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EnteralNutrition
BY:
DR. RIHAM HAZEM RAAFAT, MD
The Basics of Nutritional Support
• Most patients in ICU are unable to tolerate normal diet
• Many of them are malnourished on admission
• Nutrients can be delivered directly to the GIT by feeding tubes (enteral
feeding) or by intravenous (parenteral feeding)
• Nutrition is provided against a background of a continuously changing
physical status
• Few data directly compare feeding with no feeding in critical patients and it
suggests worse outcomes in underfed patients
• Catabolism in critically ill patients causes malnutrition
• Malnutrition closely associated with poor outcomes
• Stress, acute illness, surgery or trauma produce major changes in the metabolic
milieu of the body
- Changes in substrate utilization
- Altered substance synthesis rates
- Hyper-metabolism
- Catabolism
Why Malnutrition in Critically Ill
Poor intake
Stress
Hyper-
metabolism
Changes in
Substrate
Utilization
Surgery
Immobility
Prolonged
Bed Rest
Steroids
Consequences of Malnutrition
• Increased morbidity and mortality
• Prolonged length of stay in ICU
• Impaired tissue function and wound healing
• Defective muscle function, reduced respiratory and cardiac function
• Immuno-suppression, increased risk of infection
• Poor weaning from ventilator
Enteral Feeding
Early feeding is usually defined as starting within the first
24-48 hours of admission – Goal is reaching 50-65% of
caloric needs by the first week
(Meta-analysis suggests reduced infections if patients are
fed within 48 hours)
Indications for Enteral Nutrition
• Malnourished (unable to eat) >5-7 days
• Normally nourished patient (unable to eat) >7-9 days
• Increased needs that cannot be met through oral intake (e.g. burns,
trauma, stress)
• Adaptive phase of short bowel syndrome
• Mental incapacitation
• MV
Benefits of Enteral Feeding
• Prevents gut mucosal atrophy by preserving intestinal mucosal structure
and function
• More physiological
• Relatively non-invasive, cheaper, easier
• It reduces bacterial translocation and multi-organ failure
• Reduced risk of infectious complications of PN
Contraindications of Enteral Nutrition
Inability to gain access
• Paralytic Ileus (relative)
• Bowel Obstruction
• Intestinal ischemia
• Severe GI Bleeding
• Vomiting / Diarrhea
• High Output Proximal Fistula
Clinical shock / Hemodynamic instability
Expected need less than 5-7 days in malnourished or 7-9 days in normal
Enteral Access
Delivery method Common indications Precautions
Nasogastric/Orogastric
(up to 4-6 weeks)
(fine bore 5-8 FG or large bore)
(polyurethane, rubber & silicone)
- Unable to consume oral nutrition
(Intubated, sedated, neurologically impaired)
- Hypermetabolism in the presence of
functional GIT (e.g. burns)
- Tube must be secured
- Verify placement of tube by ausc. or x-
ray (gold) or PH or aspirate or cynography
- Higher aspiration risk in large bore ‘e
higher injury to nose/oes but ↓ clogging
Nasoduodenal/Nasojejunal
(up to 4-6 weeks)
(fine bore 6-10 FG)
1F = 1/3 mm so 12F = 4mm
-Inadequate gastric motility or intolerance
(gastroparesis, delayed gastric emptying)
- Partial gastric outlet obstruction
- Severe aspiration risk
- Oesophageal reflex - Coma lying flat
- After upper GI surgery - In high GRV
- Tube must be secured
- Verify placement of tube by X-ray
(fluoroscopy) or endoscopically
- Bedside is difficult and failure rate is 70-
85%
Gastrostomy (silicone or PU)
-PEG (pull, push, introducer, mini
laparoscopically guided)
-Radiological -Surgical
-Anyone who requires medium to
long term NG tube feeding ( > 1 month)
-Head and neck injury/surgery
-Neoplasm in UAWs or Oesophagus
- Caution in patients with severe
GERD or gastroparesis – Abs (6hr before)
- Contraindicated in patients with
ascites, coagulopathies, die <3M,
Jejunostomy (solid > balloon)
-PEJ
-Surgical
*Both G & J: 2 or 3 ports
- Injury, obstruction or fistula
proximal to jejunum
peritonitis, morbidly obese
- Monitor bleeding, not removed 14 ds,
early feeding (2hrs adults, 6hrs children)
Contraindications to NG and NJ intubation:
– Obstruction of the nasopharynx and esophagus,
– Recent foregut surgery that may predispose to perforation
– Craniofacial fractures. Contraindications of PEG:
– Intolerance to pre pyloric feeds, abdominal pain
with feeding, and repeated regurgitation of the
feeding solution
Relative contraindications to NG tube placement: include
– Severe gastroesophageal reflux,
– Coagulopathy, and
– Esophageal variceal bleeding.
