Institutional members access full text with Ovid®

Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure

Rice, Todd W. MD, MSc; Mogan, Susan RN; Hays, Margaret A. RN, MSN; Bernard, Gordon R. MD; Jensen, Gordon L. MD, PhD; Wheeler, Arthur P. MD

doi: 10.1097/CCM.0b013e31820a905a
Clinical Investigations

Objective: Enteral nutrition is provided to mechanically ventilated patients who cannot eat normally, yet the amount of support needed is unknown. We conducted this randomized, open-label study to test the hypothesis that initial low-volume (i.e., trophic) enteral nutrition would decrease episodes of gastrointestinal intolerance/complications and improve outcomes as compared to initial full-energy enteral nutrition in patients with acute respiratory failure.

Design: Randomized, open-label study.

Patients: A total of 200 patients with acute respiratory failure expected to require mechanical ventilation for at least 72 hrs.

Interventions: Patients were randomized to receive either initial trophic (10 mL/hr) or full-energy enteral nutrition for the initial 6 days of ventilation.

Measurements and Main Results: The primary outcome measure was ventilator-free days to day 28. Baseline characteristics were similar between the 98 patients randomized to trophic and the 102 patients randomized to full-energy nutrition. At enrollment, patients had a mean Acute Physiology and Chronic Health Evaluation II score of 26.9 and a Pao2/Fio2 ratio of 182 and 38% were in shock. Both groups received similar durations of enteral nutrition (5.5 vs. 5.1 days; p = .51). The trophic group received an average of 15.8% ± 11% of goal calories daily through day 6 compared to 74.8% ± 38.5% (p < .001) for the full-energy group. Both groups had a median of 23.0 ventilator-free days (p = .90) and a median of 21.0 intensive-care-unit-free days (p = .64). Mortality to hospital discharge was 22.4% for the trophic group vs. 19.6% for the full-energy group (p = .62). In the first 6 days, the trophic group had trends for less diarrhea (19% vs. 24% of feeding days; p = .08) and significantly fewer episodes of elevated gastric residual volumes (2% vs. 8% of feeding days; p < .001).

Conclusion: Initial trophic enteral nutrition resulted in clinical outcomes in mechanically ventilated patients with acute respiratory failure similar to those of early full-energy enteral nutrition but with fewer episodes of gastrointestinal intolerance.

From the Division of Allergy, Pulmonary, and Critical Care Medicine (TWR, SM, MAH, GRB, APW), Vanderbilt University School of Medicine, Nashville, TN; and Department of Nutritional Sciences (GLJ), Pennsylvania State University, University Park, PA.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.ccmjournal.com).

Supported, in part, by grants K23HL81431 (TWR), P30DK058404 (TWR), and 1 UL1 RR024975 (TWR, GRB) from the National Institutes of Health (Bethesda, MD).

Dr. Rice, Dr. Bernard, and Dr. Wheeler received funding from the National Institutes of Health. The remaining authors have not disclosed any potential conflicts of interest.

ClinicalTrials.gov registration: NCT00252616.

For information regarding this article, E-mail: todd.rice@vanderbilt.edu

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins