5. Dysphagia, Aspiration, and Nutritional Interventions for Patients with Acquired Brain Injury
Abbreviations
ABI Acquired Brain Injury
BCAA Branched-Chain Amino Acids
BSE Bedside Swallowing Evaluation
CTAR Chin Tuck Against Resistance
EEF Early Enteral Feeding
EN Enteral Nutrition
FOIS Functional Oral Intake Scale
FOTT Facial-Oral Tract Therapy
FEES Fiberoptic Endoscopic Examination of Swallowing
FIM Functional Independence Measure
GCS Glasgow Coma Scale
GH Growth Hormone
ICP Intracranial Pressure
ICU Intensive Care Unit
IEN Immune Enhancing Nutrition
IGF-1 Insulin-like Growth Factor-1
LOS Length of Stay
MBS Modified Barium Swallow
MEBD Modified Evans Blue Dye
NPO Nothing by Mouth
PEG Percutaneous Endoscopic Gastronomy
PMV Passy-Muir (Positive Closure) Speaking Valves
PN Parenteral Nutrition
RCT Randomized Controlled Trial
REE Resting Energy Expenditure
SLP Speech-Language Pathologist
TBI Traumatic Brain Injury
TPN Total Parenteral Nutrition
VFSS Videofluoroscopic Swallow Study
VMBS Videofluoroscopic Modified Barium Swallowing
WST Water-Swallowing Tests
Key Points
Oral hygiene alone results in a significant decrease in dental plaque.
There are no differences in efficacy between the use of a manual or electric toothbrush on ICP or CPP
Maintaining good oral health during hospitalization has been shown to reduce the risk of nosocomial infections and pneumonia post ABI.
Enteral nutrition may not reduce weight loss in individuals post ABI.
For those with ABI and being provided with enteral nutrition, energy expenditure levels may be beyond those predicted by equations.
Parenteral nutrition with a continuous infusion of insulin may lower blood glucose levels in ABI populations.
A combination of both enteral and parenteral nutrition has been shown to provide an increase in protein levels post ABI.
Further research is needed to clarify the effect of both feeding routes on nitrogen balance and albumin levels post ABI.
The evidence is conflicting regarding the effect of enhanced enteral nutrition on infection rates, ventilator dependency, and hospital length of stay in patients post ABI.
Early enteral nutrition may be more beneficial than standard or late enteral nutrition for several patient outcomes post ABI.
Early parenteral nutrition support of ABI patients may improve immunologic function.
There may be an increased risk of developing pneumonia for ventilated stroke and head injury patients fed by a nasogastric versus a gastrostomy tube.
The use of metoclopramide to aid in gastric emptying may not be effective post TBI.
Zinc supplementation in the immediate post-injury period has been shown to be beneficial in terms of neurologic recovery and visceral protein concentrations, but not mortality rates, in ABI patients.
Growth hormone may enhance nutritional repletion, but it is unclear as to whether or not it improves nitrogen balance in patients post ABI.
High-protein nitrogen feedings may restore nitrogen losses post ABI.
Branched-chain amino acid supplementation in patients with ABI may improve disability scores.
Introduction
After an acquired brain injury (ABI) a wide range of swallowing disorders may occur. ABI associated with focal and diffuse cortical and brainstem damage may impair swallowing ability and lead to the development of dysphagia and aspiration (Morgan & Ward, 2001). Dysphagia is defined as difficulty or discomfort with swallowing. Aspiration is defined as the entry of material into the airway below the level of the true vocal cords. The two terms are not synonymous as many patients with dysphagia do not aspirate; although, they are closely associated (Morgan & Ward, 2001). Reported rates of aspiration post ABI vary in the literature; trends illustrate a decrease in the incidence of aspiration over time, particularly beyond 3-month follow-up(Morgan & Ward, 2001). This module will discuss dysphagia, aspiration, as well as nutritional interventions for individuals post ABI. ABI-specific literature related to dysphagia, aspiration, and nutrition is limited; for this reason, many studies from the stroke literature have been included as supplementary information. The generalizability of interventions from the stroke literature to individuals with ABI has limitations and should be approached with caution due to differing etiologies in these clinical populations.
Swallowing is implicated in both dysphagia and aspiration. Swallowing has four sequential coordinated phases which are summarized in Table 5.1 and illustrated in Figure 1.
5.2 Dysphagia Post ABI
Dysphagia post ABI has been attributed to pharyngeal muscular dysfunction and lack of coordination secondary to central nervous system loss of control. The reported incidence of dysphagia among individuals with brain injury varies considerably, due in part to differences in the timing and method of assessment and the initial level of severity. Although the incidence of dysphagia can be high following ABI, swallowing function frequently improves in this population over time.
Rates of dysphagia are variable, with the literature ranging between 26% and 70% (Cherney & Halper, 1996; Cherney, 1989; Field & Weiss, 1989; Halper et al., 1999; Mackay et al., 1999; Schurr et al., 1999; Winstein, 1983). Many of these rates are determined at admission; however, Winstein (1983) reported that at the time of discharge, 84% of those patients admitted with swallowing problems were eating orally. At follow-up, in the outpatient clinic, this number increased to 94%. The most common swallowing problems among patients with ABI included prolonged oral transit (87.5%), delayed swallow reflex (87.5%), valleculae pooling (62.5%), and pyriform sinus pooling (62.5%) (Field & Weiss, 1989). In a study by Mackay et al. (1999) other swallowing abnormalities included loss of bolus control (79%), reduced lingual control (79%), decreased tongue base retraction (61%), delayed trigger of swallowing reflex (48%), reduced laryngeal closure (45%), reduced laryngeal elevation (36%), unilateral pharyngeal paralysis (24%), absent swallow reflex (6%), and cricopharyngeal dysfunction (3%). For these studies, the most common factor impacting swallowing problems was cognitive functioning (Mackay et al., 1999; Winstein, 1983).
