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
EN Enteral Nutrition
FEES Fiberoptic Endoscopic Examination of Swallowing
FIM Functional Independence Measure
GCS Glasgow Coma Scale
GH Growth Hormone
ICP Intracranial Pressure
ICU Intensive Care Unit
IGF-I Insulin-like Growth Factor-I
LOS Length of Stay
MBS Modified Barium Swallow
MEBD Modified Evans Blue Dye
NPO Nothing by Mouth
PMV Passy-Muir Speaking Valve
PN Parenteral Nutrition
REE Resting Energy Expenditure
SLP Speech-Language Pathologist
TBI Traumatic Brain Injury
TPN Total Parenteral Nutrition
VMBS Videofluoroscopic Modified Barium Swallowing
WST Water-Swallowing Test
Key Points
Oral hygiene results in a significant decrease in dental plaque.
Maintaining good oral hygiene during hospitalization has been shown to reduce the risk of nosocomial infections and pneumonia post ABI.
The evidence regarding which method of feeding (EN or PN) is optimal to deliver nitrogen, meet required energy expenditures, nutritional goals and prevent complications (e.g. diarrhea and pneumonia) is conflicting.
Enteral nutrition with high protein formulas may improve FIM motor and cognitive scores and result in less weight loss.
For those with ABI being provided with enteral nutrition, energy expenditure levels may be beyond those predicted by equations.
Early enteral nutrition may be more beneficial than standard or late enteral nutrition for several patient outcomes post ABI.
There may be an increased risk of developing pneumonia in ventilated stroke and head injury patients fed by a nasogastric tube.
Surgical feeding tube placement strategies can reduce the number of unnecessary surgical feeding tubes.
There is conflicting evidence as to whether immune enhanced enteral feeding solutions reduce infection rates, ventilator dependency, GCS, and hospital length of stay in patients post ABI.
The use of metoclopramide to aid in gastric emptying may not be effective post TBI.
Parenteral nutrition with a continuous infusion of insulin may lower blood glucose levels in ABI populations.
Early parenteral nutrition support of patients with ABI may improve immunologic function.
Further research is needed to clarify the effect of combined (EN + PN or EN or PN alone) feeding routes on nitrogen balance and albumin levels post ABI.
Combined enteral-parenteral nutrition post ABI may lead to nutritional independence by 6 months post injury.
Zinc supplementation in the immediate post-injury period may improve neurological recovery and visceral protein concentrations, but not mortality rates, in patients with ABI.
Growth hormones may enhance nutritional repletion, however, the evidence is conflicting regarding improvements in nitrogen balance, in patients post ABI.
High-protein nitrogen feedings may restore nitrogen losses post ABI.
Branched-chain amino acid supplementation may improve disability scores in patients with ABI.
Introduction
After an acquired brain injury (ABI) a wide range of swallowing disorders may occur. Focal and diffuse cortical and brainstem damage may impair swallowing ability, leading 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, however, trends illustrate a decrease in the incidence of aspiration over time, particularly beyond 3-month follow-up (Kim & Suh, 2018; 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, some stroke literature is included as supplementary information. Generalizations applied from the stroke literature to individuals with ABI should be approached with caution. In 2016, a set of clinical practice guidelines for the rehabilitation of adults with moderate to severe TBI were developed by the Ontario Neurotrauama Foundation and INESSS. A portion of these guidelines focus on dysphagia and nutrition, which can be accessed here. Many of the recommendations in this section were based off the evidence found throughout this module.
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.
Table 5.1 The Four Phases of Normal Swallowing (Platt, 2001)
Figure 5.1: The phases of swallowing
5.1 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 to differences in the timing and method of assessment, as well as 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 in ABI 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 hospital 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). Spontaenous jaw muscle activity has also been observed in those with an ABI at rates as high as triple as those compared to healthy controls (Kothari et al., 2018), which can result in further impairment as a result of an ABI.
5.1.1 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 patients with ABI (Morgan & Mackay, 1999), but their etiology is secondary compared to primary dysphagia.
Evidence Table(s)
5.2 Aspiration Post ABI
Rates of aspiration within the literature range 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-months post 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 reduced 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.
5.2.1 Risk Factors for Aspiration Post ABI
Evidence Table(s)
5.2.2 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).
5.2.3 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 is 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. They 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 increased risk of pneumonia in individuals who had lower GCS scores, as well as individuals with lower Rancho Los Amigo Scale scores. These two scales, along with the Functional Oral Intake Scale 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.
5.3 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 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.
5.3.1 The Bedside Clinical Examination
The BSE is typically completed by an 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)
5.3.2 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). 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%.
5.3.3 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, cognitive-communication, depression, underlying lung disease, and being immunocompromised must also be considered.
Evidence Table(s)
5.3.4 Fiberoptic 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 together as 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, some results suggest the opposite is 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 for 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, appears to benefit patient health outcomes.
A good quality randomized controlled trial (RCT) assessed the use of Facial-Oral Tract Therapy 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 Facial-Oral Tract Therapy 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 Facial-Oral Tract Therapy in reducing the risk of aspiration pneumonia after initiating 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. Within stroke patients, the incidence of pneumonia for those assessed with 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).
5.3.5 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.
5.3.6 Blue Dye Assessment for Swallowing
Brady et al. (1999), in a study looking at the effectiveness of the MEBD test and the VMBS, found that the MEBD test was not able to detect “trace amounts” of aspiration in patients who had a tracheostomy. On the other hand, if patients aspirated more than “trace amounts”, then the MEBD was able to detect it. Brady et al. (1999) recommended that the MEBD be followed by a VMBS to rule out the possibility of trace aspiration. Although this test is used in practice with individuals post ABI, no studies were found looking at its effectiveness within that specific population, therefore, individuals who are assessed for aspiration or dysphagia using the MEBD test should be followed up with a more established test with greater sensitivity and specificity.
5.3.7 Additional Methods
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), changes in relative average perturbation most accurately predicted aspiration.
Cervical auscultation, another tool to assess aspiration, is conducted using a stethoscope or 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 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 and it should not be used in isolation (Leslie et al., 2007).
5.4 Management 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. It 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 use small amounts of puree consistency food to promote 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 difficulty (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, and (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.
5.4.1 Oral Motor Exercises
5.4.1.1 Range of Motion Exercises
5.4.1.2 Vocal Fold Adduction Exercises
5.4.2 Strengthening Exercises
5.4.2.1 The Shaker Exercise
5.4.2.2 Chin Tuck Against Resistance
5.4.3 Swallow Maneuvers
5.4.3.1 Supraglottic Swallow
5.4.3.2 Super-Supraglottic Swallow
5.4.3.3 Effortful Swallow
5.4.3.4 Mendelsohn Maneuver
5.4.4 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.
5.4.5 Postural Techniques
For individuals with 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)
5.4.6 Diet Modification
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.
International Dysphagia Diet Standardization Initiative
In 2013 an International Dysphagia Diet Standardization Initiative committee was formed from a volunteer group of individuals in nutrition & dietetics, medicine, speech-language pathologists, 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 Standardization 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 non-oral 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 Standardization 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.
Evidence Table(s)
5.4.7 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 reduce 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.
5.5 Oral Care Interventions
Key Points
Maintaining good oral hygiene during hospitalization has been shown to reduce the risk of nosocomial infections and pneumonia post ABI.
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).
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).
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 suggest 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. The following table presents literature surrounding oral hygiene post ABI (Table 5.10).
Evidence Table(s)
Discussion
Seguin and colleagues (2014), 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.
Two RCTs 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. Furthermore, research conducted in long-term care or acute care facilities reported a decline in mortality rates, risk for developing dysphagia, and risk of aspiration pneumonia with the introduction of an oral care program (Sarin et al., 2008; Watando et al., 2004). Patients in a nursing home who received oral care had fewer febrile days and cases of pneumonia, and fewer patients were dying from pneumonia (Yoneyama et al., 2002).
Conclusions
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 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 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 oral care may reduce rates of pneumonia, febrile days, and pneumonia-related deaths in mixed populations.
5.6 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.
Incidence of Malnutrition
The incidence of malnutrition following ABI is difficult to estimate as there are no consistent criteria used, and relatively few studies have examined the issue. Given that ABI tends to occur in younger, previously healthy individuals, it is unlikely that pre-existing nutritional deficits are prevalent at the time of injury. Therefore, declines in nutritional parameters are most likely directly related to the metabolic effects of the injury. Brooke et al. (1989) reported an average weight loss of 13.2 kg from injury to rehabilitation admission, while Weekes and Elia (1996) reported 9.8 kg of weight loss from the time of injury to day 19 in four previously healthy young males. In the early rehabilitation phase, a substantial amount of patients are underweight (approximately 60%) (Brooke et al., 1989; Haynes, 1992); however, obesity has also been reported among patients, typically in the chronic phase of recovery (Henson et al., 1993). Another factor which can contribute to malnutrition or dehydration following an ABI is diarrhea, which has been shown to occur in rates as high as 70% in those receiving enteral nutrition, and in relation to the use of antibiotics for over 1-week (Vieira et al., 2018). Of the individuals who had diarrhea, they were also seen to have longer stays in the ICU and were attributed to enteral nutrition intolerance (Vieira et al., 2018).
Hypermetabolism Post ABI
Hypermetabolism is a well-known metabolic sequelae of ABI. Hypermetabolism has been defined as an increase in metabolic rate above that which is predicted using equations, which take into account age, sex, height, and weight (Souba & Wilmore, 1999). The hypermetabolic state, which is characterized by increased oxygen consumption and nitrogen excretion following injury, is thought to be mediated by an increase in i) counterregulatory hormones such as epinephrine, norepinephrine and cortisol, ii) corticosteroids, and iii) proinflammatory mediators and cytokines (Pepe & Barba, 1999). Tremendous variability has been reported regarding the magnitude of the hypermaetabolic state post ABI. The variations are likely due to the timing of the measurements, patient characteristics (i.e., initial level of injury, concomitant infections) and management (i.e., craniotomy, intubation and sedation and/or barbiturate use, ambient temperature).
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 patients with ABI 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.
Fluid Consumption and the Frazier Free Water Protocol
To increase fluid consumption and decrease the risk of dehydration, the Frazier Free Water Protocol allows patients who are receiving thickened liquids to be given regular, thin water in between meals. Thickened fluids do not quench thirst in the same way that regular thin water does. Therefore, the regular water, in combination with the recommended thickened fluids, works to assist some patients in better meeting their daily hydration needs. Patients who are NPO are often permitted to have water (following screening) and those who have found success using various postural changes are asked to use postural maneuvers when drinking water. The Frazier Free Water protocol states that, by policy, water is allowed for any patient NPO or on a dysphasic diet (Panther, 2005).
5.6.1 Enteral Nutrition
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.
5.6.1.1 Timing
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.
5.6.1.2 Administration
Key Points
Surgical feeding tube placement strategies can reduce the number of unnecessary surgical feeding tubes.
Evidence Table(s)
Discussion
Another study found that after implementation of a new Surgical Feeding Tube (SFT) placement strategy, the percentage of unnecessary SFTs significantly decreased from 25% to 8% (Marcotte et al., 2018). In addition, significant predictors of necessary SFTs were identified and included increasing age, head injury, cervical spinal cord injury and need for a tracheostomy.
Conclusions
There is level 3 evidence that a specific surgical feeding tube placement strategy can reduce the number of unnecessary surgical feeding tube placements.
5.6.1.3 Enhanced Feeding Solutions
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
5.6.1.4 Metoclopramide
Key Points
Evidence Table(s)
Discussion
Conclusions
5.6.2 Total Parenteral Nutrition
Key Points
The evidence regarding which method of feeding (EN or PN) is optimal to deliver nitrogen, meet required energy expenditures, nutritional goals and prevent complications (e.g. diarrhea and pneumonia) is conflicting.
Further research is needed to clarify the effect of both feeding routes on nitrogen balance and albumin levels post ABI.
Evidence Table(s)
Discussion
A RCT assessing the effect of glycemic control on PN complications in hospitalized patients with brain injury demonstrated that treatment using an insulin infusion significantly decreased blood glucose levels when compared to a conventional glucose treatment (Mousavi et al., 2014). The experimental group also had significantly lower concentrations of C-reactive protein and triglycerides compared to the control group (Mousavi et al., 2014). The study authors concluded that although more research is needed, insulin infusions improved some parenteral nutrition complications (Mousavi et al., 2014).
With respect to nitrogen balance, Justo Meirelles and de Aguilar-Nascimento (2011) also evaluated the effects of EN and PN in 22 patients with moderately severe TBI and found that parenteral nutrition delivered nitrogen more effectively. Both groups received increasing quantities of nitrogen each day, with those in the total parenteral nutrition (TPN) group receiving significantly more. Despite the increased daily loss of nitrogen, all patients showed significant improvement in nitrogen balance as a result of nutritional therapy (Justo Meirelles & de Aguilar-Nascimento, 2011). Nataloni et al. (1999) studied the effects of EN, PN, or both in a group of patients with ABI while in the intensive care unit. Even though there was a negative nitrogen balance in all groups, all showed improvement over the course of the study, however a positive nitrogen balance was only seen in the enteral group. Furthermore, other studies have found no difference in nitrogen balance between PN and EN (Borzotta et al., 1994; Hadley et al., 1986; Hausmann et al., 1985).
Young and colleagues investigated the effects of TPN versus EN administration on ICP levels in 95 severely brain-inured patients. Participants were randomly assigned to receive TPN or EN and ICP pressure was monitored, as well as serum glucose levels and hyperosmolality. No significant differences were observed between groups in relation to ICP levels or hyperosmolality, suggesting that EN and TPN can be administered safely to severely brain injured patients without causing serum hyperosmolality or affecting ICP therapy.
Hausmann et al. (1985) conducted a RCT to investigate the effects of combined EN and PN compared to TPN on protein catabolism. Findings from the study noted a difference in 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. Although, no other relevant differences in the metabolic data or mortality between each of these treatment groups was found (Hausmann et al., 1985).
Conclusions
There is level 2 evidence that TPN delivered nitrogen more efficiently than EN therapy. However, both groups showed a significant improvement in nitrogen balance as a result of nutritional therapy.
There is level 2 evidence that enteral feeding post ABI may be effective for improving nitrogen balance, while also increasing serum pre-albumin and RBP levels compared to parenteral nutrition and enteral plus parenteral nutrition.
There is level 2 evidence that patients treated with TPN or EN had no differences in nitrogen balance, energy expenditures, meeting nutritional goals and frequency of infections. However, enteral feeding post ABI may lead to decreased rates of hyperglycemia and diarrhea compared to parenteral nutrition.
There is level 2 evidence that intracranial pressure and serum osmolality are not affected by TPN or EN interventions.
There is level 2 evidence that patients receiving EN or PTN had no significant changes in nitrogen balance, although, EN may be more effective in reducing nitrogen intake and nitrogen loss, when compared to PN post ABI.
There is level 2 evidence that parenteral nutrition post ABI reduces the amount of regurgitated gastric fluid compared to combined enteral and parenteral nutrition post ABI, however, nitrogen balance could not be reached for either PN or combined EN and PN post ABI.
There is level 2 evidence that enteral feeding post ABI may reduce mean intake of nitrogen compared to parenteral nutrition post ABI.
There is level 2 evidence that enteral feeding post ABI may increase serum protein, the rate of aspirated pneumonia and diarrhea when compared to parenteral nutrition or combined enteral-parenteral nutrition post ABI.
5.6.2.1 Timing
Key Points
Discussion
Conclusions
5.6.3 Combination or Comparative Nutrition Administration Strategies
Key Points
Further research is needed to clarify the effect of combined feeding routes on nitrogen balance and albumin levels post ABI.
Combined enteral-parenteral nutrition post ABI may lead to nutritional independence by 6 months post injury.
Evidence Table(s)
Discussion
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).
A RCT by Rapp et al. (1983) investigating EN versus PN demonstrated a significant difference in overall nitrogen balance between groups, in favour of PN (p=0.002). Other studies have found no difference in nitrogen balance between PN and EN (Borzotta et al., 1994; Hadley et al., 1986; Hausmann et al., 1985).
They 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 a 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).
Conclusions
There is level 2 evidence that parenteral nutrition post ABI reduces the amount of regurgitated gastric fluid compared to combined enteral and parenteral nutrition post ABI, however, nitrogen balance could not be reached for either PN or combined EN and PN post ABI.
There is level 2 evidence that enteral feeding post ABI may reduce mean intake of nitrogen compared to parenteral nutrition post ABI.
There is level 2 evidence that enteral feeding post ABI may increase serum protein, the rate of aspirated pneumonia and diarrhea when compared to parenteral nutrition or combined enteral-parenteral nutrition post ABI.
There is level 3 evidence that combined enteral-parenteral nutrition post ABI leads to nutritional independence by 6 months post injury.
5.6.4 Other Nutritional Interventions
5.6.4.1 Zinc Supplementation
Key Points
Evidence Table(s)
Discussion
Conclusions
5.6.4.2 Growth Hormone
Key Points
Evidence Table(s)
Discussion
Conclusions
5.6.4.3 Increased Nitrogen Feeds
Key Points
Evidence Table(s)
Discussion
Conclusions
5.6.4.4 Branched-Chain Amino Acids
Key Points
Evidence Table(s)
Discussion
Conclusions
5.7 Conclusion
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 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 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 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 oral care may reduce rates of pneumonia, febrile days, and pneumonia-related deaths in mixed populations.
There is level 2 evidence that TPN delivered nitrogen more efficiently than EN therapy. However, both groups showed a significant improvement in nitrogen balance as a result of nutritional therapy.
There is level 2 evidence that enteral feeding post ABI may be effective for improving nitrogen balance, while also increasing serum pre-albumin and RBP levels compared to parenteral nutrition and enteral plus parenteral nutrition.
There is level 2 evidence that patients treated with TPN or EN had no differences in nitrogen balance, energy expenditures, meeting nutritional goals and frequency of infections. However, enteral feeding post ABI may lead to decreased rates of hyperglycemia and diarrhea compared to parenteral nutrition.
There is level 2 evidence that intracranial pressure and serum osmolality are not affected by TPN or EN interventions.
There is level 2 evidence that patients receiving EN or PTN had no significant changes in nitrogen balance, although, EN may be more effective in reducing nitrogen intake and nitrogen loss, when compared to PN post ABI.
There is level 2 evidence that enteral feeding post ABI may reduce mean intake of nitrogen compared to parenteral nutrition post ABI.
There is level 3 evidence that enteral feeding post ABI may be effective for meeting energy and protein requirements, while also contributing to a smaller protein deficit, compared to oral feeding post ABI.
There is level 2 evidence that enteral feeding post ABI may increase serum protein, the rate of aspirated pneumonia and diarrhea when compared to parenteral nutrition or combined enteral-parenteral nutrition 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 standard enteral nutrition or high protein formulas (greater than 20% of calories from protein) resulted in better FIM motor and FIM cognitive scores at discharge and less weight loss than similar patients not receiving enteral nutrition.
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 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 3 evidence that a specific surgical feeding tube placement strategy can reduce the number of unnecessary surgical feeding tube placements.
There is conflicting 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 metoclopramide may not be effective compared to placebo for gastric emptying in patients with TBI.
There is level 2 evidence that parenteral nutrition post ABI reduces the amount of regurgitated gastric fluid compared to combined enteral and parenteral nutrition post ABI, however, nitrogen balance could not be reached for either PN or combined EN and PN post 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 3 evidence that combined enteral-parenteral nutrition post ABI leads to nutritional independence by 6 months post injury.
There is level 1a evidence that zinc supplementation may improve neurological recovery as measured by the Glasgow Coma Scale in patients with ABI.
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.
References
Aviv, J. E. (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope, 110(4), 563-574.
Azim, A., Haider, A. A., Rhee, P., Verma, K., Windell, E., Jokar, T. O., Kulvatunyou, N., Meer, M., Latifi, R., & Joseph, B. (2016). Early feeds not force feeds: Enteral nutrition in traumatic brain injury. Journal of Trauma and Acute Care Surgery, 81(3), 520-524.
Bach, D. B., Pouget, S., Belle, K., Kilfoil, M., Alfieri, M., McEvoy, J., & Jackson, G. (1989). An integrated team approach to the management of patients with oropharyngeal dysphagia. Journal of Allied Health, 18(5), 459-468.
Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Critical Care Medicine, 29(9), 1710-1713.
Bax, L., McFarlane, M., Green, E., & Miles, A. (2014). Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke. Journal of Stroke and Cerebrovasc Disease, 23(3), e195-200.
Behrman, S. W., Kudsk, K. A., Brown, R. O., Vehe, K. L., & Wojtysiak, S. L. (1995). The effect of growth hormone on nutritional markers in enterally fed immobilized trauma patients. Journal of Parenteral and Enteral Nutrition, 19(1), 41-46.
Belafsky, P. C., Blumenfeld, L., LePage, A., & Nahrstedt, K. (2003). The accuracy of the modified Evan’s blue dye test in predicting aspiration. Laryngoscope, 113(11), 1969-1972.
Bell, S. D. (1996). Use of Passy-Muir tracheostomy speaking valve in mechanically ventilated neurological patients. Critical Care Nurse, 16(1), 63-68.
Borr, C., Hielscher-Fastabend, M., & Lucking, A. (2007). Reliability and validity of cervical auscultation. Dysphagia, 22(3), 225-234.
Borzotta, A. P., Pennings, J., Papasadero, B., Paxton, J., Mardesic, S., Borzotta, R., Parrott, A., & Bledsoe, F. (1994). Enteral versus parenteral nutrition after severe closed head injury. Journal of Trauma, 37(3), 459-468.
Brady, S. L., Hildner, C. D., & Hutchins, B. F. (1999). Simultaneous videofluoroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia, 14(3), 146-149.
Brooke, M., Barbour, P., Cording, L., Tolan, C., Bhoomkar, A., McCall, G., Lyons, C., Hudson, J., & Johnson, S. (1989). Nutritional Status During Rehabilitation After Head Injury. Journal of Neurologic Rehabilitation, 3(1), 27-33.
Bruder, N., Lassegue, D., Pelissier, D., Graziani, N., & Francois, G. (1994). Energy expenditure and withdrawal of sedation in severe head-injured patients. Critical Care Medicine, 22(7), 1114-1119.
Cabov, T., Macan, D., Husedzinovic, I., Skrlin-Subic, J., Bosnjak, D., Sestan-Crnek, S., Peric, B., Kovac, Z., & Golubovic, V. (2010). The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wien Klin Wochenschr, 122(13-14), 397-404.
Canadian Dental Association. (2009). Optimal health for frail older adults: Best practices along the continuum of care. Retrieved from Ottawa, ON:
Carnaby, G., Hankey, G. J., & Pizzi, J. (2006). Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurology, 5(1), 31-37.
Cerra, F. B., Benitez, M. R., Blackburn, G. L., Irwin, R. S., Jeejeebhoy, K., Katz, D. P., Pingleton, S. K., Pomposelli, J., Rombeau, J. L., Shronts, E., Wolfe, R. R., & Zaloga, G. P. (1997). Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. Chest, 111(3), 769-778.
Chapple, L. S., Deane, A. M., Heyland, D. K., Lange, K., Kranz, A. J., Williams, L. T., & Chapman, M. J. (2016). Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury. Clinical Nutrition, 35(6), 1315-1322.
Chaudhry, R., Batra, S., Mancillas, O. L., Wegner, R., Grewal, N., & Williams, G. W. (2017). In-Hospital Mortality with Use of Percutaneous Endoscopic Gastrostomy in Traumatic Brain Injury Patients: Results of a Nationwide Population-Based Study. Neurocritical Care, 26(2), 232-238.
Cherney, L. R., & Halper, A. S. (1996). Swallowing problems in adults with traumatic brain injury. Seminars Neurology, 16(4), 349-353.
Cherney, L. R., Halper, A. (1989). Recovery of Oral Nutrition After Head Injury in Adults. Journal of Head Trauma Rehabilitation, 4(4), 42-50.
Chong, M. S., Lieu, P. K., Sitoh, Y. Y., Meng, Y. Y., & Leow, L. P. (2003). Bedside clinical methods useful as screening test for aspiration in elderly patients with recent and previous strokes. Annals Academic Medicine Singapore, 32(6), 790-794.
Chourdakis, M., Kraus, M. M., Tzellos, T., Sardeli, C., Peftoulidou, M., Vassilakos, D., & Kouvelas, D. (2012). Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial. Journal of Parenteral and Enteral Nutrition, 36(1), 108-116.
Clayton, B. (2012). Stroke, dysphagia and oral care: what is best practice? Alta RN, 68(1), 26-27.
Clayton, J., Jack, C. I., Ryall, C., Tran, J., Hilal, E., & Gosney, M. (2006). Tracheal pH monitoring and aspiration in acute stroke. Age Ageing, 35(1), 47-53.
Clifton, G. L., Robertson, C. S., Grossman, R. G., Hodge, S., Foltz, R., & Garza, C. (1984). The metabolic response to severe head injury. Journal of Neurosurgery, 60(4), 687-696.
Collins, M. J., & Bakheit, A. M. (1997). Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke, 28(9), 1773-1775.
Daniels, S. K., Anderson, J. A., & Willson, P. C. (2012). Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke, 43(3), 892-897.
Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American Journal of Speech-Language Pathology, 6(4), 17-24.
Dempsey, D. T., Guenter, P., Mullen, J. L., Fairman, R., Crosby, L. O., Spielman, G., & Gennarelli, T. (1985). Energy expenditure in acute trauma to the head with and without barbiturate therapy. Surgical Gynecological Obstetrics, 160(2), 128-134.
Denes, Z. (2004). The influence of severe malnutrition on rehabilitation in patients with severe head injury. Disabil Rehabil, 26(19), 1163-1165.
DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology, 49(12), 1259-1261.
DePippo, K. L., Holas, M. A., & Reding, M. J. (1994). The Burke dysphagia screening test: validation of its use in patients with stroke. Archives of Physical Medicine and Rehabilitation, 75(12), 1284-1286.
Dettelbach, M. A., Gross, R. D., Mahlmann, J., & Eibling, D. E. (1995). Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy. Head and Neck, 17(4), 297-302.
Devesa, J., Reimunde, P., Devesa, P., Barbera, M., & Arce, V. (2013). Growth hormone (GH) and brain trauma. Hormonal Behaviour, 63(2), 331-344.
Dhandapani, S., Dhandapani, M., Agarwal, M., Chutani, A. M., Subbiah, V., Sharma, B. S., & Mahapatra, A. K. (2012). The prognostic significance of the timing of total enteral feeding in traumatic brain injury. Surgical Neurology International, 3, 31.
Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope, 111(10), 1746-1750.
Drake, W., O’Donoghue, S., Bartram, C., Lindsay, J., & Greenwood, R. (1997). Eating in side-lying facilitates rehabilitation in neurogenic dysphagia. Brain Injury, 11(2), 137-142.
Dziewas, R., Ritter, M., Schilling, M., Konrad, C., Oelenberg, S., Nabavi, D. G., Stogbauer, F., Ringelstein, E. B., & Ludemann, P. (2004). Pneumonia in acute stroke patients fed by nasogastric tube. Journal of Neurology and Neurosurgical Psychiatry, 75(6), 852-856.
Dziewas, R., Warnecke, T., Hamacher, C., Oelenberg, S., Teismann, I., Kraemer, C., Ritter, M., Ringelstein, E. B., & Schaebitz, W. R. (2008). Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurology, 8, 28.
Elovic, E. (2000). Pharmacological therapeutics in nutritional management. Journal of Head Trauma Rehabilitation, 15(3), 962-964.
Elpern, E. H., Borkgren Okonek, M., Bacon, M., Gerstung, C., & Skrzynski, M. (2000). Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults. Heart and Lung, 29(4), 287-293.
Falcao de Arruda, I. S., & de Aguilar-Nascimento, J. E. (2004). Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients. Clinical Science (London), 106(3), 287-292.
Fan, M., Wang, Q., Fang, W., Jiang, Y., Li, L., Sun, P., & Wang, Z. (2016). Early Enteral Combined with Parenteral Nutrition Treatment for Severe Traumatic Brain Injury: Effects on Immune Function, Nutritional Status and Outcomes. Chinese Medical Science Journal, 31(4), 213-220.
Field, L. H., & Weiss, C. J. (1989). Dysphagia with head injury. Brain Inj, 3(1), 19-26.
Finegold, S. M. (1991). Aspiration pneumonia. Reviews of Infectious Disease, 13 Suppl 9, S737-742.
Finlayson, O., Kapral, M., Hall, R., Asllani, E., Selchen, D., & Saposnik, G. (2011). Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology, 77(14), 1338-1345.
Fourrier, F., Cau-Pottier, E., Boutigny, H., Roussel-Delvallez, M., Jourdain, M., & Chopin, C. (2000). Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Medicine, 26(9), 1239-1247.
Grahm, T. W., Zadrozny, D. B., & Harrington, T. (1989). The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery, 25(5), 729-735.
Hadley, M. N., Grahm, T. W., Harrington, T., Schiller, W. R., McDermott, M. K., & Posillico, D. B. (1986). Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery, 19(3), 367-373.
Halper, A. S., Cherney, L. R., Cichowski, K., & Zhang, M. (1999). Dysphagia after head trauma: the effect of cognitive-communicative impairments on functional outcomes. Journal of Head Trauma and Rehabilitation, 14(5), 486-496.
Hansen, T. S., Larsen, K., & Engberg, A. W. (2008). The association of functional oral intake and pneumonia in patients with severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89(11), 2114-2120.
Harbrecht, B. G., Moraca, R. J., Saul, M., & Courcoulas, A. P. (1998). Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients. American Journal of Surgery, 176(4), 311-314.
Hatton, J., Kryscio, R., Ryan, M., Ott, L., & Young, B. (2006). Systemic metabolic effects of combined insulin-like growth factor-I and growth hormone therapy in patients who have sustained acute traumatic brain injury. Journal of Neurosurgery, 105(6), 843-852.
Hausmann, D., Mosebach, K. O., Caspari, R., & Rommelsheim, K. (1985). Combined enteral-parenteral nutrition versus total parenteral nutrition in brain-injured patients. A comparative study. Intensive Care Medicine, 11(2), 80-84.
Haynes, M. (1992). Review article: Nutrition in the severely head-injured patient. Clinical Rehabilitation, 6(2), 153-158.
Henson, M. B., De Castro, J. M., Stringer, A. Y., & Johnson, C. (1993). Food intake by brain-injured humans who are in the chronic phase of recovery. Brain Injury, 7(2), 169-178.
Hoppers, P., & Holm, S. E. (1999). The role of fiberoptic endoscopy in dysphagia rehabilitation. Journal of Head Trauma Rehabilitation, 14(5), 475-485.
Horn, S. D., Kinikini, M., Moore, L. W., Hammond, F. M., Brandstater, M. E., Smout, R. J., & Barrett, R. S. (2015). Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes. Archives of Physical Medicine and Rehabilitation, 96(8 Suppl), S245-255.
Horner, J., & Massey, E. W. (1988). Silent aspiration following stroke. Neurology, 38(2), 317-319.
Hui, X., Haider, A. H., Hashmi, Z. G., Rushing, A. P., Dhiman, N., Scott, V. K., Selvarajah, S., Haut, E. R., Efron, D. T., & Schneider, E. B. (2013). Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts! Journal of Surgical Research, 184(1), 438-443.
Huxley, E. J., Viroslav, J., Gray, W. R., & Pierce, A. K. (1978). Pharyngeal aspiration in normal adults and patients with depressed consciousness. American Journal of Medicine, 64(4), 564-568.
Initiative, I. D. D. S. (2018). A global initiative to improve the lives of over 590 million people worldwide living with dysphagia. Retrieved from http://iddsi.org/about-us/
Jia, K., Tong, X., & Liang, F. (2018). Effects of sequential nutritional support on nutritional status and expression of regulatory T lymphocyte in patients with early severe traumatic brain injury. Neuropsychiatric Disease and Treatment, 14, 7.
Johnson, E. R., McKenzie, S. W., & Sievers, A. (1993). Aspiration pneumonia in stroke. Archives of Physical Medicine and Rehabilitation, 74(9), 973-976.
Justo Meirelles, C. M., & de Aguilar-Nascimento, J. E. (2011). Enteral or parenteral nutrition in traumatic brain injury: a prospective randomised trial. Nutricion Hospitalaria, 26(5), 1120-1124.
Kelly, T. (2010). Review of the evidence to support oral hygiene in stroke patients. Nursing Standard, 24(37), 35-38.
Khazdouz, M., Mazidi, M., Ehsaei, M. R., Ferns, G., Kengne, A. P., & Norouzy, A. R. (2018). Impact of Zinc Supplementation on the Clinical Outcomes of Patients with Severe Head Trauma: A Double-Blind Randomized Clinical Trial. Journal of Dietary Supplements, 15(1), 1-10.
Kidd, D., Lawson, J., Nesbitt, R., & MacMahon, J. (1995). The natural history and clinical consequences of aspiration in acute stroke. Qjm, 88(6), 409-413.
Kim, H., & Suh, Y. (2018). Changes in the dysphagia and nutritional status of patients with brain injury. Journal of Clinical Nursing, 27(7-8), 1581-1588.
Kjaersgaard, A., Nielsen, L. H., & Sjolund, B. H. (2014). Randomized trial of two swallowing assessment approaches in patients with acquired brain injury: Facial-Oral Tract Therapy versus Fibreoptic Endoscopic Evaluation of Swallowing. Clinical Rehabilitation, 28(3), 243-253.
Kostadima, E., Kaditis, A. G., Alexopoulos, E. I., Zakynthinos, E., & Sfyras, D. (2005). Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. European Respiratory Journal, 26(1), 106-111.
Kothari, M., Madsen, V. L. F., Castrillon, E. E., Nielsen, J. F., & Svensson, P. (2018). Spontaneous jaw muscle activity in patients with acquired brain injuries-Preliminary findings. Journal of Prosthodontic Research, 62(2), 268-272.
Kraaijenga, S. A., van der Molen, L., Stuiver, M. M., Teertstra, H. J., Hilgers, F. J., & van den Brekel, M. W. (2015). Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects: a Prospective Effectiveness and Feasibility Study. Dysphagia, 30(4), 392-403.
Krakau, K., Hansson, A., Karlsson, T., de Boussard, C. N., Tengvar, C., & Borg, J. (2007). Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition, 23(4), 308-317.
