since 2011 , pneumonia has overtaken cerebrovascular disorders as the third leading cause of death in japan . elderly people are particularly prone to developing severe pneumonia because of various underlying conditions ( 1 ) . nutritional support plays an integral role in the treatment of critically ill patients and the enteral route is always preferred over the parenteral route ( 2 - 4 ) . enteral nutrition usually starts with gastric feeding by a nasogastric tube because it is easier to achieve but feeding intolerance , commonly defined as large gastric residual volumes ( nasogastric aspirate of > 350 - 400 ml ) along with gastrointestinal symptoms , can be as high as 40% in severely ill patients ( 5 ) . the common solution for gastric feeding intolerance is the use of post - pyloric ( duodenal or jejunal ) feeding . however , delayed gastric emptying and large gastric residual volumes that persist may still lead to microaspiration and pneumonia . here , we report the successful use of a newly developed nasojejunal tube with gastric decompression function in a patient with septic shock due to severe pneumonia . an 84-year - old japanese man with dementia in a nursing home developed fever and received treatment for upper respiratory infection from a nearby clinic . however , the fever persisted and two days later he was referred to our hospital because of a decline in blood pressure , a decrease in spo2 ( saturation of peripheral oxygen ) and loss of consciousness . on admission , his blood pressure was 77/48 mmhg , pulse rate was 107 beats per minute ( regular ) , spo2 was 84% even with oxygen administration of 10 l / min by reservoir mask and respiratory rate was 32 breaths per minute . his body temperature was 38.3 and coarse crackles were audible on bilateral lung fields ( right > left ) . his level of consciousness was altered at japan coma scale ( jcs ) iii-200 or glasgow coma scale 3 ( e1v1m1 ) . a chest radiograph and ct scan showed diffused consolidation in both lungs consistent with acute pneumonia ( fig . 1 ) . chest radiograph and ct scan on admission reveal diffuse consolidation in both lungs ( right > left ) . laboratory findings ( table ) on admission demonstrated leukocytosis ( 27,180 /l ) with neutrophilia ( 98% ) and a high c - reactive protein level ( 19.30 mg / dl ) , strongly suggesting the presence of inflammation . a slight elevation of liver and biliary enzyme levels , hypoproteinemia and renal dysfunction with high creatine kinase levels were also observed . abnormalities in coagulation parameters , such as thrombocytopenia , prolonged prothrombin time and elevated fibrin degradation products also indicated the possibility of disseminated intravascular coagulopathy ( dic ) . wbc : white blood cells , rbc : red blood cell , hb : hemoglobin , ht : hematocrit , plt : platelets , crp : c - reactive protein , abga : arterial blood gas analysis , tp : total protein , alb : albumin , t - bil : total bilirubin , amy : amylase , ck : creatine kinase , bun : blood urea nitrogen , cr : creatinine , pt - inr : international normalized ratio of prothrombin time , aptt : activated partial thromboplastin time , fdp : fibrinogen degradation products . the patient was diagnosed with septic shock from severe aspiration pneumonia and was treated in our high care unit . his apacheii score was 30 and sequential organ failure assessment ( sofa ) score 15 , reflecting the severity of disease and multiple organ dysfunction . therapy was initiated with meropenem hydrate ( 1.5 g / day ) , dopamine hydrochloride ( 3 g / kg / min ) and nafamostat mesylate ( 0.07 mg / kg / hr ) . as his condition stabilized , a 12fr size nasogastric feeding tube was inserted on day 2 and enteral nutrition using a standard polymeric formula ( 5 kcal / kg / day at 30 ml / hr ) was started the next day . the polymeric formula used had a caloric density of 1 kcal / ml , with 58% of calories as carbohydrates , 25% as lipids and provided 4 grams of protein for every 100 kcal administered . the infusion dose and speed increased gradually until 900 kcal / day ( 15 kcal / kg / day at 80 ml / hr ) on day 9 , when he developed a 39.5 fever with persistent decrease in spo2 ( < 90% ) . his white blood cell count increased to 39,020 /l and a chest radiograph revealed fresh infiltrations in the right lower field . aspiration from gastric feed reflux ( gastric feeding intolerance ) was suspected and enteral feeding was discontinued . on day 10 , a newly developed 16fr size nasojejunal feeding tube with gastric decompression function ( njt / gd , fig . a small amount of contrast medium ( gastrografin 10 ml ) was infused into the gastric lumen before removing the nasogastric feeding tube in order to ascertain the orientation of the stomach and duodenum . the njt / gd was then inserted so that the tip was placed beyond the ligament of treitz with the radiopaque marker positioned before the pylorus ( fig . 