The incidence of dysphagia in patients entering rehabilitation post-ABI ranges from 25%-78%. This incidence has been shown to vary depending on the definition of dysphagia used and the acuity of the patient at admission. An incidence of 42%-65% in patients admitted to a ABI rehabilitation unit have been observed in more recent studies.
The incidence of aspiration post-ABI occurs in approximately 30 to 50% of ABI patients with dysphagia. This represents 10-20% of rehabilitation admissions.
The incidence of silent aspiration in ABI patients has not been well documented. Such cases may be missed in the absence of VMBS studies.
The risk of developing pneumonia appears to be proportional to the severity of the aspiration.
There is Level 4 evidence indicating those with a lower GCS and FIM scores are more likely to develop pneumonia while being tube fed.
The risk of dysphagia related aspiration is proportional to the initial severity of the head injury. A history of a tracheostomy or mechanical ventilation may also be associated with increased risk of aspiration.
VMBS (or MBS) studies are generally considered the gold standard for diagnosing dysphagia and aspiration.
There is inconclusive evidence to suggest FEES is more sensitive than VMBS when assessing patients for swallowing difficulties or aspiration post stroke. Further study needs to be done.
There is limited evidence supporting the use of pulse oximetry to detect aspiration in patients who have had a stroke.
There is consensus opinion that acutely patients should be NPO until swallowing ability has been determined.
There is consensus opinion that a trained assessor should screen all acute patients for swallowing difficulties as soon as they are able.
There is consensus opinion that a speech and language pathologist should assess all patients who fail swallowing screening and identify the appropriate course of treatment.
There is consensus opinion that an individual trained in low-risk feeding strategies should provide feeding assistance or supervision to patients where appropriate.
There is consensus opinion that a dietitian should assess the nutrition and hydration status of patients who fail the swallowing screening.
In stroke patients, there is Level 4 evidence that individuals with dysphagia should feed themselves to reduce the risk of aspiration. There are no such studies in ABI.
For stroke patients who require assistance to feed there is consensus opinion (Level 5 evidence) that low-risk feeding strategies by trained personnel should be employed. There are no such consensus statements made for ABI.
Two studies were found assessing malnutrition in brain injured patients; however, only one reported seeing signs of malnutrition in patients within the first two months post injury. The results of one study indicate the incidence of obesity was comparable to normal.
Based on a series of studies, there is Level 4 evidence of a hypermetabolic state in the acute period following ABI. The extent of the response can be moderated by barbiturates.
Based on one RCT, there is Level 2 evidence that parenteral nutrition is more costly compared to enteral nutrition
Based on two RCTs, there is conflicting evidence that IGF-I is effective in enhancing growth hormone in those who have sustained a ABI.
Based on a single RCT, there is Level 2 evidence that TPN can safely be administered without causing serum hypersomolality or influencing intracranial (ICP) pressure levels or ICP therapy in post-ABI patients.
There is Level 1 evidence based on a single RCT that enhanced enteral nutrition can reduce the incidence of infection, and reduce both the ventilator dependency period and ICU stay.
There is Level 2 evidence that early parenteral nutrition support of closed head-injury patients appears to modify immunologic function by increasing CD4 cells, CD4-CD8 ratios, and T-lymphocyte responsiveness to Con A.
There is Level 1 evidence that the risk of developing pneumonia is higher among ventilated patients fed by a naso-gastric tube compared with a gastrostomy tube.
There is Level 2 evidence that early naso jejunal hyperalimentation improves caloric intake, nitrogen intake, nitrogen balance, bacterial infection and days of stay in the intensive care unit in post-ABI patients.
Based on a single RCT there is Level 2 evidence that early enteral nutrition increases total energy, nitrogen intake and median volume of enteral fluid delivered.
There is Level 1 evidence indicating that metoclopramide is not effective as an aid to gastric emptying
There is Level 2 evidence based on a single RCT that initiating enteral feeding at goal rate will increase the percentage of prescribed energy and protein actually received.
There is Level 1 evidence that the risk of developing pneumonia is higher among ventilated patients fed by a naso-gastric tube compared with a gastrostomy tube.
There is Level 2 evidence that early nasojejunal hyperalimentation improves caloric intake, nitrogen intake, nitrogen balance, bacterial infection and days of stay in the intensive care unit in post-ABI patients.
There is Level 1 evidence indicating that metoclopramide is not effective as an aid to gastric emptying.
Based on a single RCT there is Level 1 evidence that zinc supplementation in ABI patients has a positive effect on neurological recovery as measured by the Glasgow Coma Scale. However, no significant improvement in mortality rates could be attributed to zinc supplementation.
Based on two RCTs, there is conflicting evidence that IGF-I is effective in enhancing growth hormone in those who have sustained an ABI.
Based on a single RCT, there is Level 2 evidence that high nitrogen feedings of approximately 2 g protein/kg are necessary to restore the substantial nitrogen loses that occur post-ABI.
There is Level 2 evidence that supplementation of BCAAs in post-ABI patients enhances recovery of cognitive function, without negatively effecting tyrosine and tryptophan concentration.