5.2.1 Risk Factors for Dysphagia Post ABI
Typically the more severe the brain injury, the more severe the swallowing problem (Logemann, 2013); however, the relationship between injury severity/characteristics and the nature of the swallowing disorder needs to be further studied. Within the literature, many have attempted to identify the factors that may affect the presence and severity of dysphagia post ABI (Cherney & Halper, 1996; Halper et al., 1999; Mackay et al., 1999; Morgan & Mackay, 1999). For example, injuries that result from translaryngeal intubation or tracheostomy may contribute to prolonged swallowing dysfunction in ABI patients (Morgan & Mackay, 1999), but their etiology is secondary compared to primary dysphagia.
Evidence Table(s)
5.3 Aspiration Post ABI
Rates of aspiration within the literature are variable, ranging from 25% to 71% depending on the sample surveyed (Mackay et al., 1999; O’Neil-Pirozzi et al., 2003b; Schurr et al., 1999). Terre and Mearin (2009) followed 26 patients with traumatic brain injury (TBI) who aspirated; 35% were silent aspirators (no cough/throat clear response to aspiration), for one year. With silent aspiration there are no overt signs that an individual has aspirated, and the individual themselves may not be aware that either solids or liquids have entered their airway or lungs (Terre & Mearin, 2009). At 3, 6, and 12 months, the number of patients who aspirated continuously declined, such that aspiration was present in only 6 of the 26 patients by the end of the first year (Terre & Mearin, 2009). For the majority of patients, the most significant changes were seen at the 3-month evaluation. Relating to assessment, O’Neil-Pirozzi et al. (2003b) studied 12 patients with tracheostomy who also had severely disordered consciousness and found that an MBS was successfully completed with all of them; consequently, these more severely impaired patients with TBI remain potential MBS candidates. In terms of potential treatment for aspiration, a study by Steele et al. (2013) found that patients had improvements on measures of tongue pressure and penetration aspiration after the completion of a 24-session tongue-pressure resistance training program. Increased tongue strength may therefore be seen as beneficial in improving swallowing and isometric tasks. Studies examining interventions for aspiration do exist in evidence-based literature, though no studies met our inclusion criteria. For those who do develop difficulty with swallowing post injury it is reassuring to note that the majority make good gains within the first year.
5.3.1 Risk Factors for Aspiration Post ABI
Evidence Table(s)
5.3.2 Silent Aspiration
Lazarus and Logemann (1987) identified aspiration in 38% of their ABI sample and found that many of these patients, despite aspirating, did not produce a reflexive cough and required prompting to clear aspirated material. In another study, approximately 33% of the subjects silently aspirated and issues with aspiration seemed to resolve within the 12 month duration of the study (Terre & Mearin, 2009).
5.3.3 Pneumonia and Aspiration Post ABI
The clinical criteria used to define aspiration pneumonia varies between studies, impacting the reported incidence. Due to the absence of ABI specific studies, the criteria used within the stroke literature has been provided in Table 5.4.
Evidence Table(s)
Discussion
Hansen et al. (2008) explored the risk factors associated with pneumonia in patients with severe TBI. The study found that pneumonia was more common among individuals with low levels of consciousness and for those with a feeding or tracheotomy tube, similar to patterns seen in stroke. Glasgow Coma Scale (GCS) scores and Rancho Los Amigos scale scores were also associated with elevated risk of pneumonia, with individuals who had lower GCS scores, as well as individuals with lower Rancho Los Amigo Scale scores, being at high risk. These two scales, along with the Functional Oral Intake Scale (FOIS) and Functional Independence Measure (FIM) scores were found to be predictive of return to an unrestricted diet (Hansen et al., 2008). Further, Hui et al. (2013) found that patients were more likely to develop pneumonia if they were older, on ventilation for a longer period of time, suffered blunt trauma, and/or had suffered a severe TBI.
5.4 Assessment of Dysphagia and Aspiration Post ABI Using Stroke Models of Care
To be clinically useful, screening tests need to be valid, reliable, easy to use, non-invasive, quick to administer (15-20 min), and pose little risk to the patient. Although many screening tools have been developed it is unclear how many of them are used in institutions beyond those where they were initially developed. Many institutions use informal processes, or simply restrict all food and drink intake until an assessment has been completed by a Speech-Language Pathologist (SLP).
Although ERABI focuses primarily on interventional studies, information pertaining to assessment tools used in dysphagia practice have been included within this section to increase its clinical relevance. Although many of these tools are used in practice with ABI populations, none have been studied extensively within this population.
5.4.1 The Bedside Clinical Examination
The BSE is typically completed by a SLP or a professional trained in dysphagia. This examination is generally completed once the patient’s history has been reviewed by the clinician (Logemann, 1989). Clinicians are expected to make several observations: status of lip closure; oral versus nasal breathing; level of secretions; patient’s awareness of secretions; patient’s awareness of clinician’s approach; and the nature of content of initial verbalization by the patient (Logemann, 1989).
Evidence Table(s)
5.4.2 Water Swallowing Test
Stroke populations are used to illustrate the benefit of these screening tools, as research and supporting evidence specific to the TBI population is lacking. The results of a systematic review by Martino et al. (2000) evaluating the accuracy of 49 individual clinical screening tests for oropharyngeal dysphagia suggested that there was only sufficient evidence to support the value of two tests: abnormal pharyngeal sensation and the 50 mL WST. Both of these tests assessed only for the presence or absence of aspiration. Their associated likelihood ratios were 5.7 (95% CI 2.5-12.9) and 2.5 (95% CI 1.7-3.7), respectively. Evidence suggests that the number of aspirations observed increases as the amount of liquid increases (Osawa et al., 2013). 2013), although interestingly an increase in liquid volume did not increase the specificity of the VFSS. Daniels et al. (2012) reviewed the sensitivity, specificity, and positive likelihood ratio of items on 17 screening tools designed to detect aspiration. Items with high sensitivity (>80%) included weak palatal movement, cough on a 50 mL and repeated 5 mL WST, dysarthria, abnormal volitional cough, abnormal voice, and abnormal pharyngeal sensation. Only 1 item (impaired pharyngeal response) was associated with a likelihood ratio greater than 10, the clinically relevant threshold. According to Nishiwaki et al. (2005), cough/voice change in the WST was the only variable that was significantly associated with aspiration on videofluoroscopic modified barium swallow (VMBS) examination, with a sensitivity of 72% and a specificity of 67%.
5.4.3 Videofluoroscopic Modified Barium Swallow Studies
Those patients who aspirate over 10% of the test bolus or who have severe oral and/or pharyngeal motility problems on VMBS testing are considered at high risk for pneumonia (Logemann, 1983; Milazzo et al., 1989). In many cases, it is difficult to practically assess whether 10% or more of the test bolus has been aspirated, particularly since images are seen two dimensionally. Nevertheless, the degree of aspiration seen on VMBS study is a critical determinant of patient management. Predicting whether a patient will develop pneumonia post aspiration is, to some extent, dependent on other factors such as the immune state or general health of the patient with ABI.
The VMBS assessment not only establishes the presence and extent of aspiration but may also reveal the mechanism of the swallowing disorder. Aspiration most often results from a functional disturbance in the pharyngeal phase of swallowing related to reduced laryngeal closure or pharyngeal paresis. A VMBS study is recommended in those cases where the patient is experiencing obvious problems maintaining adequate hydration/nutrition, where concern is expressed regarding frequent choking while eating, or in the case of recurrent respiratory infections. Other factors such as cognition, depression, underlying lung disease, and being immunocompromised must also be considered.
Evidence Table(s)
5.4.4 Fiberoptic Endoscopic Evaluation of Swallowing
Flexible endoscopic evaluation of swallowing (FEES), is recognized as an objective tool for the assessment of swallowing function and aspiration. FEES is a procedure that allows direct viewing of swallowing function by passing a very thin flexible fiberoptic tube through the nose to obtain a view directly down the throat during swallowing. FEES allows for the full evaluation of the swallow function as food passes from the mouth into the throat. The evaluation identifies functional abnormalities and helps to determine the safest position and food texture for the patient in order to maximize nutritional status and eliminate the risk of aspiration and unsafe swallowing.
In addition to assessing the motor components of swallowing, FEES can also include a sensory testing assessment when an air pulse is delivered to the mucosa innervated by the superior laryngeal nerve. This form of assessment is known as flexible endoscopic examination of swallowing with sensory testing.
As a result of the multiple benefits of FEES (reliability, safety, ease of administration, low cost, and lack of exposure to radiation), this tool has gained much support for the detection of dysphagia, particularly in acute stroke (Bax et al., 2014). FEES in combination with a cough reflex test and clinical swallowing evaluation may focus the criteria for the induction of candidates for FEES to make this service more efficient and productive. The selection of patients for referral to instrumental assessment may be improved by the use of these assessments in conjunction since they provide stronger evidence for the presence of dysphagia and subsequent complications among those who fail the cough reflex test (Bax et al., 2014). Furthermore, conflicting evidence from other studies suggests that an increase in the length of hospital stay is associated with increased rates of pneumonia (Finlayson et al., 2011; Wilson & Howe, 2012). However, significant results suggesting the opposite are true in the study by Bax et al. (2014). The authors explain that this relationship may be due to the provision of FEES leading to a higher referral rate to swallowing rehabilitation and a subsequent increase in length of stay. In support of this conclusion, there was an increase in the proportion of patients leaving the hospital on normal diets. Overall, the use of FEES, especially in combination with cough reflex testing, seems to ultimately benefit patient health outcomes.
A good quality randomized controlled trial (RCT) assessed the use of Facial-Oral Tract Therapy (FOTT) versus FEES as a standard assessment indicating the opportunity for initiation of oral feeding (Kjaersgaard et al., 2014). After excluding patients who developed pneumonia outside of the primary study criteria, there was no difference in the incidence of this respiratory infection between the two groups (3/62 FOTT patients; 4 of 57 FEES patients). These results were supported in a study by Barquist et al. (2001) who found that the risk of pneumonia was not significantly different between 70 patients screened with either FEES or clinical assessment within 48 hours of endotracheal intubation. It seems that FEES, when combined, may be beneficial to some clinical non-instrumental assessments such as FOTT in reducing the risk of aspiration pneumonia after starting oral feeding.
Aviv (2000) compared the incidence of pneumonia over a one-year period between patients screened by MBS or FEES for dysphagia and aspiration with sensory testing and treated based on their respective outcomes. Among the stroke patients, the incidence of pneumonia for those assessed by FEES with sensory testing was significantly lower compared to those assessed with MBS. The authors speculated that one of the reasons for the lower incidence might be due to the sensory testing component of the FEES examination, absent from the MBS evaluation, which was used to more effectively guide management.
