Best Practice Guidelines for Managing Dysphagia
The Canadian Stroke Best Practice Recommendations have outlined guidelines for the assessment and management of dysphagia post stroke. A well-coordinated care plan has many benefits, such as reducing the length of acute care hospital stay, minimizing the development of dysphagia complications and more timely access to rehabilitation (Heart and Stoke Foundation of Ontario 2002). Ultimately dysphagia management has the following goals: (1) meet the nutrition and hydration requirements of the patient; (2) prevent aspiration-related complications; and (3) maintain and promote swallowing function as much as possible (Heart and Stoke Foundation of Ontario 2002). Similar guidelines have not been developed yet for ABI; however, the general principles outlined in the guidelines are felt to be applicable to this population.
Table: Best Practice Guidelines for the Assessment and Management of Dysphagia Post Stroke (Heart and Stoke Foundation 2014).
Individuals with dysphagia who are fed by someone else have a 20 times greater risk of pneumonia than those patients who are able to feed themselves (Langmore et al. 1998). It is noted that when patients with dysphagia are not able to feed themselves independently, hand-over-hand support should be provided at eye-level positioning. If full feeding assistance is required, it needs to be provided using low-risk feeding strategies.
Table: Low Risk Feeding Strategies in Stroke Patients with Dysphagia
There is consensus opinion that patients should be screened for swallowing deficits in a timely manner using a valid screening tool.
There is consensus opinion that a referral to a speech-language pathologist, occupational therapist, dietitian or other trained dysphagia clinician for a detailed assessment and identify the appropriate course of treatment.
Based on the stroke literature, individuals with dysphagia should feed themselves whenever possible. When not possible, low-risk feeding strategies should be used.
Oral hygiene and dental care have become an important component of treating individuals post stroke and TBI (Clayton 2012; Zasler et al. 1993). Proper oral hygiene management decreases the medical risks associated with dysphagia and poor oral care. The actual provision of mouth care is more challenging in patients with TBI given the frequent presentation of significant cognitive-communication issues including: fatigue, reduced level of alertness, cooperation and comprehension, as well as a lack of physical recovery necessary to complete the task of brushing independently (Zasler et al. 1993). For the reasons listed, there may be less priority placed on providing mouth care as part of their overall care routine. It becomes important then, to provide regular education about the beneficial effects of strong oral hygiene practices from a social integration, comfort, medical, and safety management standpoint.
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. There is a four to six fold increase in the incidence of aspiration pneumonia in patients with periodontal disease and/or poor oral care. 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). Improved oral care also has a positive impact on the reduction of aspiration pneumonia rates, particularly in those patients with dysphagia.
Approaches to Ease the Provision of Oral Care in the TBI Patient
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 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).
In the Zasler study (1993), patients who were provided verbally with oral hygiene instructions and taught to remove plaque had significantly less plaque on their teeth post intervention compared to the control group. Study authors suggest that this improvement can lead to greater integration back into society as the potential negative consequences associated with poor oral hygiene have been addressed (Zasler et al. 1993). Verbal education is therefore effective in promoting dental plaque control (Zasler et al. 1993).
In the Seguin study (2014), authors investigate the efficacy of povidone-iodine versus a placebo drug in reducing ventilator-associated pneumonia. It was concluded that the occurrence of ventilator-associated pneumonia, although reduced in the experimental group, was not significantly different from the control group (Seguin et al. 2014). Based on the findings from this study, povidone-iodine was ineffective in preventing ventilator-associated pneumonia, and has shown to increase the risk of secondary infections including acute respiratory distress syndrome (Seguin et al. 2014). Robertson and Carter (2013) found that patients in the enhanced oral care protocol had a significant decrease in acquired pneumonia when compared to the standard oral care group. These results suggest that an enhanced oral care protocol is more beneficial in improving oral hygiene, as well as overall health of patients (Robertson & Carter 2013).
There is Level 1b evidence that povidone-iodine is not beneficial in preventing ventilator-associated pneumonia.
There is Level 2 evidence that providing oral hygiene education to patients post TBI results in a significant reduction of dental plaque, measured by the Plaque Index Score.
Education in oral health and good oral care is needed to reduce the risk of dysphagia and other swallowing complications that can result from a brain injury.
Good oral health can promote recovery and reintegration into society by reducing some of the negative consequences associated with poor oral hygiene.
Provision of Mouth Care as a Means of Managing Aspiration Pneumonia Risk
In the clinical practice of SLPs, good mouth care is a significant component of treating swallowing disorders (Eisenstadt 2010). Oral care has generally focused on oral cleaning; however, it includes both oral hygiene and training for oral function (swallowing, mastication and saliva secretion; Tada & Miura 2012).