Complications of Enteral Nutrition
Reactions Possible Causes
Diarrhea +/- Nausea and Vomiting
Dehydration
Infection
Medications/C. difficile/lack of dietary fiber/hyperosmolar
formula/bacterial contamination/improper administration/fat
malabsorption
Constipation Inadequate fluid intake/insufficient fiber/GI obstruction
Aspiration of tube feeding/high
gastric residuals (>250 in 2 or 500 in 1)
Regurgitation of stomach contents/feeding while supine/delayed
gastric emptying/tube dislodgement/GERD
Hypoglycemia Sudden cessation of tube feeding in patients on oral HG/insulin
Hyperglycemia Diabetes/stress/trauma/corticosteroid/sepsis/refeeding $
Hypophosphatemia / Hypokalemia Refeeding syndrome / excessive losses
Others due to technique itself or after
tube insertion
(minor 13% or major 3%)
GERD/aspiration/wound infection/bleeding/misplacement:
pnthx/ epistaxis/ pneumoperitoneum/fistula/neoplastic
seeding/infection/mortality (1%)
Clogging/sinusitis/intestinal ischemia (if hemodyn unstable
EN)/dislodgment/malfunction/peristomal infection/leak/BPS
If Starvation for 7-10ds:
Arrhythmia, HF, RF  you have to correct imbalance before NS
Methods of Administration
Continuous Intermittent Bolus
Use - Intubated.
- Jejunostomy.
- Critically ill.
- Glycemic index control
- Refeeding.
- Intolerance to intermittent.
*↑ time of absorption
- In stomach.
- ↑ fluid tolerance.
- During day or sleeping hrs
by using alarm. -
↑aspiration
- Better ↑ in day & ↓ in
night→ ↑ QOL (in rehab &
home)
- Needs N gastric function
I. Bags → clamp.
II. Syringe & Funnel→ raise &
down or pressure.
- Mimic normal eating.
- ↓cost - ↑ aspiration,
distension, delay GE
- ↑movement of patient
Rate 20-60ml/hr &
advance by 10-20ml/hr/8-
24hrs
240-400ml (begin 60-120ml)
(1-3 cups) in →
30-45mins→
4-6 times daily (flush)
Gravity drip.
150-500ml/ 5-15mins/ 3-6 times.
Broad Lines
• Choose full strength, isotonic formulas for initial feeding regimen.
• Diluting formulas may increase the risk of microbial contamination  intolerance due to diarrhea
• Gastric Feeding and Stable Patients:
– Initiate with full strength formula: 50 ml/hr X 3-8 times bolus/gravity method.
– Increase up to 50-100ml/hr every 10-12 hrs till goal volume (usually 24-48hrs)
• Small-bowel feedings & Gastric feedings in critically ill patients or severely malnourished patients:
– A pump is generally required as the slower administration rate of continuous feedings often
enhances tolerance.
– Start as full strength (iso/hyperosmolar/elemental): 10-40ml/hr 3-8 feeds, if tolerates well  increase
by 10-20ml/hr every 10-12 hrs till goal reached.
• Elevate the backrest to a minimum of 30º, and preferably to 45º, for all patients receiving
EN unless a medical contraindication exists. Chlorhexidine mouth wash twice daily.
• If patient can’t tolerate high rates  feeding rate decreased till he adapts.
• If the GRV (amount of formula and GI secretions remaining) is > 250 mL x2 times a
prokinetic agent should be considered in adult patients (erythromycin / metoclopramide)
• If the GRV > 500 mL/6hr  hold EN and reassess patient’s tolerance by using an
established algorithm including: physical assessment, GI assessment, evaluation of
glycemic control, minimization of sedation, and consideration of promotility (prokinetic)
agent use if not already prescribed.
