alexa Open versus Closed Tube Feeding in Critically Ill Patients–Which is the Best? | OMICS International
ISSN: 2155-9600
Journal of Nutrition & Food Sciences

Like us on:

Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Open versus Closed Tube Feeding in Critically Ill Patients–Which is the Best?

Sewify K1* and Genena D2

1Adult ICU Department, President of Critical Care Educational Support Professionals, Saudi Arabia

2Department of Clinical Nutrition, Medical Research Institute, University of Alexandria, Saudi Arabia

*Corresponding Author:
Sewify K
Senior Consultant Intensivist
Adult ICU Department
President of Critical Care Educational Support Professionals
Saudi Arabia
Tel: +966544802229
E-mail: [email protected]

Received Date: July 13, 2017; Accepted Date: July 25, 2017; Published Date: July 31, 2017

Citation: Sewify K, Genena D (2017) Open versus Closed Tube Feeding in Critically Ill Patients–Which is the Best? J Nutr Food Sci 7:621. doi: 10.4172/2155-9600.1000621

Copyright: © 2017 Sewify K, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Nutrition & Food Sciences


Although, Enteral Nutrition (EN) is a long established practice in critical care but, the ideal prescription and administration still represent a challenge. Patients admitted to intensive care unit, always receive less EN than the prescribed volume, leading to increase the risk of malnutrition, and contributing to negative hospital outcomes. Also contamination of the enteral formulations is very common and might lead to the occurrence of nosocomial infections in the form of diarrhea, bacteremia and pneumonia. EN delivery is available in two main systems: An Open System (OS) or Closed System (CS) which sometimes called a «Ready to Hang» system (RTH). Despite recognition of the importance of nutrition within the modern health agenda, evaluation of the efficacy of how such feeds are delivered (open or closed) is very limited. This review highlights current practice and areas of concern and establishes our current knowledge in this field.


Enteral nutrition; Diarrhea; Pneumonia; Contamination


Although Enteral Nutrition Therapy (ENT) is the optimum treatment option for patients with intact gastrointestinal tracts, the ideal prescription and administration still represent a challenge [1]. Patients admitted to hospital always receive less Enteral Nutrition (EN) than the prescribed volume, leading to increase the risk of malnutrition, and contributing to negative hospital outcomes (Figure 1) [2,3]. Enteral feeding is an excellent environment for microbial growth and has been associated with contamination and nosocomial infections [4,5].


Figure 1: Difference between prescribed energy and energy received from Enteral Feed.

A lot of studies have linked the occurrence of nosocomial infections in the form of diarrhoea, bacteremia and pneumonia to contamination of enteral feeding. Different factors are involved with the contamination of enteral formulations, including:

1. The quality of the ingredients.

2. Hygiene of the environment.

3. The people involved with preparation, distribution and administration of this feeding [6,7].

What are the Differences between Open, Closed and Semi-closed?

Open tube system

It needs a lot of manipulations.

Example: Ready-to-use cans and Powdered/sterilized formulas both requiring reconstitution with water.

Kitchen made tube feeds are usually stored for 24 h after preparation.

Recommended hang times are: 4 h for unsterilized formulas.

8-12 h for sterilized formula (hospital=8 h; home=12 h).

Modulars and additives need to be blenderized in a mixer.

Less than full strength as well and all these are considered manipulations (Figure 2) [8].


Figure 2: Example of Open Tube Feeding.

Semi-closed tube system: Semi-closed TF delivery systems consist of a semi-rigid container that requires a filtered vent to avoid air lock, which can stop flow of the formula, with a normal hang time approximately 24-36 h.

Closed tube system

Completely closed non-air dependent collapsible bag system has a hang time of 24-48 h. It consists of 500 mL, 1000 mL, and 1500 mL sterile formulas [9,10]. It is sometimes called RTH.

It has been developed mainly to reduce the nursing time needed to administer enteral nutrition and reduce the risk of bacterial contamination by requiring less handling [11,12].

What to Consider When Prescribing EN in Critically Ill Patients-Open, Semi-closed or Totally Closed Tube System?