Rather than attempt to compare the accuracy of swallowing abnormalities assessed between VMBS and FEES evaluations, Leder and Espinosa (2002) compared the ability of six clinical identifiers of aspiration (dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow) with FEES assessment to determine the accuracy of predicting aspiration risk following stroke. Their results suggest that the ability of the test to correctly identify patients not at risk of aspiration was poor using clinical criteria (low specificity). However, two studies conclude that FEES is the gold standard to assess the accuracy of either the WST and/or pulse oximetry to detect aspiration within the stroke population (Chong et al., 2003; Lim et al., 2001).
5.4.5 Pulse Oximetry
Although pulse oximetry is a quick and non-invasive method to detect aspiration following stroke, its association with oxygen desaturation has been inconclusive. Generally, its performance when measured against VMBS studies has been poor due to its low sensitivity and specificity (39%-87%) (Collins & Bakheit, 1997; Smith et al., 2000; Wang et al., 2005). Therefore, it is unclear whether it is a clinically viable tool for the detection of dysphagia and aspiration.
5.4.6 Blue Dye Assessment for Swallowing
5.4.7 Other Methods of Assessing Dysphagia and Aspiration
Another assessment tool is voice analysis. Ryu et al. (2004) evaluated voice analysis as a means to clinically predict laryngeal penetration among 93 patients (46% of whom had suffered a stroke) using VMBS to confirm aspiration. Of five voice parameters tested (average fundamental frequency, relative average perturbation, shimmer percentage, noise-to-harmonic ratio, and voice turbulence index), relative average perturbation most accurately predicted aspiration.
Cervical auscultation, another tool to assess aspiration, is generally conducted using a stethoscope or some other listening device (Borr et al., 2007; Leslie et al., 2007; Youmans & Stierwalt, 2005). It is believed that this type of test can provide additional information on the pharyngeal swallow in all patients without any additional costs or by using any intrusive methods (Borr et al., 2007; Youmans & Stierwalt, 2005). Cervical auscultation was compared to the VMBS in patients being treated for dysphagia (Zenner et al., 1995). Although agreement was found between the two tests on the oral phase, pharyngeal phase, and diet management components, the VMBS did appear to be slightly more sensitive in identifying patients who had aspirated. In another study, Stroud et al. (2002) found that raters were able to identify patients who were aspirating quite easily but challenges arose when evaluating patients who were not aspirating resulting in a significant number of false positives. Due to the limited evidence for cervical auscultation, caution should be taken when using this technique (Leslie et al., 2007).
5.5 Treatment of Dysphagia Post ABI
The non-feeding program was designed as a stimulation program for very low-level patients, in order to prepare them for later feeding and includes desensitization techniques (e.g., stroking, applying pressure, or stretching) to facilitate normal swallowing, sucking, and intraoral responses (Winstein, 1983). The facilitation and feeding program uses small amounts of puree consistency food to assist normal feeding patterns (Winstein, 1983). Finally, the progressive feeding program uses specialized techniques to help the patient develop swallowing endurance by systematically increasing the amount of oral intake. This progressive feeding program continues until the patient can consume a complete meal within thirty minutes without difficulties (Winstein, 1983).
For patients who are safe with some form of oral intake, therapeutic strategies utilized in dysphagia management can be divided into two categories: (a) compensatory treatment techniques and (b) therapy techniques (Logemann, 1999). Compensatory treatment techniques do not involve direct treatment of the swallowing disorder; rather they reduce or eliminate the symptoms of dysphagia and risk of aspiration by altering how swallowing occurs (Logemann, 1991, 1999). The types of compensatory strategies include: (a) postural adjustment of the head, neck, and body to modify the dimensions of the pharynx and improve the flow of the bolus; (b) sensory stimulation techniques used to improve sensory input either prior to or during the swallow; (c) food consistency and viscosity alterations; (d) modifying the volume and rate of food/fluid presentation; (e) use of intraoral prosthetics (Logemann, 1999). Conversely, therapy techniques are designed to alter the swallow physiology (Logemann, 1999). They include range-of-motion and bolus handling tasks to improve neuromuscular control without actually swallowing. They also include swallowing maneuvers that target specific aspects of the pharyngeal stage of the swallow. Medical and surgical management techniques are included in this category (Logemann, 1999), with these interventions typically only introduced once trials with more traditional behavioural treatment techniques have proven to be unsuccessful.
Several interventions have been investigated for the treatment of dysphagia. Included among these are vocal fold adduction exercises, range of motion exercises for the lips, tongue, and jaw, and chewing exercises (Logemann, 1993). Many of these exercises, although tested within stroke or other populations, have not been tested specifically within the ABI population. As there is a need for more clinical data supporting dysphagia treatments within an ABI population, this section will focus on research based on both ABI populations that did not meeting inclusion criteria, as well as stroke patient data and will discuss the literature supporting dysphagia management in a stroke population.
5.5.1 Stroke Best Practice Guidelines for Managing Dysphagia
Evidence Table(s)
5.5.2 Oral Motor Exercises
5.5.2.1 Range of Motion Exercises for the Pharyngeal Structures: Airway Entrance
5.5.2.2 Vocal Fold Adduction Exercises
5.5.3 Strengthening Exercises
5.5.3.1 The Shaker Exercise
5.5.3.2 Chin Tuck Against Resistance
5.5.4 Swallow Maneuvers
5.5.4.1 Supraglottic Swallow
5.5.4.2 Super-supraglottic Swallow
5.5.4.3 Effortful Swallow
5.5.4.4 Mendelsohn Maneuver
5.5.5 Thermal-tactile Stimulation
The use of a chilled laryngeal mirror applied to the anterior faucial pillars (three strokes per side) before swallowing was compared to 10 consecutive swallows of semi-solid boluses in 22 patients with dysphagia post stroke (Rosenbek et al., 1996). Following the stimulation, patients were asked to swallow a bolus. Results indicated that the duration of stage transition and total swallow duration was reduced following thermal stimulation (Rosenbek et al., 1996). This method requires further research before conclusions on its efficacy in post-ABI populations may be made.
5.5.6 Postural Techniques
For individuals who have significant cognitive deficits post injury, having the patient engage in any one of these techniques may be challenging. It has been suggested that patients with oral and pharyngeal deficits consistently do the following: remain upright for 30 minutes post meal to reduce the risk of aspiration, take controlled bites/sips, alternate solids and liquids, take multiple swallows, and clear or remove food that has pocketed in the mouth (Kramer et al., 2007).
Evidence Table(s)
5.5.7 Diet Modification
International Dysphagia Diet Standardization Initiative (IDDSI)
In 2013 an IDDSI committee was formed from a volunteer group of individuals in nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, patient safety, engineering, food science & technology. The goal was to develop standardization in terminology used in describing dysphagia diets for individuals across age, care settings and cultures, internationally. The work by this committee resulted in the creation of what is now known as the International Dysphagia Diet Framework (Initiative, 2018).
Research efforts by Steele et al. 2018 to evaluate the International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed strong consensual validity, criterion validity, and interrater reliability (Steele et al., 2018). In their study, 176 respondents from 29 countries completed a web based survey related to 16 clinical cases. They found poorest consensus with the cases “involving liquid-only diets, transition from nonoral feeding, or trial diet advances in therapy”. Perhaps more telling was the finding that “most (>70%) respondents indicated enthusiasm for implementing the International Dysphagia Diet Standardisation Initiative Functional Diet Scale” in general (Steele et al., 2018). This certainly speaks to great need for standardization of language and descriptors in providing best practices in therapeutic diet interventions.
It should be noted that restrictions to diet and specific consistencies of food should be the last strategy examined (Logemann, 1997). Restrictions to diets and consistencies, especially thin fluids, can be very challenging for individuals (Logemann, 1997). Often patients may begin with a very restrictive diet (liquids of various consistencies – purees) and move to less restrictive diets (diced to regular foods) at a pace that has been deemed safe for that individual (Kramer et al., 2007). Asking the patient to limit the amount of food they attempt to swallow (taking smaller bites) will also help reduce difficulties with swallowing.
Evidence Table(s)
5.5.8 Passy-Muir Speaking Valve (PMV)
The valve may be attached to the 15mm connector found on most adult tracheostomy tubes (Dettelbach et al., 1995; Passy et al., 1993). With the PMV in place, a noticeable decrease in the amount aspirated has been observed. While wearing the valve, patients also have the opportunity to more easily express themselves verbally (Bell, 1996). Passy et al. (1993) found that patients began speaking almost immediately and their speech improved making it easier for them to communicate with hospital staff, doctors, and family. This ease of communication is very beneficial to the patient’s ability to direct their own care related to feeding, swallowing and diet preferences.
Within the literature, the benefits of the PMV have been supported. Manzano et al. (1993) found that patients experienced a decrease in secretions and showed improvement in ability to cough with the PMV in place; further supporting its effectiveness, the volume of secretions appears to increase when the PMV is removed (Lichtman et al., 1995; Passy et al., 1993). The use of a PMV has also been shown to significantly improve the degree of aspiration (Elpern et al., 2000; Stachler et al., 1996), provide the ability to safely ingest thin liquids (Suiter et al., 2003), improve oxygenation, decrease oral and nasal secretions, improve sense of smell, enhance airway clearance, and improve swallowing (Bell, 1996). To determine its effectiveness specifically within the ABI population more research is recommended.
5.6 Oral Care Interventions
Key Points
There are no differences in efficacy between the use of a manual or electric toothbrush on ICP or CPP
Oral biofilm (or plaque) is a combination of proteins/glycoproteins and bacteria. Following oral care, oral biofilm/plaque begins forming again in as little as 15 minutes. Within two hours, bacteria have multiplied and this biofilm may even double in mass and begin forming complex networks of bacteria colonies that are able to communicate with each other. There is a four to six-fold increase in the incidence of aspiration pneumonia in patients with periodontal disease and/or poor oral care (Maddi & Scannapieco, 2013). In patients who are NPO (nothing by mouth) with enteral feeding for total nutrition there is no mechanical disruption of the biofilm through movement of food and liquid or by the tongue and oral muscles; therefore, biofilm accumulates more easily (including formation on the soft issues). For this reason, the role of thorough mouth care for patients who are NPO becomes even more critical (written communication from Dr. Greenhorn-November 23, 2012). With our current understanding of the oral-systemic link, improved oral care also has a positive impact on the reduction of aspiration pneumonia rates, particularly in those patients with dysphagia.
As noted earlier, many patients with TBI may be more difficult to approach with regards to mouth care. For this reason, the key elements of care must be known so care is as efficient as possible. Clayton (2012) states “education of staff regarding the importance of oral hygiene and obtaining quality oral care equipment is vital.” Currently, there is very little evidence in the literature to support the fact that oral care is routinely performed, particularly when the patient with TBI is in hospital or long-term care (Kelly, 2010; Landesman et al., 2003; Talbot et al., 2005). Education in oral health and good oral care is needed to reduce the risk of dysphagia and other associated complications that can result from a brain injury.
Evidence Table(s)
Discussion
Of note, Prendergast et al. (2011) found individuals in a neuroscience intensive care unit, who were still intubated, were able to tolerate tooth brushing (manual and electric). Intracranial pressure and cerebral perfusion pressure monitoring showed no significant differences between the groups before, during, or after the procedure. Overall results suggest tooth brushing is possible in an intensive care unit, and patients post-ABI can tolerate it without any adverse effects.
Conclusions
There is Level 1b evidence that the use of a manual compared to an electric toothbrush has no significant effect on ICP and CPP.
There is Level 2 evidence that providing oral hygiene education to patients post TBI results in a significant reduction of dental plaque, measured by the Plaque Index Score.
5.6.1 Provision of Mouth Care as a Means of Managing Aspiration Pneumonia Risk
Key Points
oral hygiene and training for oral function (swallowing, mastication, and saliva secretion) (Tada & Miura, 2012).
In individuals without swallowing difficulty, oral bacteria routinely travel along with the food ingested through the esophagus to the stomach, where it is neutralized and presents less threat to the health of the lungs. Even in healthy individuals the importance of a proper mouth care program can not be understated. In patients who are NPO, problems are compounded by xerostomia (dry mouth). Xerostomia is an undesirable side effect associated with up to 500 medications (e.g., anti-hypertensives, anticonvulsants, antidepressants) (Bartels, 2005; Canadian Dental Association, 2009; Nicol et al., 2005), many of which are administered to those who sustain an ABI. In these patients, reduced salivary flow and thicker secretions contribute to increased micro-organisms and increased risk of infection (Bartels, 2005).
Unlike the general population, mouth care in patients with dysphagia is best performed before eating/drinking. The rationale is that the introduction of oral bacteria to the lungs via aspiration is more problematic than the food or liquid that is aspirated alone. Brushing before eating/drinking for patients with dysphagia means that bacteria have no opportunity to be introduced to the lungs even in “known aspirators”, thereby reducing the incidence of pneumonia (Seguin et al., 2014).
Evidence Table(s)
Discussion
Two RCTs were have investigated the effectiveness of chlorhexidine gel on the development of nosocomial infections in patients assigned to the intensive care unit (Cabov et al., 2010; Fourrier et al., 2000). Both studies showed that chlorhexidine gel was effective in reducing the number of nosocomial infections and overall length of stay compared to placebo or standard oral care.
In the Seguin study (2014) , authors investigated the efficacy of povidone-iodine versus a placebo drug in reducing ventilator-associated pneumonia. The occurrence of ventilator-associated pneumonia, although reduced in the experimental group, was not significantly different from the control group (Seguin et al., 2014). Povidone-iodine was also shown to increase the risk of secondary infections including acute respiratory distress syndrome (Seguin et al., 2014). However, another study demonstrated reduced rates of non-ventilator hospital-acquired pneumonia among patients receiving enhanced oral care; Robertson and Carter (2013) found that patients receiving the enhanced oral care protocol had a significant decrease in acquired pneumonia when compared to the standard oral care group.
Conclusions
There is level 1b evidence that povidone-iodine may be effective for reducing the incidence of ventilator-associated pneumonia compared to placebo post stroke or ABI.
There is level 1b evidence that oral care may reduce rates of pneumonia, febrile days, and pneumonia-related deaths in mixed populations.
There is level 3 evidence that enhanced oral care may reduce rates of non-ventilator hospital-acquired pneumonia compared to standard oral care in mixed brain injury populations.
5.7 Nutritional Management
Secondary to ABI, a catabolic and counter regulatory hormone (glucagon and cortisol cortical increase takes place (Loan, 1999). Deficiencies of follicle-stimulating hormones, luteinizing hormone, and growth hormone (GH) indicate alteration in the hypothalamic-pituitary feed-back mechanism that normally regulates metabolism (Loan, 1999). As a result of hypermetabolism and hypercatabolism, both energy and protein requirements will be elevated in the first several weeks following injury. Negative energy and nitrogen balance, which may exceed 30 grams per day, have been reported within the first week following injury (Bruder et al., 1994; Weekes & Elia, 1996; Wilson et al., 2001; Young et al., 1985). Unfortunately, although muscle wasting occurs as a consequence of bed rest and immobilization, only a portion of these losses are responsive to nutritional interventions (Behrman et al., 1995).
A case control study examined the cost associated with enteral nutrition (EN) compared to parenteral nutrition (PN) treatment (Ott et al., 1999). It was found that on average the cost of PN was almost double of the cost of EN. However, it should be emphasized that cost is not a sufficient determinant of which treatment should be allocated to an individual as that is determined by their physiological state and their ability to absorb nutrients.
5.7.1 Incidence of Malnutrition
5.7.2 Hypermetabolism Post ABI
Resting energy expenditure (REE) represents the amount of calories required for a 24-hour period by the body during a non-active period. Young et al. (1985) found REE to decrease consistently over time post ABI (151% to 116% over 22-day evaluation). Bruder et al. (1994) compared REE in ABI patients who were weaned off from sedation, while others were re-sedated. REE increased to 143% of predicted values in those who were weaned from sedations, while the increases in REE were only 122% of predicted values in those who received additional sedation (Bruder et al., 1994), demonstrating that sedation can impact metabolic rates. Barbiturate use as it relates to REE was examined by Dempsey et al. (1985); the findings showed that mean REE was significantly lower during barbiturate therapy than without barbiturate therapy, when it was administered to those with failing intracranial pressure (ICP) (p<0.01). Other factors that affected REE after head injury were evaluated by Robertson et al. (1984); the authors found that patients with GCS 4-5 had the highest REE at 168±53% of expected values, and was lowest in patients with GCS 6-7 at 129±31% of expected values (Robertson et al., 1984).
The evidence suggests that patients with ABI are often hypermetabolic, with significantly higher resting energy expenditure in the acute period following the injury. Continued research in this area will help to establish meaningful guidelines regarding use of barbiturates and sedations as modifiable factors.
