Lecture 3/18 Flashcards
Malnutrition
- Loss of body composition (e.g., fats, proteins)
- Primary Malnutrition: decrease in nutrient intake in the absence of underlying disease process (e.g. inadequate food supply or inability to ingest nutrients)
- Secondary Malnutrition: Underlying organic disease process (e.g. malabsorption, due to GI tract or lier disease; excessive secretion)
Example of risk for inadequate nutrition and hydration
Cancer and cancer treatments can cause barriers to oral intake.
- Chemotherapy: nausea and vomiting; decreased
appetite; mouth sores and ulcers; diarrhea; transient
dysphagia (e.g., transient cranial nerve damage or
muscle weakness)
- Radiation: xerostomia; inflammation of oral cavity;
esophagitis; hypogeusia or ageusia; odynophagia
- Premature babies, strokes, and surgery
Alternative means of nutrition and hydration
- Safe and adequate nutrition and hydration cannot be met by mouth
Successful feedings is crucial for:
Healthy physical and cognitive development
Restoration of health following disease and interventions
Maintenance of health (e.g. GI tract: malnutrition-malabsorption cycle)
Healthy immune system (malnutrition causes immunodeficiency)
Options:
Enteral nutrition
Parenteral nutrition
Orogastric Tube
- Tube through oral cavity, pharynx, and esophagus
May be preferred for:
- Infants to prevent even partial obstruction of the nasal
airway (Arvedson & Brodsky, 2002)
- Facial trauma
- Sinusitis
Nasogastric (NG) tube
- Tube through nose, pharynx, and esophagus
Example:
- Dobhoff: small bore feeding tube; narrow diameter to minimize irritation in pharynx, UES
Disadvantages: Orogastric and NG tubes
Disadvantages:
- removed by patient
- irritation to nose, pharynx, and esophagus
- risk for reflux
- Unsightly
- uncomfortable
- temporary solution
-other tubes: nasoduodenal and nasojejunal
Percutaneous Endoscopic Gastrostomy (PEG) Tube
- Surgery requiring local anesthetic creates opening in abdomen into stomach
- Advantage: avoid nasal pharyngeal irritation associated with NG tube
- Disadvantages: more invasive, risk for infection at stoma site, risk for reflux
Percutaneous Endoscopic Jejunostomy (PEJ) Tube
Surgery requiring local anesthetic that creates an opening in the abdomen into the small intestine.
Disadvantages:
- more invasive
- risk for reflux remains
Fundoplication: surgery to twist the top of stomach around the LES in reinforce LES in prevent reflux.
Cautions
- None alleviate risk of reflux and may even increase
rate of reflux - Sites need to be cleaned, monitored for infection and
leakage - All can be temporary
Weaning
- To induce hunger, hold feedings 1 hour before meal
or infuse feedings at night only - End feedings when patient can ingest 65-75% of
nutrients over 2-3 days via oral feeding - Dietician should be involved in this process
Parenteral nutrition
Total parenteral nutrition (TPN)
- Circumvent gastrointestinal tract
- Intravenous delivery
Indications:
- Very small premature babies
- Short-term intensive nutrition
- Obstruction in or deformation of GI tract
- Inability to absorb nutrients (chronic disease; intractable vomiting; diarrhea; intestinal disease)
Disadvantage: Parenteral Nutrition
Total parenteral nutrition (TPN)
Disadvantage: Risk for (bacterial) infection; Premature babies: atrophy of the GI tract
Total Parenteral Nutrition
Peripherally Inserted Central Catheter (PICC) line; Inserted via peripheral vein and through to central vein
Examples of Risk for Inadequate Nutrition and Hydration
Thickened liquids provide the same amount of free
water as thin water
BUT intake may be limited by
- Dislike of taste (few naturally occurring thick liquids)
- Limited availability
Fluids
- Fluid is anything that is in a liquid state at room temperature (includes jello, ice chips and ice cream)
- Non-fluids can contain fluids (e.g. fruit)
Amount of fluid needed is determined by:
- Height
- Weight
- Age
- Gender
- Physiologic activity
- Medical diagnosis
- Medications
Aging and fluid balance
- Fluid and electrolyte imbalance is common
- Reduced total body water (45-50%) (reduction in lean
muscle) and reserve capacities - Reduced ability to regulate water balance in response
to changes in condition - Increased likelihood of onset of disease
- Increased use of medications
- Reduced fluid intake (e.g. due to bladder dysfunction)
- Morbidity and hospitalization
Withholding thin liquids results in…
- Increased risk for dehydration
Recommendation: 6-8 cups of fluid
Prevalence: Common in health care especially in elderly (35-85% NH residents) and is often underdiagnosed
Consequences: Increased risk for morbidity and mortality; Increased risk for UTI, lethargy, constipation, renal failure, development of sores, poor healing of sores - Reduced likelihood of “compliance”
- Reduced quality of life: Unable to quench thirst effectively
Aspiration
- Aspiration can be problematic since it is often colonized with pathogens
- It constitutes 5%-15% of the 4.5 million cases of community-acquired pneumonia per year with a mortality rate as high as 21%.5
- Clave et al. (1996) studied patients with stroke/TBI or neurodegenerative diseases, and healthy volunteers using MBSS while swallowing liquid, nectar, and pudding boluses
** 21.6% of stroke/TBI had aspiration of liquid into the airway, but was reduced to 10.5% and 5.3% when the diet was modified to nectar and pudding.
