Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > L. Dysphagia and Nutrition

L. Dysphagia and Nutrition

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Individuals having sustained a traumatic brain injury (TBI) often present swallowing difficulties, known as dysphagia. As dysphagia increases the risk of pneumonia, it is essential to assess the swallowing functions as soon as the person’s condition allows it. Interventions to reduce swallowing difficulties and related complications include adapted feeding strategies, safe feeding training, proper oral care and education.

Individuals with TBI are also at a greater risk of inadequate nutrition in the acute and post-acute phases. A comprehensive assessment of the nutritional and hydration status should be conducted and appropriate nutritional support should be installed as soon as possible after TBI. Parenteral and enteral nutrition are both effective feeding strategies to increase caloric intake in individuals unable to self-feed. Consider monitoring protein and mineral intake closely as they have been shown to improve neurological functions when supplementation is provided.

The adequate management of dysphagia and nutrition requires the availability of professionals with proper training and expertise in these areas, usually through the combination of nutritionists, speech language pathologists and occupational therapists. Videofluoroscopic equipment should be available to support dysphasia assessment.

Nutrition management should be an integral part of the interdisciplinary plan, with close monitoring of the person’s global nutrition and hydration status, regular reviews of the target objectives and adaptation of the feeding strategies as required. Family members need to be educated and trained as they often participate intensively to the feeding sessions. 

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The evidence for dysphagia and nutritional assessments are limited for brain injury. Therefore, many recommendations are modelled after practices studied in the stroke literature and utilized in stroke rehabilitation.

Since dysphagia is a significant concern post acquired brain injury (ABI) which can lead to aspiration pneumonia, feeding strategies should be monitored. One RCT found an increased risk of developing pneumonia for ventilated patients fed by a naso-gastric versus a gastrostomy tube (Kostadima, Kaditis, Alexopoulos, Zakynthinos, & Sfyras, 2005). A retrospective audit found that pneumonia was more common among individuals with low levels of consciousness and for those with a feeding or tracheotomy tube (Hansen, Engberg, & Larsen, 2008). None the less, self-feeding is encouraged for individuals with dysphagia. An observational study of elderly outpatients found that dependence in self-feeding could accurately predict the risk of pneumonia; individuals with dysphagia who were fed by another person had a 20-times greater risk of developing aspiration pneumonia than those patients who are able to feed themselves (Langmore et al., 1998).

Oral hygiene is important for all individuals post ABI but it can be complicated by a diagnosis of dysphagia. One RCT found that patients with TBI who were provided verbal oral hygiene instructions and taught to remove plaque had significantly less plaque on their teeth post intervention compared to the control group. The reduction of plaque and greater oral hygiene lead to greater integration back into society as well (Zasler, Devany, Jarman, Friedman, & Dinius, 1993). Good oral care also can reduce the risk of pneumonia. A study examining an enhanced oral care protocol found a significant decrease in acquired pneumonia when compared to the standard oral care group (Robertson & Carter, 2013).

Ensuring patients with TBI have adequate nutrition is an important part of their medical management. Denes (2004) found that malnutrition increased the risk of complications such as pressure sores, pneumonia and increased lengths of stay. Both enteral and parenteral nutrition are effective in increasing caloric intake to patients with TBI. RCTs have found that parenteral nutrition results in greater caloric intake when compared to enteral nutrition (Hadley et al., 1986; Meirelles & Aguilar-Nascimento, 2011; Young et al., 1987). Parenteral nutrition can be safely administered without causing serum hyperosmorality or influencing intracranial pressure levels in patients post TBI (Young et al., 1987).