5.7.3 Fluid Consumption and the Frazier Free Water Protocol
5.7.4 Routes and Timing of Non-Oral Nutritional Interventions
One study found that enteral feeding intolerance may be related to increased intracranial pressure (Ott et al., 1990). Medications may also play a role in delayed gastric emptying. Although the placement of feeding tubes into the small bowel may theoretically improve tolerance, placement can be difficult and empirical evidence of superiority is lacking. If intolerance is prolonged, parenteral feeding may be indicated (Cerra et al., 1997), although the risk of hyperglycemia and cerebral edema is increased.
5.7.4.1 Enteral Nutrition Administration
Key Points
For those with ABI and being provided with enteral nutrition, energy expenditure levels may be beyond those predicted by equations.
Evidence Table(s)
Discussion
Conclusions
There is level 4 evidence that patients with ABI may expend more energy when on enteral nutrition than predicted by equations, and that this effect may be greater for non-sedated individuals.
5.7.4.2 Parenteral Nutrition Administration
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7.4.3 Combination or Comparative Nutrition Administration Strategies
Key Points
Further research is needed to clarify the effect of both feeding routes on nitrogen balance and albumin levels post ABI.
Evidence Table(s)
Discussion
The RCT by Rapp et al. (1983) also reported fewer deaths occurring among individuals receiving TPN compared to standard EN (0 versus 44%, p<0.0001). However, there were no significant differences in terms of serum albumin levels over time. This is contrary to a later study which found that patients who received EN showed significant increases in serum pre-albumin and retinol-binding protein compared to the PN or combined EN and PN (Nataloni et al., 1999).
Hausmann et al. (1985) conducted an RCT to investigate the effects of combined EN and PN compared to TPN on protein catabolism. Findings from the study noted the difference in the nitrogen balance between the two feeding regimes; however, these differences were not significant. The combination EN and PN group did have significantly higher protein concentrations compared to the TPN group, but no other relevant differences in the metabolic data or mortality between each of these treatment groups was found (Hausmann et al., 1985).
A case control study by Chapple et al. (2016) investigated EN versus oral feeding; the results demonstrated a significantly greater energy deficit for patients receiving nutrition orally versus EN (p=0.016), however, protein deficits were similar. However, it was found that ward admission had significantly higher levels of caloric intake prescribed than intensive care unit (ICU) admission overall. Fan et al. (2016) conducted a prospective controlled trial comparing EN versus PN versus combined EN and PN. Total serum protein, prealbumin, and hemoglobin were significantly decreased in the PN group (p<0.01), which corresponds to a degradation in nutritional status; in the EN and EN+PN groups, total serum and protein levels significantly increased (p<0.01) after nutritional treatment. Therefore, the authors suggest a combination of EN+PN to improve prognosis and nutritional status for post-ABI patients. A case control conducted by Krakau et al. (2007) found that 68% of patients who had sustained an ABI showed signs of malnutrition within the first two months of injury. When first admitted to hospital, all patients initially received nutrition parenterally for the first 19 days following injury. The majority of these patients (86%) then received EN (Krakau et al., 2007).
Conclusions
There is conflicting evidence regarding whether or not one nutrition administration method (enteral or parenteral) is more effective compared to the other for improving the nitrogen balance of patients with ABI.
There is conflicting evidence regarding whether or not one nutrition administration (enteral or parenteral) is more effective compared to the other for improving serum albumin levels in patients with ABI.
There is level 2 evidence that enteral nutrition results in higher mortality compared to parenteral nutrition in patients with ABI, however enteral and parenteral nutrition may have similar effects on morbidity.
There is level 2 evidence that enteral nutrition in combination with parenteral nutrition versus parenteral nutrition alone have a similar effect on mortality in patients with ABI.
There is level 2 evidence that parenteral nutrition can safely be administered without causing serum hyperosmolarity compared to enteral nutrition, and that neither treatment influences intracranial pressure levels, in patients post ABI.
5.7.4.4 Enhanced Enteral Nutrition
Key Points
Discussion
Brain injury patients have higher energy and protein expenditures and are prone to infections, thus supplementing diet and enhancing feeding solutions may be a feasible option to consider when improving outcomes.
Conclusions
5.7.4.5 Timing of Enteral Nutrition
Key Points
Evidence Table(s)
Discussion
Minard et al. (2000) and Azim et al. (2016) found that timing of enteral feeding had no significant impact on mortality, number of infections, ventilator days, or incidence of pneumonia. Chaudhry et al. (2017) looked at inpatients who received early, standard, or late percutaneous endoscopic gastronomy (PEG) for nutritional support post ABI. Their results showed that late PEG was associated with a higher comorbidity index, longer LOS, and more complications compared to early PEG.
In a prospective study comparing total EN at various time points (within 3 days, 4-7 days, and after 7 days) there were unfavourable outcomes associated with total EN after 3 days (Dhandapani et al., 2012). Those who began later lost significantly more mid-arm circumference and mid arm muscle circumference and had worse malnutrition. At the third and sixth month follow-ups, those receiving total EN within the first 7 days were more likely to have favourable outcomes on the GOS (Dhandapani et al., 2012).
A Cochrane review by Yanagawa et al. (2000) identified six RCTs that addressed the timing to initiation of feeding and mortality as an outcome. The relative risk for death associated with early nutritional support was 0.71 (95% CI 0.43-1.16). The pooled relative risk from three trials, which also assessed death and disability, for early feeding was 0.75 (0.50-1.11). Although the results were not statistically significant, it was concluded that early feeding may be associated with a trend towards better outcomes in terms of survival and disability (Yanagawa et al., 2000).
Conclusions
There is level 2 evidence that early versus late enteral feeding has a similar effect on mortality, number of infections, ventilator days, or incidence of pneumonia in patients with ABI.