3 , right ) . the newly developed nasojejunal feeding tube with gastric decompression function ( njt / gd ) . placement of njt / gd with the use of fluoroscopy enteral feeding was recommenced on the same day of tube placement at 800 kcal / day ( 13 kcal / kg / day at 60 ml / hr ) while simultaneously draining any residual gastric contents ( fig . the feeding dose was gradually increased until 1,500 kcal / day ( 25 kcal / kg / day , without pump ) from day 15 . during the course of jejunal feeding with the njt / gd no drainage of enteral feed was observed and there was no recurrence of high grade fever or persistent decrease in spo2 during the use of the njt / gd , implying that enteral nutrition was well tolerated . simultaneous gastric decompression ( drainage ) with jejunal feeding . although the patient 's condition improved , an evaluation by our dysphagia team showed that oral intake was not yet safe and long term enteral nutrition through a percutaneous route was indicated . by day 22 upper gastrointestinal endoscopy performed before the procedure did not reveal any abnormalities ( such as hiatal hernia etc . ) that may have impeded enteral nutrition . postoperative clinical course was uneventful and on day 30 , he was transferred to our rehabilitation ward . swallowing therapy enabled him to be discharged from our hospital on day 43 with some oral intake . penicillin - susceptible streptococcus pneumoniae ( pssp ) was isolated from the patient 's aspirated sputum during admission . meropenem hydrate was used until day 14 , after which sulfamethoxazole ( administered through the njt / gd ) was employed . middle : endoscopic view ( taken before peg tube insertion ) of njt / gd with the radiopaque marker ( arrow head ) correctly placed before the pylorus . right : gastric decompression holes of njt / gd ( arrow heads ) . clinical course and enteral nutrition provision ( ngt : nasogastric tube , njt / gd : nasojejunal tube with gastric decompression function , peg : percutaneous endoscopic gastrostomy , transfer : transfer to rehabilitation ward ) . on day 10 , a newly developed 16fr size nasojejunal feeding tube with gastric decompression function ( njt / gd , fig . 2 ) was inserted into the jejunal lumen under fluoroscopic guidance . a small amount of contrast medium ( gastrografin 10 ml ) was infused into the gastric lumen before removing the nasogastric feeding tube in order to ascertain the orientation of the stomach and duodenum . the njt / gd was then inserted so that the tip was placed beyond the ligament of treitz with the radiopaque marker positioned before the pylorus ( fig . 3 , left ) . after the procedure , tube placement was confirmed using contrast medium again ( fig . 3 , right ) . the newly developed nasojejunal feeding tube with gastric decompression function ( njt / gd ) . placement of njt / gd with the use of fluoroscopy . left : positioning of radiopaque marker ( arrow head ) before the pylorus . enteral feeding was recommenced on the same day of tube placement at 800 kcal / day ( 13 kcal / kg / day at 60 ml / hr ) while simultaneously draining any residual gastric contents ( fig . the feeding dose was gradually increased until 1,500 kcal / day ( 25 kcal / kg / day , without pump ) from day 15 . during the course of jejunal feeding with the njt / gd no drainage of enteral feed was observed and there was no recurrence of high grade fever or persistent decrease in spo2 during the use of the njt / gd , implying that enteral nutrition was well tolerated . simultaneous gastric decompression ( drainage ) with jejunal feeding . although the patient 's condition improved , an evaluation by our dysphagia team showed that oral intake was not yet safe and long term enteral nutrition through a percutaneous route was indicated . by day 22 upper gastrointestinal endoscopy performed before the procedure did not reveal any abnormalities ( such as hiatal hernia etc . ) that may have impeded enteral nutrition . postoperative clinical course was uneventful and on day 30 , he was transferred to our rehabilitation ward . swallowing therapy enabled him to be discharged from our hospital on day 43 with some oral intake . penicillin - susceptible streptococcus