Weaning from Ryle’s Tube Feeding to Oral Diabetes Diet in a patient with Diabetes, and with Respiratory Compromise

Weaning from ryle’s tube feeding to oral diabetes diet in a patient with diabetes, and with respiratory compromise

Archana R*

Senior Clinical Dietitian, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

*Correspondence

Abstract

Transitioning from Ryle’s tube (nasogastric) feeding to oral intake in patient with diabetes and respiratory compromises is a complex clinical process. It requires careful assessment of swallowing ability, respiratory stability and metabolic control. A gradual, monitored approach helps prevent complications such us aspiration, malnutrition, and glycemic fluctuations. This article outlines a structured protocol for safe and effective weaning.

Key words: Ryle’s tube; Nasogastric tube; Diabetes Mellitus

Introduction

Ryles tube feeding is commonly used in patients who are unable to maintain adequate oral intake due to critical illness or respiratory compromise. Nasogastric tube feeding is often used to provide optimal nutrition and hydration in patients with aspiration pneumonia. In diabetic patients, this process is further complicated by the need for strict glycemic control. Weaning from tube feeding to oral diet must therefore balance nutritional adequacy, airway safety and metabolic stability. A 75-year-old man with a history of Diabetes Mellitus, Hypertension, and Drug induced Parkinsonism, Pneumonitis and newly diagnosed Small vessel ischemic disease. Following a comprehensive nutritional assessment using the Patient-Generated Subjective Global Assessment (PG-SGA), an individualized, multidisciplinary nutritional support plan was initiated. This plan involved a gradually increase high-protein, high-calorie and enteral feeding with nutritional supplement, combined with dietary counseling. Following the intervention, the patient demonstrated a clinically significant weight gain.

Assessment of Readiness:

Before initiating Ryle’s tube feeding, a comprehensive clinical evaluation is essential:

Airway protection: Presence of intact cough and gag reflex.

Swallowing function: Ideally assessed by a speech and swallow therapist.

Respiratory stability: Minimal oxygen requirement, absence of distress during feeding.

Level of consciousness: Patient should be alert and cooperative.

Swallowing Trial and Diet Initiation:

Weaning begins with supervised swallowing trials:

Start with thickened liquids, as they are easier to control and less likely to be aspirated.
- Progress gradually to pureed and soft food.
- Monitor closely for signs of aspiration:
Coughing or choking.
Oxygen desaturation.
Wet and gurgling voice.

Successful tolerance of these trials allows progression to partial oral feeding.

Gradual Transition Strategy:

Abrupt discontinuation of tube feeding is not recommended. A stepwise approach ensures safety and nutritional adequacy.

25 % Oral intake+ 75 % tube feeding
50 % Oral intake + 50 % tube feeding
75 % Oral intake +25 % tube feeding
Full oral intake, followed by removal of the tube.

Advancement should occur every 24 – 48 hours based on patient tolerance and intake.

Nutritional Strategy during Transition:

Provide small frequent meals (5-6 per day)
Include high protein foods (dal, eggs, dairy and legumes)
Administer ONS between meals, not as meal replacements initially.

Monitoring and Adjustment:

Close monitoring is essential:

Daily intake assessment (Calories and protein).
Weight monitoring (weekly).
Blood glucose in diabetic patients.
Hydration status.

Adjust tube feeding and supplement quantity to oral intake.

Criteria for discontinuation of Ryles tube:

The tube can be removed when:

Oral intake meets >70 – 75 % of nutritional requirements.
Patient tolerates diet and supplements without difficulties.
No signs of aspiration
Clinical condition is stable.

Case presentation

A 74-year-aged man with 55kg of weight and 165cm of height was admitted with the following medial history.