** 16.2% of neurodegenerative patient had aspiration of liquid into the airway, which was reduced to 8.3% and 2.9% when given nectar and pudding boluses
** Thus, thickened liquids significantly improved the MBSS results, leading to a presumptive decrease in the rate of respiratory complications.
But thickening liquids is not always the answer!
So, what is so bad about thickening liquids??
- Evidence supporting other forms of treatment (over
thickening) goes back to the 1990s. - Depippo et al. (1994) found family instruction on appropriate compensatory swallowing techniques without the use of thickened liquids carried no increased risk of pneumonia, dehydration, malnutrition, or death when compared with thickened liquids.
- Some studies reveal the harm of thickening liquids
- In one study, patients assigned to thickened liquids
had a higher rate of dehydration (6%-2%), fever (4%-
2%), and UTIs (6%-3%) than those assigned to thin
liquids (Robbins et al., 2008)
Thickened Liquids and QOL
- Patients perceived QOL is also lower when on
thickened liquids - One study found that those started on thickened
liquids had a significant reduction in their SWAL-
QOL score by nearly 14 points (Carlaw et al.,
2012). Patient compliance has been reported to be
as low as 35% at five days, likely due to this
impact on QOL (Leiter, 1996).
When can thick liquids be helpful?
- In patients who have extreme choking with water intake
- In end-of-life situations, if coughing is so bothersome to
patients as to be inconsistent with goals of care, then
thickened liquids for comfort measures may be
reasonable. - One study found that combining thickened liquids with
texture modified diets and intensive training sessions
with SLPs who focused on swallowing techniques led to
a reduced risk for aspiration pneumonia during the first
seven days following stroke - Since risk reduction did not persist after seven days,
prolonged modification is likely not helpful.
What can we do instead of thickening liquids?
- Access to free water is important for hydration &
QOL - Collaborate with patient, team members/family to focus on strategies to prevent aspiration pneumonia via positioning, oral hygiene, and patient and family education
Water and Aspiration Pneumonia
- Aspiration of different materials presents different risks for developing aspiration pneumonia
- Aspiration of water is less harmful than water plus
glucose in rabbits. - Aspiration of thick liquids and solids results in a
greater risk for aspiration pneumonia and death than
aspiration of water - Aspiration pneumonia may result from aspiration if
material is pathogenic to lungs and resistance to
material is compromised
Frazier Free Water Protocol
Study by Garon, Engle & Ormiston (1997)
Participants
- 20 patients
- Post CVA
- Aspirated on thin liquids per MBS
- Randomly assigned to 2 groups
Procedure
- Experimental group received thin liquids between meals after rinsing their mouth, thick liquids with meals over 30 days
- Control group received thick liquids between meals and with meals over 30 days
- All participants were monitored for development of aspiration pneumonia
Results
- No participants developed aspiration pneumonia
- Experimental group had significantly greater overall
intake of fluids
- Experimental group reported higher degree of
satisfaction
Limitations
- Small sample size
- Relatively healthy participants
Frazier Free Water Protocol (Continued)
Bedside and instrumental swallow study
- If impulsive require supervision
- No water if choking or strict NPO per MD
Water allowed between meals
- Provide aggressive oral care
- At least 30 minutes after a meal if eat by mouth
- Any time if NPO
- Unrestricted quantity
- Use any recommended swallow strategies
- No medication with thin liquid
Aspiration, health status and pneumonia
- Dysphagia does not imply aspiration pneumonia
- Why do some patients with dysphagia succumb to
aspiration pneumonia while others do not’?
Should we focus on
- Aspiration?
- Prevailing health status?
- Both?
Predictors of Aspiration PNA (Langmore study)
“Dysphagia by itself is not sufficient to cause
pneumonia” (Langmore, 1998, p.76).
Among the significant predictors of pneumonia
were
- feeding dependency
- oral care dependency
- number of decayed teeth
- more than one medical diagnosis
- number of medications
- presence of smoking
Three Pillars of PNA
Pneumonia from Aspiration
- Impaired Health Statues
- High Prevalence of Dysphagia Signs
- Poor oral health status.
**Must consider the presence and severity of all three when determining if your patient is at risk for pneumonia from aspiration or not
International Dysphagia Diet Standardization Initiative (IDDSI)
- Provides a level of consistency in terminology
used to describe dysphagia diets/textures and
viscosities - New framework standardized terminology and
definitions for food textures and liquid thicknesses - Designed to avoid the confusion created by the
different names used throughout world to describe
texture-modified foods and thickened liquids, so as
to ensure patient safety - Includes characteristics and examples of food or liquid at each level, testing methods, as well as photos and videos of the testing methods.
Tips for Implementation of IDDSI Framework
- Become familiar with IDDSI. (Free app available.)
- Decide who will participate on the implementation/leadership team(s). Typically, head of SLP dept. and the head of clinical nutrition. In others, food service controls new programs (or can be all three).
- Identify who the administrator is who will approve
commencement of the IDDSI framework implementation at your facility/network. - Identify the leadership team and then decide who else can support implementation In many settings, SLPs and registered dietitians might fill this role. Some places rely on food service managers for overseeing the process.
- Begin “mapping process’ where you match your menus to IDDSI framework