pneumoniae ( pssp ) was isolated from the patient 's aspirated sputum during admission . meropenem hydrate was used until day 14 , after which sulfamethoxazole ( administered through the njt / gd ) was employed . middle : endoscopic view ( taken before peg tube insertion ) of njt / gd with the radiopaque marker ( arrow head ) correctly placed before the pylorus . right : gastric decompression holes of njt / gd ( arrow heads ) . clinical course and enteral nutrition provision ( ngt : nasogastric tube , njt / gd : nasojejunal tube with gastric decompression function , peg : percutaneous endoscopic gastrostomy , transfer : transfer to rehabilitation ward ) . this case illustrates the successful provision of enteral nutrition , which is integral to mainstream therapy , in a severely ill patient . as the patient 's pneumonia was classified as severe , our mainstream therapy included the use of meropenem , a broad spectrum antibacterial agent which has been demonstrated to be very effective and tolerable in elderly patients with potentially fatal aspiration pneumonia ( 6 ) . enteral nutrition ( via tube feeding ) has been established as the preferred way of feeding the critically ill patient and is often associated with favorable outcomes ( 2 - 4 ) . not only is it more physiological , enteral nutrition may also preserve mucosal architecture and immune function while reducing inflammation response ( 7 ) . the initiation of enteral nutrition has been demonstrated to be feasible and safe even within 6 hours of admission into the intensive care unit ( 8) . although some earlier studies concluded that post - pyloric feeding has no clear advantages over gastric feeding in terms of overall nutrition received and complications ( 9,10 ) , this may be influenced by the differences in severity of illness ( 11 ) . recent systemic reviews and meta - analyses suggest that post - pyloric feeding may reduce the incidence of feeding - related pneumonia but does not necessarily improve clinically important outcomes , such as mortality or length of stay ( 12 - 15 ) . furthermore , procedural challenges of post - pyloric tube insertion makes it difficult to recommend routine placement in all critically ill patients . the current consensus is still to initiate enteral nutrition by the nasogastric route , such as in this case , and then move to post - pyloric feeding only when gastric feeding intolerance occur ( 16 ) . however , post - pyloric feeding does not actually address the problem of delayed gastric emptying and large gastric residual volumes that may persist may still lead to microaspiration or pneumonia . the ideal solution in severely ill patients with gastric feeding intolerance would then be to feed them post - pyloric while simultaneously decompressing the stomach . although the concept and design of a dual - purpose nasogastrojejunal tube with gastric decompression capacity have been described recently ( 17,18 ) , we are not aware of any recorded clinical use of such a tube in the literature . the njt / gd used in this case was developed by create medic ( yokohama , japan ) with some design input from the corresponding author . to the best of our knowledge , this is the first reported use of a nasojejunal feeding tube with gastric decompression function in a patient . the use of the njt / gd enabled the almost continuous ( interruption of less than 24 hours ) provision of enteral nutrition to the patient until he was well enough to undergo peg . it also enabled the gradual increase of enteral feeding dose to 67% more than what was accomplished using a nasogastric tube . a question that should be addressed is whether a similar outcome was achievable using a regular nasojejunal tube ( without any gastric decompression function ) in this case . although there is no clear answer , seeing that gastric drainage volume reached 450 ml / day throughout the course of jejunal feeding , we believe that the njt / gd was the best transitory option to effectively deliver enteral nutrition . in conclusion , we reported the successful use of a newly developed nasojejunal feeding tube with gastric decompression function in a severely ill patient . the use of this tube improved the delivery of enteral nutrition when gastric feeding was not well tolerated . we consider the njt / gd to be instrumental in clinical practice as we strive to meet the nutritional and therapeutic needs of individual patients . mohammad shukri jahit from hospital sungai buloh , who is also the current president of the parenteral and enteral nutrition society of malaysia .