Patient details:

Name : xxx
Age: 75yrs/ male
Lifestyle: Sedentary lifestyle
Past history: Diabetes mellitus, hypertension, drug induced Parkinsonism, pneumonitis.
Present complaints: Giddiness, vomiting, altered sensorial
Present diagnosis: Small vessel ischemic disease
MRI reports: Small vessel ischemic disease(newly diagnosed)
Date of admission: 11.2025
Date of discharge:11.2025
Los : 16 days

Course in the hospital

Patient was admitted with H/o alcohol binge followed by giddiness and then fall on 26.10.2025 at 4 p.m. H/O vomiting. Initially he went to outside hospital, treated with fluids thiamine, waxing waning sensorium and RT inserted. He had low GCS. He came for further management. Patient known case of type 2 DM, HTN, drug induced parkinsonism. On examination patient was conscious and oriented, slurring speech. Patient GCS worsened hypoxia. So, the patient shifted to ICU.

Physical Examination

PR: 118/min
BP:150/100 mm Hg
RR:20 /min

Anthropometric Assessment

Height: 165cm

Weight: 55kg

BMI : 20.3kg/m²

Ideal Body Weight : 65kg

Biochemical Assessment

Investigation	5.11.2025	7.11.2025	16.11.2025	17.11.2025	19.11.2025
Blood sugar (FBS)	200 mg/dl	120 mg/dl	129 mg/dl	121 mg/dl	125 mg/dl
HBA1C	11.0 %	-	-	-	-
Hemoglobin	11.9 mg	12.2 mg	13.4 mg	-	-
TC	9700	8900	18300	-	-
Monocyte	7.6 %	-	5.5 %	-	-
Eosinophil	2.7 %	-	0.3 %	-	-
Urea	86 mg/dl	42 mg/dl	-	-	-
Creatinine	0.96 mg/dl	0.91 mg/dl	-	-	-
Sodium	140 mEq/L	133 mEq/L	125 mEq/L	130 mEq/L	-
Potassium	3.4 mEq/L	3.3 mEq/L	5.5 mEq/L	5.2 mEq/L	-
Total Bilirubin	0.54 mg/dl	-	-	-	-
SGPT	20 U/L	-	-	-	-
SGOT	28 U/L	-	-	-	-

Blood Glucose Monitoring (CBG)

DATE	VALUES (FBS)
5.11.2025	200 mg/dl
6.11.2025	96 mg/dl
8.11.2025	104 mg/dl
11.11.2025	132 mg/dl
12.11.2025	108 mg/dl
13.11.2025	125 mg/dl
14.11.2025	137 mg/dl
16.11.2025	120 mg/dl
17.11.2025	121 mg/dl
19.11.2025	120 mg/dl
20.11.2025	108 mg/dl
21.11.2025	125 mg/dl

Dietary Assessment

24 hrs recall

Timing (24 Hours Recall)	Menu
Early Morning (7.0 Am)	Tea With Sugar -1 Cup (150 Ml)
Breakfast (9.0-10.0am)	Idli-2,Sambar-1 Cup (150 Ml)
Mid-Morning (12.0pm)	Tea With Sugar- 1 Cup (150 Ml)
Lunch (2.00-3.00pm)	Rice- 1 Cup, Buttermilk/Rasam (150 Ml)
Mid-Evening (5.00pm)	Tea With Sugar- 1 Cup (150 Ml)
Dinner (9.00-10.00pm)	Idli-2 ,Sambar- 1 Cup (150 Ml)
Bed-Time (11.00pm)	Milk With Sugar- 1 Cup (150 Ml)

Calorie	(kcal) Protein	(gm)
Total	fluid	(ml)
781	kcal 25	gm 1050

Day 1 RT Feed Menu-1-Ensure DM 6.11.2025-10.11.2025

Time	Menu	Amount (ml)	Calories (K.cal)	Protein (gm)
7.00 AM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	150	130	6.2
9.00 AM	Egg flip (2 no’s)	200	160	12
11.00 AM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	150	130	6.2
1.00 PM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	150	130	6.2
3.00 PM	Egg Flip (2 no’s)	200	160	12
5.00 PM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	200	130	6.2
7.00 PM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	150	130	6.2
9.00 PM	Ensure DM (3 scoops) dil. in 150 ml lukewarm water	150	130	6.2
Total		1100	1100	61.2