• Consideration of a feeding tube placed below the ligament of Treitz when GRVs are
consistently measured at > 500 mL
Catheter Care:
- Skin Care: water and soap is the best, avoid pressure, oral hygiene
- Clogging Prevention:
1. Flushing protocol: Flush with water 30-60ml (flush of choice) or pancreatic enzymes.
2. Medications: Administered separately, Flush before and after, Use liquid medications.
- Exchange and Removal: not before 2 weeks (or 4-6 weeks in IS, CS, Obese)  for G or J tubes
1- Removal at bed side with traction method:
Patient lies supine and bend his knees (For solid bolsters → tube grasped by force and For
balloon bolsters → balloon inflated and removed)
2- We better use surgical lubricant.
• Flush feeding tubes with:
– 30 mL of water every 4 hours during continuous feeding.
– Before and after bolus/intermittent feedings in an adult patient.
– After measuring GRV (measured every 4 hrs till goal reached and in critically ill patients (decrease
measuring to every 6-8 hrs if patient is stable)
• Sterile water is usually recommended, for flushing and mixing medications (contribute to fluid intake)
• Precautions in flushing:
Orange Juice  Damages PU tubes.
Papain and NaHCO3  Damages PU & silicone tubes.
H2O + pineapple juice  Can be used.
↑ intact protein + Acidic medications  ↑ clogging so not use soda or cranberry juice for flush.
Formulations
Formula Composition: (1-2kcal/ml)
1. Carbohydrates (30-60% of Cal)
2. Fibers (+/-)
3. Fats (15-30% of Calories)
4. Proteins (15-25% of Calories)
5. Vitamins and Minerals (RDA)
6. Water (70-85% of Volume – 30-40ml/kg/d)
7. Osmolality (270-700 mOsm/kg) (iso/hyper)
8. Immuno-modulating Agents (arginine/glutamine/omega 3 …etc.)
Types of Formulas:
• Standard (polymeric)
• Disease specific
• Elemental or defined (mono/oligomeric)
• Home made
• Modular (only one)
Don’t Mix drugs or additives with enteral
formulas  flush before & after
Formula Selection Depends on:
– Patient’s Condition (age / allergies / tolerances / diseases)
– GI status
– Need of Fiber Modifications
– Enteral Route (gastric vs small bowel)
– Nutritional and Fluid Requirements
1.2 up to 2 gm/kg/d
in critically ill
Open System Closed system
Advantages Product is into: powder or ready to fed
- Allows modulars such as protein and
fiber to be added to feeding formulas
- Less waste in unstable
patients (maybe)
- Containers are sterile until spiked for
hanging (ready to hang 1L, 1.5L, 2L)
- Can be used for continuous or bolus
delivery - Less waste of formula
- Less nursing time
- Increases safe hang time (24-48hr)
- Less risk of contamination
Disadvantages - Increase nursing time
- Increase risk of contamination
- - Shortens hang time (4-8 hrs)
- - Rinsing of bag and tubing
- No flexibility in formula additives
(can use Y port for additions)
- More Expensive than open formula
Monitoring
Tube
Placement
Medication
Nutrition
Goals
GIT Issues Aspiration
Metabolic
Complicati
ons
EN Safety
We should handle EN in a safe manner to avoid contamination in all aspects of care e.g.
preparation, manufacturing, infusion.
• Contamination: Precautions to avoid contamination:
- Use gloves, hand washing.
- Pump Cleaned daily.
- Cans with alcohol,
- Container sanitized and labeled with name & time.
• Sanitization
- Changed every 24 hrs.
- Use screw top connectors not flip top.
- Use spike set. - Connections differ than IV lines are better
- Infusion chambers→↓ retrograde bacteria.
• EN set (different hang times)
- Closed system - Open system → Refrigerated if not adm. immediate & the remaining is discarded
Transitional Feeding
- From continuous → intermittent → oral.
- Stop EN if oral intake → 66-75% (2/3) of total calories.
