Nutrition support has an important impact on the prognosis of critically ill patients, and enteral nutrition (EN) is increasingly recognized as an integral part of the management of critically ill patients. Early EN has been shown to reduce disease severity, maintain gastrointestinal (GI) physiology, and regulate the immune system .A meta-analysis shows that post-pyloric feeding can increase daily caloric intake in critically ill patients as compared with gastric feeding. However, it is controversial whether it can reduce the incidence of pneumonia. There is no significant difference in mortality, ICU stay time and complication rate between the two feeding methods . Most of the previous studies were carried out in the ICU, and patients were not screened for the type of diseases. It was difficult to compare the severity of the disease among patients with different diseases. At the same time, many studies have not ruled out the effects of other treatments on the above indicators, such as the depth of sedation , It may be more likely to determine the duration of mechanical ventilation and ICU hospital stay as compared with the development of pneumonia. In this study, patients with cerebral hemorrhage undergoing surgery and mechanical ventilation were excluded to minimize the impact of other factors on the results. There were no significant differences in age, gender, APACHEⅡ score, GCS score, and bleeding volume between the two groups.
Studies have shown that most critically ill patients receiving gastrointestinal feeding receive only 50–70% of the target calorie and protein load [17–19]. However, a meta-analysis has shown that enteral feeding delivers better or similar calories per day as compared with gastric feeding . It has been suggested that delivery of nutrition into the small bowel using a nasojejunal tube may be preferable to nasogastric feeding since the small bowel has better absorptive capacity7 and motility,8 leading to fewer interruptions . In this study, no significant differences in nutritional status parameters were noted between the 2 groups prior to beginning enteral feeding. However, while the values of all indices in both groups were lower at 2 weeks and 4 weeks after beginning feeding, the values in the nasojejunal tube feeding group were significantly greater than in the nasogastric tube feeding group at both 2 and 4 weeks. The results of this study demonstrated that nasojejunal feeding can provide more effective nutritional support than nasogastric feeding for patients with an intracerebral hemorrhage. Acutely ill patients lose an average of 5–10% of skeletal muscle mass per week during the ICU stay. Even among paralyzed patients, some trauma patients can increase energy consumption by 20–30%. Weight loss, negative nitrogen balance, and immune dysfunction are characteristic responses of critically ill patients, which can easily induce acute inflammation and infectious complications, leading to increased incidence and mortality of pneumonia . Rice and colleagues reported that patients who received fewer calories were less likely to return to independent living on discharge . Therefore, we think that providing adequate nutritional support for critically ill patients is vitally important to protect the body's immune function and reduce the risk of pneumonia, and better nutritional support may be conducive to the rehabilitation of patients with an intracerebral hemorrhage. Of particular note is that our results suggest that patients with an intracerebral hemorrhage have substantial nutritional needs, and that our nutritional plan did not fully meet the needs of the patients. As such, patients with intracerebral hemorrhage should be provided greater nutrition than that provided in this study.
Complications of enteral nutrition can compromise nutritional treatment and result in failure to reach nutritional goals. The reported incidence of gastric retention in patients with an intracerebral hemorrhage is > 80% . Critically ill patients are frequently sedated, and sedation with morphine and midazolam has been show to slow gastric emptying and increase retention .In the event of gastric retention or pulmonary aspiration, the administration of enteral nutrition may be interrupted and thus patients will not meet calorie goals. Furthermore, if pneumonia occurs the nutrient requirement will increase greatly. Some studies have suggested that trauma and surgery can inhibit gastrointestinal emptying and peristalsis, causing esophageal-cardia sphincter relaxation [24, 25]. In these patients neither nasogastric feeding nor gastrostomy feeding can effectively reduce gastric retention and gastroesophageal reflux . Under conditions of stress, the functions of the stomach and colon are mainly affected, whereas the functions of the jejunum and ileum are rarely affected . Mentec et al.  demonstrated that patients with feeding intolerance due to delayed gastric emptying exhibit relatively normal small intestine function.
