5. Dysphagia, Aspiration, and Nutritional Interventions for Patients with Acquired Brain Injury Penny Welch-West M.Cl.Sc. SLP Pavlina Faltynek MSc Amber Harnett MSc Magdalena Mirkowski MSc MScOT OT Reg.(Ont.) Jo-Anne Aubut BA Robert Teasell MD erabi.ca Version 13.0 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. erabi.ca Version 13.0 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. erabi.ca Version 13.0 Table of Contents 5.0 Introduction ...................................................................................................................................... 1 5.1 Dysphagia Post ABI ........................................................................................................................... 2 5.1.1 Risk Factors ............................................................................................................................... 2 5.2 Aspiration Post ABI ........................................................................................................................... 3 5.2.1 Risk Factors ............................................................................................................................... 3 5.2.2 Silent Aspiration........................................................................................................................ 4 5.2.3 Pneumonia and Aspiration ........................................................................................................ 4 5.3 Assessment of Dysphagia and Aspiration ......................................................................................... 5 5.3.1 Bedside Clinical Examination .................................................................................................... 6 5.3.2 Water Swallowing Test ............................................................................................................. 7 5.3.3 Videofluoroscopic Modified Barium Swallow Studies ............................................................... 7 5.3.4 Fiberoptic Endoscopic Evaluation of Swallowing ...................................................................... 8 5.3.5 Pulse Oximetry ........................................................................................................................ 10 5.3.6 Blue Dye Assessment for Swallowing ...................................................................................... 10 5.3.7 Additional Methods ................................................................................................................ 11 5.4 Management of Dysphasia ............................................................................................................. 11 5.4.1 Oral Motor Exercises ............................................................................................................... 12 5.4.1.1 Range of Motion Exercises ............................................................................................. 12 5.4.1.2 Vocal Fold Adduction Exercises ...................................................................................... 12 5.4.2 Strengthening Exercises .......................................................................................................... 13 5.4.2.1 The Shaker Exercise ....................................................................................................... 13 5.4.2.2 Chin Tuck Against Resistance ......................................................................................... 13 5.4.3 Swallow Maneuvers ................................................................................................................ 13 5.4.3.1 Supraglottic Swallow ..................................................................................................... 14 5.4.3.2 Super-Supraglottic Swallow ........................................................................................... 14 5.4.3.3 Effortful Swallow ........................................................................................................... 14 5.4.3.4 Mendelsohn Maneuver .................................................................................................. 14 5.4.4 Thermal-tactile Stimulation .................................................................................................... 14 5.4.5 Postural Techniques ................................................................................................................ 15 erabi.ca Version 13.0 5.4.6 Diet Modification .................................................................................................................... 15 5.4.7 Passy-Muir Speaking Valve (PMV)........................................................................................... 17 5.5 Oral Hygiene Interventions ............................................................................................................. 17 5.6 Nutritional Interventions ................................................................................................................ 21 5.6.1 Enteral Nutrition ..................................................................................................................... 23 5.6.1.1 Timing ........................................................................................................................... 29 5.6.1.2 Administration............................................................................................................... 32 5.6.1.3 Enhanced Feeding Solutions .......................................................................................... 33 5.6.1.4 Metoclopramide ............................................................................................................ 36 5.6.2 Total Parenteral Nutrition ....................................................................................................... 37 5.6.2.1 Timing ........................................................................................................................... 42 5.6.3 Combined Nutritional Interventions ....................................................................................... 43 5.6.4 Other Nutritional Interventions .............................................................................................. 46 5.6.4.1 Zinc Supplementation .................................................................................................... 46 5.6.4.2 Growth Hormone ........................................................................................................... 48 5.6.4.3 Increased Nitrogen Feeds .............................................................................................. 50 5.6.4.4 Branched-Chain Amino Acids ......................................................................................... 51 5.7 Conclusion ...................................................................................................................................... 52 5.8 Summary ......................................................................................................................................... 53 5.9 References ...................................................................................................................................... 56 This review has been prepared based on the scientific and professional information available up to December 2018. The ERABI information is provided for informational and educational purposes