Calorie kg /body weight	Protein kg /body weight	Total fluid (ml)
20 Kcal	1.28 gm	1350+400=1750 ml

Day 6- RT Feed Menu-2-Ensure DM 11.11.2025-15.11.2025

Time	Menu	Amount (Ml)	Calories (K.cal)	Protein (gm)
7.00 am	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
9.00 am	Egg flip(2 no’s)	200	160	12
11.00 am	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
1.00 pm	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
3.00 pm	Egg Flip(2 no’s)	200	160	12
5.00 pm	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
7.00 pm	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
9.00 pm	Ensure DM (4 scoops) dil. in 200 ml lukewarm water	200	174	8.3
Total	1600	1364	73.8

Calorie kg /body weight	Protein (kg /body weight)	Total fluid(ml)
24.8 kcal	1.34 gm	1600+400=2000 ml

Day 11 Menu Plan-3-Liquid Diet-16.11.2025-17.11.2025

Timing	Food Items (Quantity)
07:00am	Skimmed Milk-200 ml
09:00am	Rice kanji -200 ml
11:00am	Broken Wheat Kanji -200 ml
01:00pm	Millet Kanji -200 ml
03:00pm	Skimmed Milk – 200 ml
05:00pm	Clear Veg soup – 200 ml
07:00pm	Wheat Kanji-200 ml
09:00pm	Skimmed Milk -200 ml

Calorie (kcal)	Protein (gms)	Total fluid(ml)
750 kcal	30 grams	1600 ml

Day 13 Menu Plan-4 – 18.11.2025 Diabetic-Soft Diet

Timing	Menu
Early morning (6.30 am )	Skimmed milk with ensure DM (1 scoop)
Breakfast (8.00 am- 8.30 am )	Idly -3 with sambar & tomato chutney (1 cup)
Mid-morning (12.00 am )	Veg soup -1 cup ,apple – half
Lunch (1.30 pm )	Rasam rice and curd rice with 2 veggies, boiled egg -1 no’s
Mid-evening (4.30 pm )	Skimmed milk with ensure DM (1 scoop)
Dinner (7.30 pm- 8.00 pm )	Wheat dosa 2 with sambar & chutney
Bed-time (9.00 pm)	Skimmed milk with ensure DM (1 scoop)

Calorie (kcal)	Protein (gm)	Fat (gm)
1740	61.8	40

Day 14 Menu Plan -5 – 19.11.2025 –20.11.2025 Diabetic-Normal Diet

Timing	Menu
Early Morning (6.30 am )	Skimmed Milk -150 Ml with ensure DM (2 Scoop)
Breakfast (8.00 am- 8.30 am)	Wheat Rava Upma-150 gm with Sambar & Chutney- 1 Cup
Mid-Morning (12.00 am )	Veg Soup-1 Cup / Cut Fruit -100 gm
Lunch (1.30 pm )	Rice With Sambar, Rasam, Veggies, Glv, Buttermilk and Boiled Egg
Mid-Evening (4.30 pm )	Boiled Pulses / Cut Fruit + Skimmed Milk -150 ml with ensure DM (1scoop)
Dinner (7.30 Pm- 8.00 pm)	Othappam-3 No’s With Sambar & Chutney- 1 Cup
Bed-Time (9.00 pm )	Skimmed Milk -150 ml with ensure DM (2scoop)

Calorie (kcal)	Protein (gm)	Fat (gm)
1620 (Kcal)	68 (gm)	40 (gm)

