5.6 Management of Dysphagia Post ABI

Describe a dysphagia management program at the time of acute care admission in an ABI patient suspected of suffering from dysphagia.

  1. Acutely patients should be NPO until swallowing ability has been determined.
     
  2. A trained assessor should screen all acute patients for swallowing difficulties as soon as they are able.
     
  3. A speech and language pathologist should assess all patients who fail swallowing screening and identify the appropriate course of treatment.
     
  4. VMBS is the “gold standard” for diagnosis of aspiration.
     
  5. An individual trained in low-risk feeding strategies should provide feeding assistance or supervision to patients where appropriate.
     
  6. A dietitian should assess the nutrition and hydration status of patients who fail the swallowing screening.

5.6.1 Best Practice Guidelines for Managing Dysphagia

Best practice guidelines for managing dysphagia were developed by a consensus committee of the Heart and Stroke Foundation of Ontario. Although these guidelines were developed for stroke they are applicable to ABI Rehabilitation. These guidelines are summarized below.  Similar guidelines have not been developed yet for ABI rehabilitation.

Best Practice Guidelines for Managing Dysphagia Post-Stroke 36
 

Maintain NPO until swallowing status is determined.
 

Regular oral care, with minimum of water to limit build-up of bacteria.


Screen for swallowing status once awake and alert by trained team member.


Screen for risk factors of poor nutrition early by trained team member.


Swallowing assessment by speech language pathologist to:

  • assess ability to swallow
  • determine swallowing complications
  • identify associated factors which may be compromising swallowing and nutrition.
  • recommend appropriate individualized management program including appropriate diet.
  •  monitor hydration status.

 

Where appropriate feeding assistance or mealtime supervision by individuals trained in low risk feeding strategies.


Assess nutrition and hydration status and needs of those who fail screening; reassess regularly.
 

Education of patient and family with follow-up upon discharge.
 

Consider the wishes and values of the patient and family concerning oral and non-oral nutrition; provide information to allow informed choices.

 

5.6.2  Low Risk Feeding Strategies

Describe why low risk feeding strategies are necessary?

  1.  Individuals with dysphagia who are fed by someone else have a 20 times greater risk of pneumonia than patients who are able to feed themselves.

Q14.  Describe some of these low risk strategies?

1.    Calm eating environment with a minimum of distractions

2.    Patient is properly positioned in an upright position with neck slightly flexed

3.    Proper oral care

4.    Feed at eye level

5.    Feed slowly

6.    Drink from wide mouth cup or a straw to reduce the neck extending back

7.    Ensure swallowing before offering more

8.    Properly position the patient and monitor for 30 minutes after each meal.

The Heart and Stroke Foundation Dysphagia Guidelines for stroke patients note that 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 37. It is noted that where dysphagia patients 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 (see below).

Low Risk Feeding Strategies in Dysphagia Stroke Patients (HSFO Guidelines)

  • Ability of feeder to deal with emergencies, such as choking.
  • Calm eating environment with a minimum of distractions.
  • Patient properly positioned – upright, midline with neck slightly flexed.
  • Proper oral care.
  • Feed at eye-level.
  • Metal teaspoons (no tablespoons or plastic).
  • Feed slowly.
  • Drink from wide-mouth cup or a straw to reduce neck extending back.
  • Ensure swallowing before offering more.
  • Properly position and monitor for swallowing problems for at least 30 minutes after each meal.
  • Carefully monitor patient’s oral intake.

 

It’s of note that 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 that low-risk feeding strategies by trained personnel should be employed. There are no such consensus statements made for ABI.