There is level 2 evidence that early enteral nutrition may improve energy and nitrogen intake compared to standard enteral nutrition in ABI populations.
There is level 4 evidence that late percutaneous endoscopic gastrostomy may be associated with a higher comorbidity index, longer length of stay, and more complications compared to early percutaneous endoscopic gastrostomy in patients with ABI.
There is level 2 evidence that late total enteral feeding can result in reduced arm circumference, worse malnutrition, and more disability compared to early total enteral feeding in patients with ABI.
5.7.4.6 Timing of Parenteral Nutrition
Key Points
Discussion
Conclusions
5.7.4.7 Types of Enteral Feeding
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7.4.8 Metoclopramide and Enteral Feeding
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7.5 Miscellaneous Therapies
5.7.5.1 Zinc Supplementation
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7.5.2 Growth Hormone
Evidence Table(s)
5.7.5.3 Increased Nitrogen Feeds
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7.5.4 Branched-Chain Amino Acids
Key Points
Evidence Table(s)
Discussion
Conclusions
5.8 Conclusions
Until an ABI-specific research knowledge base regarding effective rehabilitative interventions is established for dysphagia, aspiration, oral care, and malnutrition, therapeutic management will continue to be guided by extrapolation from the stroke literature. As such, further research is needed to better determine the appropriateness of generalizing post-stroke dysphagia rehabilitation practices to an ABI population.
Summary
There is Level 1b evidence that the use of a manual compared to an electric toothbrush has no significant effect on ICP and CPP.
There is Level 2 evidence that providing oral hygiene education to patients post TBI results in a significant reduction of dental plaque, measured by the Plaque Index Score.
There is level 1b evidence that 0.2% chlorohexidine gel is beneficial for reducing nosocomial infections and hospital length of stay compared to placebo in non-ABI populations.
There is level 1b evidence that povidone-iodine may be effective for reducing the incidence of ventilator-associated pneumonia compared to placebo post stroke or ABI.
There is level 1b evidence that oral care may reduce rates of pneumonia, febrile days, and pneumonia-related deaths in mixed populations.
There is level 3 evidence that enhanced oral care may reduce rates of non-ventilator hospital-acquired pneumonia compared to standard oral care in mixed brain injury populations.
There is level 2 evidence that enteral nutrition may not reduce weight loss or improve FIM scores compared to no EN in patients post ABI.
There is level 4 evidence that patients with ABI may expend more energy when on enteral nutrition than predicted by equations, and that this effect may be greater for non-sedated individuals.
There is level 1b evidence that insulin infusions significantly decrease blood glucose levels when compared to a conventional glucose treatment in TBI patients.
There is level 2 evidence that enteral in combination with parenteral nutrition may be effective for increasing protein levels compared to parenteral nutrition alone in patients with ABI.
There is conflicting evidence regarding whether or not one nutrition administration method (enteral or parenteral) is more effective compared to the other for improving the nitrogen balance of patients with ABI.
There is conflicting evidence regarding whether or not one nutrition administration (enteral or parenteral) is more effective compared to the other for improving serum albumin levels in patients with ABI.
There is level 2 evidence that enteral nutrition results in higher mortality compared to parenteral nutrition in patients with ABI, however enteral and parenteral nutrition may have similar effects on morbidity.
There is level 2 evidence that enteral nutrition in combination with parenteral nutrition versus parenteral nutrition alone have a similar effect on mortality in patients with ABI.
There is level 2 evidence that parenteral nutrition can safely be administered without causing serum hyperosmolarity compared to enteral nutrition, and that neither treatment influences intracranial pressure levels, in patients post ABI.
There is conflicting level 1b and level 3 evidence regarding whether or not enhanced enteral nutrition can reduce the incidence of infection, ventilator dependency period, or length of stay compared to standard formula nutrition in patients post ABI.
There is level 1b evidence that early enteral nutrition may improve the hormonal profile of patients with TBI compared to delayed enteral feeding.
There is level 2 evidence that early versus late enteral feeding has a similar effect on mortality, number of infections, ventilator days, or incidence of pneumonia in patients with ABI.
There is level 2 evidence that early enteral nutrition may improve energy and nitrogen intake compared to standard enteral nutrition in ABI populations.
There is level 4 evidence that late percutaneous endoscopic gastrostomy may be associated with a higher comorbidity index, longer length of stay, and more complications compared to early percutaneous endoscopic gastrostomy in patients with ABI.
There is level 2 evidence that late total enteral feeding can result in reduced arm circumference, worse malnutrition, and more disability compared to early total enteral feeding in patients with ABI.
There is level 2 evidence that early parenteral nutrition support may improve immunologic function compared to delayed parenteral nutrition in patients with closed head injury.
There is level 1b evidence that the risk of developing pneumonia is higher among ventilated patients (stroke and head injury) fed by a nasogastric tube compared with a gastrostomy tube.
There is level 1b evidence that metoclopramide may not be effective compared to placebo for gastric emptying in patients with TBI.
There is level 1b evidence that zinc supplementation has a positive effect on neurological recovery compared to placebo as measured by the Glasgow Coma Scale in ABI patients.
There is conflicting evidence regarding whether or not insulin-like growth factor-1/growth hormone is effective for enhancing growth hormone concentration and nitrogen balance compared to placebo in those who have sustained an ABI.
There is level 2 evidence that high-protein nitrogen feedings of approximately 1 g nitrogen/90 calories may be effective for restoring nitrogen losses that occur post ABI compared to low-protein nitrogen feedings.
There is level 2 evidence that branched-chain amino acid supplementation may improve disability scores compared to placebo in patients with ABI.
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