In terms of patient safety and care, many questions have to be answered first before choosing the appropriate system:

1. Can we limit any source of contamination and infection?

2. How can we meet at least 60% of the patient’s nutrient needs safely?

3. Can we use the nursing time more efficiently?

4. Can we cut the cost–long-term cost?

5. Can we keep our staff satisfied and retain good people?

The answer to all these questions is yes if we used closed tube system because of it is very adventitious.

Does the use of a closed system for enteral feeding result in better outcomes when compared to an open system in the critically ill adult patient?

We have to understand that, the formula itself is sterile in open system (but not the bag it hangs in), while, the entire closed system (RTH) is sterile because it is not exposed to the outside environment. So, it is definitely associated with a reduced risk of contamination [13,14].

Therefore, potential risk reduction from nosocomial infection from contamination of enteral nutrition encourages many clinicians to select closed over open system. However, prospective trials did not reveal significant impact on the outcome. Clostridial difficile infection is one of the most life-threatening infections associated with hospitalized patients, especially those on EN and one of the measures to prevent this infection is by avoiding food contamination [15,16].

Only One level 2 study compared the incidence of bacterial contamination and diarrhoea using a closed system vs. an open system. The study concluded that less incidence of bacterial contamination and diarrhoea were more observed with the use of a closed system/aseptic technique of enteral nutrition administration vs. open system/routine (p=0.06) [17].

Some other studies revealed the association between longer hang times in the closed feeding system and increased percentage of prescribed EN, that actually received by the patient because of the longer hangs time [7,18].

Also Atkins and Phillips [19], revealed that open system provided patients with 74% (range 43-104%) of the ordered EN volume compared to 84% (range 59-101%) with closed system. Despite it involved a small number of patients, (n=60), this study suggests that the closed system may provide patients with a greater volume of their caloric needs, and confirms results found in other studies [7,18].

What are the criteria of unacceptable contamination of EN based on FDA Guidelines?

1. Any aerobic plate count for sample >10000 colony forming unit/mL.

2. Three or more samples exceeding 1000 cfu/mL.

3. Any pure culture of Bacillus cereus, Listeria monocytogenes, Staphylococcus aureus, or coliforms [20].

Where is the closed tube system in the current guidelines?

Guidelines endorse the use of closed systems: The National Institute for Clinical Excellence (NICE) Guidelines recommends strongly using closed feeding system [21]. ASPEN Guidelines stated that, usage of closed system enteral administration sets has been demonstrated to be safe for 24-48 h [22,23].


Open systems in acute care settings are linked to decreased nutritional intake and increased formula waste.

Significantly larger quantities of the prescribed diet were infused with the closed system compared with the open one. Formula waste varied from 20 to 60% with the open system compared with 3% for the closed system.

Closed system is very practical way of EN because of ease of use, longer hanging time, safety including less contamination and associated with better staff satisfaction and saves more nursing time. Any measures that can be taken to prevent bacterial contamination and a culture of safe practices while prescribing EN should be the goal.


Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

  • 28th World Nutrition Congress
    August 9- 10 2018 Manila, Philippines
  • 6th International Conference on Sports Nutrition & Fitness
    August 06-07, 2018 Tokyo, Japan
  • 27th World Congress on Diet, Nutrition and Obesity
    September 7- 8, 2018 Auckland, Newzealand
  • 17th World Congress on Nutrition and Food Chemistry
    September 13-15, 2018 London, UK
  • 8th Annual Congress on Probiotics & Functional Foods
    September 24-25, 2018 Tokyo, Japan
  • International Conference on Food Production and Preservation
    Oct 17-18, 2018 Ottawa, Canada
  • International conference on Probiotics and Prebiotics
    October 31 - November 01, 2018 San Francisco, USA
  • 30th International Conference on Nutraceuticals & Public Health
    November 5-6, 2018 Bangkok, Thailand

Article Usage

  • Total views: 1422
  • [From(publication date):
    July-2017 - Jul 21, 2018]
  • Breakdown by view type
  • HTML page views : 1336
  • PDF downloads : 86

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2018-19
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

+1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals


[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

© 2008- 2018 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
Leave Your Message 24x7