Day 16 Menu Plan-6 -Discharge Menu Plan 21.11.2025

Timing	Menu
Early Morning (6.30 am-7.00 am)	Skimmed Milk-150 Ml With 1 Scoop Ensure DM
Breakfast (8.00 am-9.00 am)	Millet Idly-3 / Millet Dosa-2 / Othappam-3 / Ragi Idiappam-3 No’s / With Sambar & Greens Chutney
Mid-Morning (10.30 am-11.00 am)	Apple-1 (Small) / Veg Soup-1 Cup / Butter Milk-1 Cup / Lime Juice-1 Cup (With Salt) / Vegetable Salad-1 Cup
Lunch (12.30 pm-1.30 pm)	Brown Rice/Red Rice-200 Gms With Sambhar, Rasam, Vegetables, Greens, Egg-1 (Non Veg – Chicken, Fish-Weekly Basis)
Mid-Evening (4.00 pm-5.00 pm)	Skimmed Milk-150 Ml Well Cooked Channa-50 Gms (All Variety)
Dinner (7.00 pm-8.00 pm)	Millet Idly-3 / Millet Dosa-2 / Othappam-2 / Ragi Idiappam-3 No’s / Wheat Dosa-3 / With Sambar / Channa Gravy & Tomato Chutney
Bed-Time (9.00 pm-9.30 pm)	Skimmed Milk-150 Ml With 1 Scoop Ensure DM

Calories	Protein	Fat
1700 (Kcal)	72 (gm)	40 (gm)

Note: Ryle’s tube feeding was given from Day 1 to Day 6, oral nutritional supplements were provided via Ryle’s tube to meet the patient’s calorie and protein requirements. Followed by initiating oral feeding. Calories and protein intake gradually increased according to the patient’s clinical condition and tolerance. Day 11 oral liquid diet initiated, followed by progression to a soft diet and subsequently a normal diet as tolerated. Day 16 patients were discharged with advice of continuing a normal diet.

Summary

This case study focuses on the transition of a diabetic patient from Ryle’s tube feeding to an oral diabetic diet. Initially, enteral feeding was required to meet nutrition needs while the patient was unable to take food orally. As the patient’s clinical condition improved, a gradual shift to oral intake was initiated after assessing swallowing ability, gastrointestinal tolerance and respiratory stability. Blood glucose levels were closely monitored throughout the transition, and insulin therapy was adjusted accordingly. A multidisciplinary team approach involving physicians, dietitians, nurses and respiratory therapists ensured safe feeding practices and minimized complications such as aspiration and glycemic imbalance. The patient successfully tolerated the oral diabetic diet, demonstrating improved nutritional status and greater independence. And also, he gained weight 4 kg (During discharge weight- 59kg).

Reference

Lee, Hyun Woo MD^a; Kim, Dong Hyun MD^b; Jin, Kwang Nam MD^b; Lee, Hyo-Jin MD^a; Lee, Jung-Kyu MD^a; Park, Tae Yeon MD^a; Kim, Deog Kyeom MD^a; Heo, Eun Young MD^a,* Association between successful weaning from nasogastric tube feeding and thoracic muscle mass in patients with aspiration pneumonia, Medicine 102(30):p e34298, July 28, 2023.
Marinos Elia, MD, BSC(HONS), FRCP;Antonio Ceriello, MD;Heiner Laube, MD, PHD;Alan J. Sinclair, MD, PHD;Meike Engfer, PHD;Rebecca J. Stratton, BSC(HONS), PHD, SRD, Enteral Nutritional Support and Use of Diabetes-Specific Formulas for Patients With Diabetes: A systematic review and meta-analysisADA Medical Affairs Article Collection
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Omorogieva Ojo ^*and Joanne Brooke, Evaluation of the Role of Enteral Nutrition in Managing Patients with Diabetes: A Systematic Review, Submission received: 29 September 2014 / Revised: 14 October 2014 / Accepted: 17 October 2014 / Published: 18 November 2014.

Weaning from Ryle’s Tube Feeding to Oral Diabetes Diet in a patient with Diabetes, and with Respiratory Compromise

Weaning from ryle’s tube feeding to oral diabetes diet in a patient with diabetes, and with respiratory compromise

Archana R*

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