Like, this is hard.

[17:53] And like, they're not ever going to eat a same meal like me and you. Like they would not, someone who's in advanced dementia is not going to sit down and eat a full cheeseburger french fries and a milkshake like their body can't handle like a an adult american huge oh my god dude i was with this woman who her mother was at the sniff and she was like i really want to go for a peg tube and i was like she's not eating she's like well that's because therapy's insufficient going off on like everybody in every every department and I was like why don't you just come in and like watch us try to eat and during our bedside her mom tried to eat the sheets I was like she's not recognizing like food versus just random objects like we are not having the conversation like this conversation about prolonging her enjoyment of food and like that quality of life component I'm like she doesn't realize it's the bedsheets so like the peg tube is not gonna to your point i'm gonna like improve that quality of care like suddenly she's going to be enjoying meals again that was a hard conversation to have i'm not trying to convince families to like go hospice i think it should be, talked about way more often than it is but um no that that particular daughter was like.

[19:19] She's gonna eat and get nutrition by any means possible not it was kind of hard to watch at my facilities, they've always had hospice conversations led by nursing. Is that true for you, too, Eva? Different facilities are obtained in different ways. I have, in a majority of cases, been told, you do not bring up hospice, which is always tricky because... You do not. Do not say. You do not. Do not say the H word. It's a bad, bad word. But particularly when it comes to pegs and instances with dementia, you're like, it's usually because it's an end of life care decision. So it's kind of hard for hospice not to come up. So the way I kind of get around it is not saying like, hey, have you had the hospice talk? But I'm like, well, in consideration with PEG tubes, there's also palliative care and hospice. And, you know, here are some people in the building you could reach out to talk to about those options. So I just like gently put that card on the table and see what happens.

[20:23] Yeah, that's a good way to kind of just ease that conversation without saying, like, here's a brochure, you know. Here's a brochure. I imagine that it has a halo and wings on it. Big shout out to all our people doing hospice work, by the way. All right, let's talk about, I think we're moving on to, like, action items and what we can do. Is that right? Yeah. So for this, it's just for best practices for PEG tube management, we want to consider attending like workshops or taking CEUs just to kind of expand our knowledge further. And there's a lot on ASHA, but talk to your nursing, talk to your doctors, call hospital.

[21:05] I've talked to patients' GIs before because I once had a family member tell me that their GI doctor told them they could not come off a peg tube for yada, yada, yada, yada, yada, and I called their GI, and they're like, no, I never said that. That's not a thing. So it was a very productive conversation. We were able to upgrade to trials immediately. It's best practice to stay informed. It's not our scope of care to be doing all of the education on PEG tubes, but those questions are going to come up. It's distally related and it's totally okay if someone's asking you about a PEG tube consideration and you're just like, I don't know, man, let me get back to you. So I would much rather have someone tell me that they don't know and they'll help me find someone who can tell me or just listen to me for a second rather than feed me something that doesn't make sense. Yeah, would not like it if people just made up random medical advice. I'm looking for help in any dire situation. Lie to me. No, but like if I'm dying, you can lie to me.

[22:17] I'll lie to you. I'll be like this isn't a pillow approaching your face sleep go to sleep go to sleep Emily I would never smother you by the way I couldn't do it I'd put you on the hospice though, No, girl, I love you so much. I will put you on hospice. No, for the record, if I break, if it's a bad break, I'm going. Let me go. My mom is like, just roll me out to sea and put me overboard. No one will know what happened. I'm like, or not. Or I could just visit you every day at home peacefully until you go. Anyways, thanks for joining us this week. As always, we redo a little in-service. This one was to help provide some educational considerations on PegTubes based on the article. Leave us some comments. Let us know what you think. We want to know all your Unfiltered opinions about the podcast, the topic, and what you want to hear next. Do you have any issues at your placement that you want to workshop? Do you need some research for us to go over? Send us things. Yeah. Are there weird practices you want to know about that you're seeing at work? are there questions you have? We are happy to do the research for you. Yeah, happy, happy to do it. Until next time, thanks for joining us, everybody. Thanks.

[23:38] You've been listening to Speech Talk. Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research. If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, Because as podcasters, our love language is in positive affirmations. If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com. If you want even more Speech Talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more. We're your hosts, Eva Johnson and Emily Brady. Our editor and engineer is Andrew Sims. Our music is by Omar Benzvi. Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke. To learn about SpeechTalk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers. SpeechTalk is a proud member of the Human Rights Act.

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