- Monitor tolerance (↓ duration, ↑ volume)
Videos that may help:
• https://www.youtube.com/watch?v=2MPM9XvadQo
• https://www.youtube.com/watch?v=_EDUAVTHQtk&index=2&list=FLa_kHXFy
UdiFBuZLLkzLMXg&t=24s
• https://www.youtube.com/watch?v=yRmRMHfG7g0&index=1&list=FLa_kHXFy
UdiFBuZLLkzLMXg
• https://www.youtube.com/watch?v=lpxdUFVOibk
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Enteral nutrition

  • 2. The Basics of Nutritional Support • Most patients in ICU are unable to tolerate normal diet • Many of them are malnourished on admission • Nutrients can be delivered directly to the GIT by feeding tubes (enteral feeding) or by intravenous (parenteral feeding) • Nutrition is provided against a background of a continuously changing physical status • Few data directly compare feeding with no feeding in critical patients and it suggests worse outcomes in underfed patients • Catabolism in critically ill patients causes malnutrition • Malnutrition closely associated with poor outcomes
  • 3. • Stress, acute illness, surgery or trauma produce major changes in the metabolic milieu of the body - Changes in substrate utilization - Altered substance synthesis rates - Hyper-metabolism - Catabolism
  • 4. Why Malnutrition in Critically Ill Poor intake Stress Hyper- metabolism Changes in Substrate Utilization Surgery Immobility Prolonged Bed Rest Steroids
  • 5. Consequences of Malnutrition • Increased morbidity and mortality • Prolonged length of stay in ICU • Impaired tissue function and wound healing • Defective muscle function, reduced respiratory and cardiac function • Immuno-suppression, increased risk of infection • Poor weaning from ventilator
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  • 8. Enteral Feeding Early feeding is usually defined as starting within the first 24-48 hours of admission – Goal is reaching 50-65% of caloric needs by the first week (Meta-analysis suggests reduced infections if patients are fed within 48 hours)
  • 9. Indications for Enteral Nutrition • Malnourished (unable to eat) >5-7 days • Normally nourished patient (unable to eat) >7-9 days • Increased needs that cannot be met through oral intake (e.g. burns, trauma, stress) • Adaptive phase of short bowel syndrome • Mental incapacitation • MV
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  • 11. Benefits of Enteral Feeding • Prevents gut mucosal atrophy by preserving intestinal mucosal structure and function • More physiological • Relatively non-invasive, cheaper, easier • It reduces bacterial translocation and multi-organ failure • Reduced risk of infectious complications of PN
  • 12. Contraindications of Enteral Nutrition Inability to gain access • Paralytic Ileus (relative) • Bowel Obstruction • Intestinal ischemia • Severe GI Bleeding • Vomiting / Diarrhea • High Output Proximal Fistula Clinical shock / Hemodynamic instability Expected need less than 5-7 days in malnourished or 7-9 days in normal
  • 13. Enteral Access Delivery method Common indications Precautions Nasogastric/Orogastric (up to 4-6 weeks) (fine bore 5-8 FG or large bore) (polyurethane, rubber & silicone) - Unable to consume oral nutrition (Intubated, sedated, neurologically impaired) - Hypermetabolism in the presence of functional GIT (e.g. burns) - Tube must be secured - Verify placement of tube by ausc. or x- ray (gold) or PH or aspirate or cynography - Higher aspiration risk in large bore ‘e higher injury to nose/oes but ↓ clogging Nasoduodenal/Nasojejunal (up to 4-6 weeks) (fine bore 6-10 FG) 1F = 1/3 mm so 12F = 4mm -Inadequate gastric motility or intolerance (gastroparesis, delayed gastric emptying) - Partial gastric outlet obstruction - Severe aspiration risk - Oesophageal reflex - Coma lying flat - After upper GI surgery - In high GRV - Tube must be secured - Verify placement of tube by X-ray (fluoroscopy) or endoscopically - Bedside is difficult and failure rate is 70- 85% Gastrostomy (silicone or PU) -PEG (pull, push, introducer, mini laparoscopically guided) -Radiological -Surgical -Anyone who requires medium to long term NG tube feeding ( > 1 month) -Head and neck injury/surgery -Neoplasm in UAWs or Oesophagus - Caution in patients with severe GERD or gastroparesis – Abs (6hr before) - Contraindicated in patients with ascites, coagulopathies, die <3M, Jejunostomy (solid > balloon) -PEJ -Surgical *Both G & J: 2 or 3 ports - Injury, obstruction or fistula proximal to jejunum peritonitis, morbidly obese - Monitor bleeding, not removed 14 ds, early feeding (2hrs adults, 6hrs children)
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  • 17. Contraindications to NG and NJ intubation: – Obstruction of the nasopharynx and esophagus, – Recent foregut surgery that may predispose to perforation – Craniofacial fractures. Contraindications of PEG: – Intolerance to pre pyloric feeds, abdominal pain with feeding, and repeated regurgitation of the feeding solution Relative contraindications to NG tube placement: include – Severe gastroesophageal reflux, – Coagulopathy, and – Esophageal variceal bleeding.