Kramer, P., Shein, D., & Napolitano, J. (2007). Rehabilitation of speech, language and swallowing disorders Acquired Brain Injury (pp. 238-258): Springer.
Lam, O. L., McMillan, A. S., Samaranayake, L. P., Li, L. S., & McGrath, C. (2013). Effect of oral hygiene interventions on opportunistic pathogens in patients after stroke. American Journal of Infection Control, 41(2), 149-154.
Landesman, A., Murphy, M., Richards, J., Smyth, J., & Osakue, B. (2003). Oral hygiene in the elderly: a quality improvement initiative. Nursing Leadership (Tor Ont), 16(3), 79-90.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81.
Lazarus, C., & Logemann, J. A. (1987). Swallowing disorders in closed head trauma patients. Archives of Physical Medicine and Rehabilitation, 68(2), 79-84.
Lazzara, G. L., Lazarus, C., & Logemann, J. A. (1986). Impact of thermal stimulation on the triggering of the swallowing reflex.
Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17(3), 214-218.
Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia, 22(4), 290-298.
Levenson, C. W. (2005). Zinc supplementation: Neuroprotective or neurotoxic? Nutrition reviews, 63(4), 122-125.
Lichtman, S. W., Birnbaum, I. L., Sanfilippo, M. R., Pellicone, J. T., Damon, W. J., & King, M. L. (1995). Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation. Journal of Speech and Hearing Research, 38(3), 549-555.
Lim, S. H., Lieu, P. K., Phua, S. Y., Seshadri, R., Venketasubramanian, N., Lee, S. H., & Choo, P. W. (2001). Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia, 16(1), 1-6.
Linden, P., & Siebens, A. A. (1983). Dysphagia: predicting laryngeal penetration. Archives of Physical Medicine and Rehabiltation, 64(6), 281-284.
Loan, T. (1999). Metabolic/nutritional alterations of traumatic brain injury. Nutrition, 15(10), 809-812.
Logemann, J. A. (1983). Evaluation and treatment of swallowing disorders. San Diego: College-Hill Press.
Logemann, J. A. (1989). Evaluation and treatment planning for the head-injured patient with oral intake disorders. Journal of Head Trauma Rehabilitation, 4(4), 24-33.
Logemann, J. A. (1991). Approaches to management of disordered swallowing. Baillieres Clinical Gastroenterology, 5(2), 269-280.
Logemann, J. A. (1993). The dysphagia diagnostic procedure as a treatment efficacy trial. Clinical Communication Disorders, 3(4), 1-10.
Logemann, J. A. (1997). Role of the modified barium swallow in management of patients with dysphagia. Otolaryngoogyl Head and Neck Surgery, 116(3), 335-338.
Logemann, J. A. (1998). The evaluation and treatment of swallowing disorders. Austin Texas: Pro-Ed;.
Logemann, J. A. (1999). Behavioral management for oropharyngeal dysphagia. Folia Phoniatrica et Logopaedica, 51(4-5), 199-212.
Logemann, J. A. (2008). Treatment of oral and pharyngeal dysphagia. Physical Medicine and Rehabilitation Clinics, 19(4), 803-816, ix.
Logemann, J. A. (2013). Evaluation and Treatment of Swallowing Problems. In N. D. Zasler, Katz, D. I., Zafonte, R. D. (Ed.), Brain Injury Medicine: Principles and Practice (2 ed.). New York: Demos Medical Publishing.
Logemann, J. A., Pauloski, B. R., Rademaker, A. W., & Colangelo, L. A. (1997). Super-supraglottic swallow in irradiated head and neck cancer patients. Head Neck, 19(6), 535-540.
Mackay, L. E., Morgan, A. S., & Bernstein, B. A. (1999). Swallowing disorders in severe brain injury: risk factors affecting return to oral intake. Archives of Physical Medicine and Rehabilitation, 80(4), 365-371.
Maddaiah, V. T., Sharma, R. K., Balachandar, V., Rezvani, I., Collipp, P. J., & Chen, S. Y. (1973). Effect of growth hormone on mitochondrial protein synthesis. Journal of Biology and Chemistry, 248(12), 4263-4268.
Maddi, A., & Scannapieco, F. A. (2013). Oral biofilms, oral and periodontal infections, and systemic disease. American Journal of Dentistry, 26(5), 249-254.
Mann, G., Hankey, G. J., & Cameron, D. (2000). Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovascular Disease, 10(5), 380-386.
Manson, J. M., Smith, R. J., & Wilmore, D. W. (1988). Growth hormone stimulates protein synthesis during hypocaloric parenteral nutrition. Role of hormonal-substrate environment. Annals of Surgery, 208(2), 136-142.
Manson, J. M., & Wilmore, D. W. (1986). Positive nitrogen balance with human growth hormone and hypocaloric intravenous feeding. Surgery, 100(2), 188-197.
Manzano, J. L., Lubillo, S., Henriquez, D., Martin, J. C., Perez, M. C., & Wilson, D. J. (1993). Verbal communication of ventilator-dependent patients. Critical Care Medicine, 21(4), 512-517.
Marcotte, J., Hazelton, J. P., Arya, C., Dalton, M., Batool, A., Gaughan, J., Nguyen, L., Porter, J., & Fox, N. (2018). A selective placement strategy for surgical feeding tubes benefits trauma patients. Journal of Trauma and Acute Care Surgery, 85(1), 135-139.
Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15(1), 19-30.
McCallum, S. L. (2003). The National Dysphagia Diet: implementation at a regional rehabilitation center and hospital system. Journal of American Diet Association, 103(3), 381-384.
McClain, C. J., Twyman, D. L., Ott, L. G., Rapp, R. P., Tibbs, P. A., Norton, J. A., Kasarskis, E. J., Dempsey, R. J., & Young, B. (1986). Serum and urine zinc response in head-injured patients. Journal of Neurosurgery, 64(2), 224-230.
Merimee, T. J., & Rabin, D. (1973). A survey of growth hormone secretion and action. Metabolism, 22(9), 1235-1251.
Milazzo, L., Bouchard, J., & Lund, D. (1989). The swallowing process: Effects of aging and stroke. Physical Medicine and Rehabilitation: state of the arts reviews, 3, 489-499.
Minard, G., Kudsk, K. A., Melton, S., Patton, J. H., & Tolley, E. A. (2000). Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN Journal of Parenteral and Enteral Nutrition, 24(3), 145-149.
Morgan, A., & Ward, E. (2001). Swallowing: Neuroanatomical and physiological framework. In T. D. Murdoch BE (Ed.), Traumatic brain injury: associated speech, language, and swallowing disorders (pp. 313-329). San Diego: Singular Publishing Group.
Morgan, A. S., & Mackay, L. E. (1999). Causes and complications associated with swallowing disorders in traumatic brain injury. Journal of Head Trauma Rehabilitation, 14(5), 454-461.
Moseley, A. M., Herbert, R. D., Sherrington, C., & Maher, C. G. (2002). Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Australian Journal of Physiotherapy, 48(1), 43-49.