In individuals without swallowing difficulty, oral bacteria routinely travel along with the food ingested through the esophagus to the stomach. Here it is neutralized and presents less threat to the lungs. Even in healthy individuals the importance of a solid mouth care program cannot be understated. In patients who are NPO problems are compounded by xerostomia (dry mouth). Xerostomia is an undesirable side effect in some 400 to 500 medications (Bartels 2005; Canadian Dental Association 2009; Nicol et al. 2005). Many of these medications (e.g., anti-hypertensives, anticonvulsants, antidepressants) are administered to those who sustain an ABI. In these patients reduced salivary flow and thicker secretions contribute to increased micro-organisms and increased risk of infection (Bartels 2005).
Unlike the general population, mouth care in the patients with dysphagia is best performed before eating/drinking and not just following these times. 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”.
According to the Canadian Dental Association (2009) diabetes, hypertension, circulatory problems, cognitive and mental health impairments, and stroke are only a few of the common systemic diseases that can affect individuals as they age. Of importance to the Dental Association is the teaching of sound preventative habits, such as an appropriate diet and patient-specific oral hygiene techniques. In a randomized controlled trial (RCT) conducted by Lam et al. (2013), multiple oral care protocols were examined including various combinations of instruction, mouth rinse and assisted tooth brushing. No significant differences were found between the three protocols when looking at the amount of oral opportunistic pathogens that developed.
Research conducted in long term care or acute care facilities report mortality rates, risk for developing dysphagia, and risk of aspiration pneumonia decline 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, fewer cases of pneumonia and fewer patients were dying from pneumonia (Yoneyama et al. 2002).
Two RCTs were reviewed investigating 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 chlorhexidine gel was effective in reducing the number of nosocomial infections and overall length of stay. Of note, Prendergast et al. (2011) found individuals in a neuroscience intensive care unit, who were still intubated, were able to tolerate tooth brushing (manual and electric). Intracranial pressure and cerebral perfusion pressure monitoring showed no significant differences between the groups before, during, or after the procedure. Overall results suggest tooth brushing is possible in an intensive care unit, and patients post ABI can tolerate it without any adverse effects.
Maintaining good oral health during hospitalization may help to reduce the risk of nosocomial infections by decreasing dental bacterial colonization and hospital recovery time.
Good oral care has not been shown to have any adverse effects on normal intracranial pressure or cerebral perfusion pressure values in intubated patients.
Management of Dysphagia for Patients with ABI
The careful management of dysphagia is essential for the successful rehabilitation of acute brain injury patients (Hoppers & Holm 1999). For patients with dysphagia following head injury, based on the status of swallowing function at the time of admission, three distinct types of rehabilitation programs have been described: 1) non-feeding, 2) facilitation and feeding, and 3) progressive feeding (Winstein 1983).
The non-feeding program was designed as a stimulation program for very low-level patients, in order to prepare them for later feeding and includes desensitization techniques (e.g., stroking, applying pressure or stretching) to facilitate normal swallowing, sucking and intraoral responses (Winstein 1983). The facilitation and feeding program uses small amounts of puree consistency food to assist normal feeding patterns (Winstein 1983). Finally, the progressive feeding program uses specialized techniques to help the patient develop swallowing endurance by systematically increasing the amount of oral intake. This progressive feeding program continues until the patient can consume a complete meal within thirty minutes without difficulties (Winstein 1983).
For patients who are safe with some form of oral intake, therapeutic strategies utilized in dysphagia management can be divided into two categories: (a) compensatory treatment techniques and (b) therapy techniques (Logemann 1999). Compensatory treatment techniques do not involve direct treatment of the swallowing disorder; rather they reduce or eliminate the symptoms of dysphagia and risk of aspiration by altering how swallowing occurs (Logemann 1991, 1999). The types of compensatory strategies include: (a) postural adjustment of the head, neck, and body to modify the dimensions of the pharynx and improve the flow of the bolus; (b) sensory stimulation techniques used to improve sensory input either prior to or during the swallow; (c) food consistency and viscosity alterations; (d) modifying the volume and rate of food/fluid presentation; (e) use of intraoral prosthetics (Logemann 1999).
Conversely, therapy techniques are designed to alter the swallow physiology (Logemann 1999). They include range-of-motion and bolus handling tasks to improve neuromuscular control without actually swallowing. They also include swallowing maneuvers that target specific aspects of the pharyngeal stage of the swallow. Medical and surgical management techniques are included in this category (Logemann 1999), with these interventions only introduced once trials with more traditional behavioural treatment techniques have proven to be unsuccessful.