  • 18. Complications of Enteral Nutrition Reactions Possible Causes Diarrhea +/- Nausea and Vomiting Dehydration Infection Medications/C. difficile/lack of dietary fiber/hyperosmolar formula/bacterial contamination/improper administration/fat malabsorption Constipation Inadequate fluid intake/insufficient fiber/GI obstruction Aspiration of tube feeding/high gastric residuals (>250 in 2 or 500 in 1) Regurgitation of stomach contents/feeding while supine/delayed gastric emptying/tube dislodgement/GERD Hypoglycemia Sudden cessation of tube feeding in patients on oral HG/insulin Hyperglycemia Diabetes/stress/trauma/corticosteroid/sepsis/refeeding $ Hypophosphatemia / Hypokalemia Refeeding syndrome / excessive losses Others due to technique itself or after tube insertion (minor 13% or major 3%) GERD/aspiration/wound infection/bleeding/misplacement: pnthx/ epistaxis/ pneumoperitoneum/fistula/neoplastic seeding/infection/mortality (1%) Clogging/sinusitis/intestinal ischemia (if hemodyn unstable EN)/dislodgment/malfunction/peristomal infection/leak/BPS
  • 19. If Starvation for 7-10ds: Arrhythmia, HF, RF  you have to correct imbalance before NS
  • 20. Methods of Administration Continuous Intermittent Bolus Use - Intubated. - Jejunostomy. - Critically ill. - Glycemic index control - Refeeding. - Intolerance to intermittent. *↑ time of absorption - In stomach. - ↑ fluid tolerance. - During day or sleeping hrs by using alarm. - ↑aspiration - Better ↑ in day & ↓ in night→ ↑ QOL (in rehab & home) - Needs N gastric function I. Bags → clamp. II. Syringe & Funnel→ raise & down or pressure. - Mimic normal eating. - ↓cost - ↑ aspiration, distension, delay GE - ↑movement of patient Rate 20-60ml/hr & advance by 10-20ml/hr/8- 24hrs 240-400ml (begin 60-120ml) (1-3 cups) in → 30-45mins→ 4-6 times daily (flush) Gravity drip. 150-500ml/ 5-15mins/ 3-6 times.
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  • 25. Broad Lines • Choose full strength, isotonic formulas for initial feeding regimen. • Diluting formulas may increase the risk of microbial contamination  intolerance due to diarrhea • Gastric Feeding and Stable Patients: – Initiate with full strength formula: 50 ml/hr X 3-8 times bolus/gravity method. – Increase up to 50-100ml/hr every 10-12 hrs till goal volume (usually 24-48hrs) • Small-bowel feedings & Gastric feedings in critically ill patients or severely malnourished patients: – A pump is generally required as the slower administration rate of continuous feedings often enhances tolerance. – Start as full strength (iso/hyperosmolar/elemental): 10-40ml/hr 3-8 feeds, if tolerates well  increase by 10-20ml/hr every 10-12 hrs till goal reached.