Mousavi, S. N., Nematy, M., Norouzy, A., Safarian, M., Samini, F., Birjandinejad, A., Philippou, E., & Mafinejad, A. (2014). Comparison of intensive insulin therapy versus conventional glucose control in traumatic brain injury patients on parenteral nutrition: A pilot randomized clinical trial. Journal of Research in Medical Science, 19(5), 420-425.
Muller-Lissner, S. A., Fimmel, C. J., Will, N., Muller-Duysing, W., Heinzel, F., & Blum, A. L. (1982). Effect of gastric and transpyloric tubes on gastric emptying and duodenogastric reflux. Gastroenterology, 83(6), 1276-1279.
Nataloni, S., Gentili, P., Marini, B., Guidi, A., Marconi, P., Busco, F., & Pelaia, P. (1999). Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins. Clinical Nutrition, 18(4), 247-251.
Nishiwaki, K., Tsuji, T., Liu, M., Hase, K., Tanaka, N., & Fujiwara, T. (2005). Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables. Journal of Rehabilitative Medicine, 37(4), 247-251.
Nursal, T. Z., Erdogan, B., Noyan, T., Cekinmez, M., Atalay, B., & Bilgin, N. (2007). The effect of metoclopramide on gastric emptying in traumatic brain injury. Journal of Clinical Neuroscience, 14(4), 344-348.
O’Neil-Pirozzi, T. M., Lisiecki, D. J., Jack Momose, K., Connors, J. J., & Milliner, M. P. (2003a). Simultaneous modified barium swallow and blue dye tests: a determination of the accuracy of blue dye test aspiration findings. Dysphagia, 18(1), 32-38.
O’Neil-Pirozzi, T. M., Momose, K. J., Mello, J., Lepak, P., McCabe, M., Connors, J. J., & Lisiecki, D. J. (2003b). Feasibility of swallowing interventions for tracheostomized individuals with severely disordered consciousness following traumatic brain injury. Brain Injury, 17(5), 389-399.
Osawa, A., Maeshima, S., & Tanahashi, N. (2013). Water-swallowing test: screening for aspiration in stroke patients. Cerebrovascular Disease, 35(3), 276-281.
Ott, L., Annis, K., Hatton, J., McClain, M., & Young, B. (1999). Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN. Journal of Neurotrauma, 16(3), 233-242.
Ott, L., Young, B., Phillips, R., & McClain, C. (1990). Brain injury and nutrition. Nutrition in Clinical Practice, 5(2), 68-73.
Painter, T. J., Rickerds, J., & Alban, R. F. (2015). Immune enhancing nutrition in traumatic brain injury – A preliminary study. International Journal of Surgery, 21, 70-74.
Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4-9.
Passy-Muir Incorporated. (2004). Passy-Muir Clinical Inservice Outline. Retrieved from http://www.passy-muir.com/pdfs/inservice_outline.pdf
Passy, V., Baydur, A., Prentice, W., & Darnell-Neal, R. (1993). Passy-Muir tracheostomy speaking valve on ventilator-dependent patients. Laryngoscope, 103(6), 653-658.
Pepe, J. L., & Barba, C. A. (1999). The metabolic response to acute traumatic brain injury and implications for nutritional support. Journal of Head Trauma Rehabilitation, 14(5), 462-474.
Perry, L. (2001). Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Cliniial Nursing, 10(4), 463-473.
Phillips, L. S., & Vassilopoulou-Sellin, R. (1980). Somatomedins (first of two parts). New England Journal of Medicine, 302(7), 371-380.
Platt, J. (2001). Dysphagia management for long-term care: A manual for nurses and other healthcare professionals. Clinical and Educational Services.
Ponting, G. A., Halliday, D., Teale, J. D., & Sim, A. J. (1988). Postoperative positive nitrogen balance with intravenous hyponutrition and growth hormone. Lancet, 1(8583), 438-440.
Rapp, R. P., Young, B., Twyman, D., Bivins, B. A., Haack, D., Tibbs, P. A., & Bean, J. R. (1983). The favorable effect of early parenteral feeding on survival in head-injured patients. Journal of Neurosurgery, 58(6), 906-912.
Rasley, A., Logemann, J. A., Kahrilas, P. J., Rademaker, A. W., Pauloski, B. R., & Dodds, W. J. (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. AJR American Journal of Roentgenology, 160(5), 1005-1009.
Robertson, C. S., Clifton, G. L., & Grossman, R. G. (1984). Oxygen utilization and cardiovascular function in head-injured patients. Neurosurgery, 15(3), 307-314.
Robertson, T., & Carter, D. (2013). Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients. Canadian Journal of Neuroscience Nursing, 35(2), 10-17.
Rosenbek, J. C., Roecker, E. B., Wood, J. L., & Robbins, J. (1996). Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia, 11(4), 225-233.
Ryu, J. S., Park, S. R., & Choi, K. H. (2004). Prediction of laryngeal aspiration using voice analysis. American Journal of Physical Medicine and Rehabilitation, 83(10), 753-757.
Sacks, G. S., Brown, R. O., Teague, D., Dickerson, R. N., Tolley, E. A., & Kudsk, K. A. (1995). Early nutrition support modifies immune function in patients sustaining severe head injury. JPEN Journal of Parenteral and Enteral Nutrition, 19(5), 387-392.
Sarin, J., Balasubramaniam, R., Corcoran, A. M., Laudenbach, J. M., & Stoopler, E. T. (2008). Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. Journal of American Medical Directors Association, 9(2), 128-135.
Schurr, M. J., Ebner, K. A., Maser, A. L., Sperling, K. B., Helgerson, R. B., & Harms, B. (1999). Formal swallowing evaluation and therapy after traumatic brain injury improves dysphagia outcomes. Journal of Trauma, 46(5), 817-821; discussion 821-813.
Seguin, P., Laviolle, B., Dahyot-Fizelier, C., Dumont, R., Veber, B., Gergaud, S., Asehnoune, K., Mimoz, O., Donnio, P. Y., Bellissant, E., & Malledant, Y. (2014). Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: a multicenter, randomized controlled trial. Critical Care Medicine, 42(1), 1-8.
Shaker, R., Easterling, C., Kern, M., Nitschke, T., Massey, B., Daniels, S., Grande, B., Kazandjian, M., & Dikeman, K. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122(5), 1314-1321.
Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E. T., Hoffmann, R. G., Arndorfer, R. C., Hofmann, C., & Bonnevier, J. (1997). Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. American Journal of Physiology, 272(6 Pt 1), G1518-1522.
Smith, H. A., Lee, S. H., O’Neill, P. A., & Connolly, M. J. (2000). The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age Ageing, 29(6), 495-499.
Smithard, D. G., O’Neill, P. A., Parks, C., & Morris, J. (1996). Complications and outcome after acute stroke. Does dysphagia matter? Stroke, 27(7), 1200-1204.
Souba, W., & Wilmore, D. (1999). Diet and nutrition in the care of the patient with surgery, trauma, and sepsis. In O. J. Shils ME, Shike M, Ross AC (Ed.), Modern nutrition in health and disease (book) (pp. 1589-1618). Baltimore, MD: Williams and Wilkins.