In the current study, the incidence of gastric retention and pulmonary aspiration were lower in the early nasojejunal group than in the nasogastric group, whereas the incidence of diarrhea was not significantly different between the 2 groups. We agree that intracerebral hemorrhage may cause varying degrees of cardiac esophageal sphincter relaxation, and inhibit gastrointestinal emptying and peristalsis. Thus, delayed gastric emptying may be present in patients with an intracerebral hemorrhage due to impaired brain function . Delayed gastric emptying in patients receiving nasogastric tube feeding results in gastric retention, which may lead to reflux and pulmonary aspiration. With nasojejunal tube feeding, however, the food directly enters the jejunum without passing through the stomach and the relatively normal function of the small intestine can move food distally to reduce the incidence of reflux. In addition, the pylorus blocks food from entering the stomach in a retrograde manner, which reduces the potential for gastric retention. This study shows that the incidence of gastric retention was significantly lower in the jejunal feeding group than in the gastric feeding group, which can reduce the interruption of feeding, increase the supply of nutrients, and accelerate the achievement of nutrition goals.
Reflux and pulmonary aspiration are important causes of pneumonia. Pneumonia is a common complication in patients with an intracerebral hemorrhage, and can seriously affect the prognosis of these patients. An indwelling nasogastric tube increases the risk of pneumonia in patients with an intracerebral hemorrhage. In this situation, there are a number of mechanisms that contribute to the development of pneumonia. 1) Reflexive pharyngeal swallowing can normally prevent pulmonary aspiration; however, this mechanism can be dysfunctional in patients with an intracerebral hemorrhage and thus increase the risk of aspiration . 2) Dysfunction of the upper and lower esophageal sphincters can be causes by the presence of a nasogastric tube, and thus increase the risk of gastroesophageal reflux and aspiration . An indwelling nasogastric tube can cause gastric flora to migrate to the oropharynx and lower respiratory tract, a hypothesized gastro-pulmonary route of infection . It has been suggested that the incidence of microaspiration can be reduced by placing the feeding tube below the stomach . Similarly, this study also showed that the incidence of aspiration by jejunal feeding was reduced, which helped prevent pneumonia.
We found the incidence of pneumonia was significantly lower in the nasojejunal feeding group. We can postulate a number of reasons for this finding. 1) As mentioned above, the nutritional status of patients who received nasojejunal tube feeding was significantly better than those who received nasogastric tube feeding, and sufficient nutritional support can protect immune function. 2) Reflux and pulmonary aspiration were greater in patients receiving nasogastric tube feeding, and both are associated with pneumonia. 3) Reflux and pulmonary aspiration also led to the suspension or interruption of enteral feeding, and thus reduce the effectiveness of nutrition therapy. Inadequate nutritional support can weaken the immune system functions, and thus increase the risk pneumonia. Subsequently, pneumonia greatly increases the demand for nutrition and exacerbates nutritional deficiencies, thus forming a vicious cycle.
There are limitations to this study that should be considered. The number of patients was relatively small; however, the inclusion criteria were strict to eliminate the influence of confounding factors such as type of disease, and surgery and mechanical ventilation. While it is well-known that pulmonary aspiration can lead to pneumonia, we did not study the relations between the features or amount of pulmonary aspirate and the development of pneumonia. This study only compared the incidence and related factors of pneumonia but did not compare the ICU stay time, recovery degree and mortality rate between the two groups.
A previous study has shown that due to the high technical requirements, the success rate of nasojejunal tube placement in some hospitals is relatively low, delaying the start of early nutrition and the time to achieve nutrition goals . Nevertheless, most studies did not mention the time and success rate of nasojejunal tube placement. This may also be one of the reasons for the contradiction between previous research results. Deane et al. believe that only those institutions capable of quickly placing nasojejunal jejunal feeding tube can generally improve nutrition intake . In our study, the medical staffs who performed the jejunal tube placement were all well-trained and experienced, and the success rate of the tube placement was 100%. But we did not calculate the time taken for the tube placement.