  • 26. • Elevate the backrest to a minimum of 30º, and preferably to 45º, for all patients receiving EN unless a medical contraindication exists. Chlorhexidine mouth wash twice daily. • If patient can’t tolerate high rates  feeding rate decreased till he adapts. • If the GRV (amount of formula and GI secretions remaining) is > 250 mL x2 times a prokinetic agent should be considered in adult patients (erythromycin / metoclopramide) • If the GRV > 500 mL/6hr  hold EN and reassess patient’s tolerance by using an established algorithm including: physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility (prokinetic) agent use if not already prescribed. • Consideration of a feeding tube placed below the ligament of Treitz when GRVs are consistently measured at > 500 mL
  • 27. Catheter Care: - Skin Care: water and soap is the best, avoid pressure, oral hygiene - Clogging Prevention: 1. Flushing protocol: Flush with water 30-60ml (flush of choice) or pancreatic enzymes. 2. Medications: Administered separately, Flush before and after, Use liquid medications. - Exchange and Removal: not before 2 weeks (or 4-6 weeks in IS, CS, Obese)  for G or J tubes 1- Removal at bed side with traction method: Patient lies supine and bend his knees (For solid bolsters → tube grasped by force and For balloon bolsters → balloon inflated and removed) 2- We better use surgical lubricant.
  • 28. • Flush feeding tubes with: – 30 mL of water every 4 hours during continuous feeding. – Before and after bolus/intermittent feedings in an adult patient. – After measuring GRV (measured every 4 hrs till goal reached and in critically ill patients (decrease measuring to every 6-8 hrs if patient is stable) • Sterile water is usually recommended, for flushing and mixing medications (contribute to fluid intake) • Precautions in flushing: Orange Juice  Damages PU tubes. Papain and NaHCO3  Damages PU & silicone tubes. H2O + pineapple juice  Can be used. ↑ intact protein + Acidic medications  ↑ clogging so not use soda or cranberry juice for flush.
  • 29. Formulations Formula Composition: (1-2kcal/ml) 1. Carbohydrates (30-60% of Cal) 2. Fibers (+/-) 3. Fats (15-30% of Calories) 4. Proteins (15-25% of Calories) 5. Vitamins and Minerals (RDA) 6. Water (70-85% of Volume – 30-40ml/kg/d) 7. Osmolality (270-700 mOsm/kg) (iso/hyper) 8. Immuno-modulating Agents (arginine/glutamine/omega 3 …etc.) Types of Formulas: • Standard (polymeric) • Disease specific • Elemental or defined (mono/oligomeric) • Home made • Modular (only one) Don’t Mix drugs or additives with enteral formulas  flush before & after
  • 30. Formula Selection Depends on: – Patient’s Condition (age / allergies / tolerances / diseases) – GI status – Need of Fiber Modifications – Enteral Route (gastric vs small bowel) – Nutritional and Fluid Requirements
  • 31. 1.2 up to 2 gm/kg/d in critically ill
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  • 33. Open System Closed system Advantages Product is into: powder or ready to fed - Allows modulars such as protein and fiber to be added to feeding formulas - Less waste in unstable patients (maybe) - Containers are sterile until spiked for hanging (ready to hang 1L, 1.5L, 2L) - Can be used for continuous or bolus delivery - Less waste of formula - Less nursing time - Increases safe hang time (24-48hr) - Less risk of contamination Disadvantages - Increase nursing time - Increase risk of contamination - - Shortens hang time (4-8 hrs) - - Rinsing of bag and tubing - No flexibility in formula additives (can use Y port for additions) - More Expensive than open formula
  • 35. EN Safety We should handle EN in a safe manner to avoid contamination in all aspects of care e.g. preparation, manufacturing, infusion. • Contamination: Precautions to avoid contamination: - Use gloves, hand washing. - Pump Cleaned daily. - Cans with alcohol, - Container sanitized and labeled with name & time. • Sanitization - Changed every 24 hrs. - Use screw top connectors not flip top. - Use spike set. - Connections differ than IV lines are better - Infusion chambers→↓ retrograde bacteria. • EN set (different hang times) - Closed system - Open system → Refrigerated if not adm. immediate & the remaining is discarded
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  • 37. Transitional Feeding - From continuous → intermittent → oral. - Stop EN if oral intake → 66-75% (2/3) of total calories. - Monitor tolerance (↓ duration, ↑ volume)
  • 38. Videos that may help: • https://www.youtube.com/watch?v=2MPM9XvadQo • https://www.youtube.com/watch?v=_EDUAVTHQtk&index=2&list=FLa_kHXFy UdiFBuZLLkzLMXg&t=24s • https://www.youtube.com/watch?v=yRmRMHfG7g0&index=1&list=FLa_kHXFy UdiFBuZLLkzLMXg • https://www.youtube.com/watch?v=lpxdUFVOibk