Splaingard, M. L., Hutchins, B., Sulton, L. D., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of Physical Medicine and Rehabilitation, 69(8), 637-640.
Stachler, R. J., Hamlet, S. L., Choi, J., & Fleming, S. (1996). Scintigraphic quantification of aspiration reduction with the Passy-Muir valve. Laryngoscope, 106(2 Pt 1), 231-234.
Steele, C. M., Bailey, G. L., Polacco, R. E., Hori, S. F., Molfenter, S. M., Oshalla, M., & Yeates, E. M. (2013). Outcomes of tongue-pressure strength and accuracy training for dysphagia following acquired brain injury. International Journal of Speech Language Pathology, 15(5), 492-502.
Steele, C. M., Namasivayam-MacDonald, A. M., Guida, B. T., Cichero, J. A., Duivestein, J., Hanson, B., Lam, P., & Riquelme, L. F. (2018). Creation and Initial Validation of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale. Archives of Physical Medicine and Rehabilitation, 99(5), 934-944.
Stroud, A. E., Lawrie, B. W., & Wiles, C. M. (2002). Inter- and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia. Clinical Rehabilitation, 16(6), 640-645.
Suiter, D. M., McCullough, G. H., & Powell, P. W. (2003). Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia, 18(4), 284-292.
Sze, W. P., Yoon, W. L., Escoffier, N., & Rickard Liow, S. J. (2016). Evaluating the Training Effects of Two Swallowing Rehabilitation Therapies Using Surface Electromyography–Chin Tuck Against Resistance (CTAR) Exercise and the Shaker Exercise. Dysphagia, 31(2), 195-205.
Talbot, A., Brady, M., Furlanetto, D. L., Frenkel, H., & Williams, B. O. (2005). Oral care and stroke units. Gerodontology, 22(2), 77-83.
Taylor, S., & Fettes, S. (1998). Enhanced enteral nutrition in head injury: effect on the efficacy of nutritional delivery, nitrogen balance, gastric residuals and risk of pneumonia. Journal of Human Nutrition and Dietetics, 11(5), 391-401.
Taylor, S. J., Fettes, S. B., Jewkes, C., & Nelson, R. J. (1999). Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Critical Care Medicine, 27(11), 2525-2531.
Teasell, R. W., McRae, M., Marchuk, Y., & Finestone, H. M. (1996). Pneumonia associated with aspiration following stroke. Archives of Physical Medicine and Rehabilitation, 77(7), 707-709.
Terre, R., & Mearin, F. (2009). Evolution of tracheal aspiration in severe traumatic brain injury-related oropharyngeal dysphagia: 1-year longitudinal follow-up study. Neurogastroenterol Motility, 21(4), 361-369.
Tolep, K., Getch, C. L., & Criner, G. J. (1996). Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest, 109(1), 167-172.
Twyman, D. (1997). Nutritional management of the critically ill neurologic patient. Critical Care Clinics, 13(1), 39-49.
Vejdan, A. K., & Khosravi, M. (2013). BAL for pneumonia prevention in tracheostomy patients: A clinical trial study. Pakistan Journal of Medical Sciences, 29(1), 148-151.
Vieira, L. V., Pedrosa, L. A. C., Souza, V. S., Paula, C. A., & Rocha, R. (2018). Incidence of diarrhea and associated risk factors in patients with traumatic brain injury and enteral nutrition. Metabolic Brain Disease, 33(5), 1755-1760.
Wang, T. G., Chang, Y. C., Chen, S. Y., & Hsiao, T. Y. (2005). Pulse oximetry does not reliably detect aspiration on videofluoroscopic swallowing study. Archives of Physical Medicine and Rehabilitation, 86(4), 730-734.
Watando, A., Ebihara, S., Ebihara, T., Okazaki, T., Takahashi, H., Asada, M., & Sasaki, H. (2004). Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest, 126(4), 1066-1070.
Weekes, E., & Elia, M. (1996). Observations on the patterns of 24-hour energy expenditure changes in body composition and gastric emptying in head-injured patients receiving nasogastric tube feeding. JPEN Journal of Parenteral and Enteral Nutrition, 20(1), 31-37.
Westergren, A., Ohlsson, O., & Rahm Hallberg, I. (2001). Eating difficulties, complications and nursing interventions during a period of three months after a stroke. Journal of Advance Nursing, 35(3), 416-426.
Wilson, R. D., & Howe, E. C. (2012). A cost-effectiveness analysis of screening methods for dysphagia after stroke. Physical medicine and rehabilitation, 4(4), 273-282.
Wilson, R. F., Dente, C., & Tyburski, J. G. (2001). The nutritional management of patients with head injuries. Neurology Research, 23(2-3), 121-128.
Winstein, C. J. (1983). Neurogenic dysphagia. Frequency, progression, and outcome in adults following head injury. Physical Therapy, 63(12), 1992-1997.
Yanagawa, T., Bunn, F., Roberts, I., Wentz, R., & Pierro, A. (2000). Nutritional support for head-injured patients. Cochrane Database Syst Rev(2), Cd001530.
Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., Ihara, S., Yanagisawa, S., Ariumi, S., Morita, T., Mizuno, Y., Ohsawa, T., Akagawa, Y., Hashimoto, K., & Sasaki, H. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of American Geriatric Society, 50(3), 430-433.
Yoon, W. L., Khoo, J. K., & Rickard Liow, S. J. (2014). Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia, 29(2), 243-248.
Youmans, S. R., & Stierwalt, J. A. (2005). An acoustic profile of normal swallowing. Dysphagia, 20(3), 195-209.
Young, B., Ott, L., Haack, D., Twyman, D., Combs, D., Oexmann, J. B., Tibbs, P., & Dempsey, R. (1987). Effect of total parenteral nutrition upon intracranial pressure in severe head injury. Journal of Neurosurgery, 67(1), 76-80.
Young, B., Ott, L., Kasarskis, E., Rapp, R., Moles, K., Dempsey, R. J., Tibbs, P. A., Kryscio, R., & McClain, C. (1996). Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury. Journal of Neurotrauma, 13(1), 25-34.
Young, B., Ott, L., Norton, J., Tibbs, P., Rapp, R., McClain, C., & Dempsey, R. (1985). Metabolic and nutritional sequelae in the non-steroid treated head injury patient. Neurosurgery, 17(5), 784-791.
Young, B., Ott, L., Yingling, B., & McClain, C. (1992). Nutrition and brain injury. Journal of Neurotrauma, 9 Suppl 1, S375-383.
Zasler, N. D., Devany, C. W., Jarman, A. L., Friedman, R., & Dinius, A. (1993). Oral hygiene following traumatic brain injury: a programme to promote dental health. Brain Injury, 7(4), 339-345.
Zenner, P. M., Losinski, D. S., & Mills, R. H. (1995). Using cervical auscultation in the clinical dysphagia examination in long-term care. Dysphagia, 10(1), 27-31.
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