Early enhanced enteral feeding solutions enriched with immune-enhancing nutrients may decrease the occurrence of sepsis and reduce the inflammatory response. Chourdakis et al. (2012) compared delayed enteral feeding with early enteral feeding in 59 individuals post severe TBI. Although rates of complications were comparable between groups, the length of feeding was significantly shorter in the early enteral feeding group, and there was greater improvement in hormone production. Similarly, Minard, Kudsk, Melton, Patton, and Tolley (2000) found timing had no significant impact on mortality, length of stay or complications. Further, enhanced enteral nutrition was shown to accelerate neurologic recovery while reducing complications and also inflammatory post injury responses (Taylor, & Fettes, S. , 1998; Taylor, Fettes, Jewkes, & Nelson, 1999). A Cochrane review by Yanagawa, Bunn, Roberts, Wentz, and Pierro (2000) identified six RCTs that addressed the timing to initiation of feeding and mortality as an outcome. The relative risk for death associated with early nutritional support was 0.71 (95% CI 0.43-1.16). The pooled relative risk from three trials, which also assessed death and disability, for early feeding was 0.75 (0.50-1.11). Although the results were not statistically significant, it was concluded that early feeding may be associated with a trend towards better outcomes in terms of survival and disability (Yanagawa et al., 2000). A study found that among individuals with closed head injuries, early parenteral nutrition was beneficial in modifying immunologic function by increasing production of lymphocytes (Sacks et al., 1995).

After a brain injury, some individuals have difficulty with managing gastric emptying. A single RCT by Nursal et al. (2007) found that administration of 10 mg of metoclopramide did not influence absorption parameters compared to the control group.

Other supplements have been suggested to be beneficial in improving post ABI recovery. An RCT examined the effect of parenteral zinc supplementation following ABI (Young et al., 1996) and reported an improvement in protein synthesis and neurological recovery in patients who received supplementation. Amino acids are not just nutritionally beneficial, but they may also impact cognitive function. It is thought that the BCAAs improve cognitive functioning by providing substrates and increasing brain insulin availability (Aquilani et al., 2005).

Finally, following an ABI, metabolic changes can influence cell turnover use of substrate and body composition. Twyman (1997) noted that urinary urea nitrogen levels increase by a factor of three compared with normal levels within 10 days after severe head injury. On average, about 5 to 10 g of urea nitrogen are excreted daily from an individual; however, patients with ABI lose a mean of 21g urinary urea in a single day (Twyman, 1997).

REFERENCES
Aquilani, R., Iadarola, P., Contardi, A., Boselli, M., Verri, M., Pastoris, O., . . . Viglio, S. (2005). Branched-chain amino acids enhance the cognitive recovery of patients with severe traumatic brain injury. Arch Phys Med Rehabil, 86(9), 1729-1735.

Chourdakis, M., Kraus, M. M., Tzellos, T., Sardeli, C., Peftoulidou, M., Vassilakos, D., & Kouvelas, D. (2012). Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial. JPEN J Parenter Enteral Nutr, 36(1), 108-116.

College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO). (2015). Practice Standards and Guidelines for Acquired Cognitive Communication Disoders.

Denes, Z. (2004). The influence of severe malnutrition on rehabilitation in patients with severe head injury. Disabil Rehabil, 26(19), 1163-1165.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Hadley, M. N., Grahm, T. W., Harrington, T., Schiller, W. R., McDermott, M. K., & Posillico, D. B. (1986). Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery, 19(3), 367-373.

Hansen, T. S., Engberg, A. W., & Larsen, K. (2008). Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury. Arch Phys Med Rehabil, 89(8), 1556-1562.

Justo Meirelles, C. M., & de Aguilar-Nascimento, J. E. (2011). Enteral or parenteral nutrition in traumatic brain injury: a prospective randomised trial. Nutr Hosp, 26(5), 1120-1124.

Kostadima, E., Kaditis, A. G., Alexopoulos, E. I., Zakynthinos, E., & Sfyras, D. (2005). Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. Eur Respir J, 26(1), 106-111.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81.

Minard, G., Kudsk, K. A., Melton, S., Patton, J. H., & Tolley, E. A. (2000). Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN J Parenter Enteral Nutr, 24(3), 145-149.

Nursal, T. Z., Erdogan, B., Noyan, T., Cekinmez, M., Atalay, B., & Bilgin, N. (2007). The effect of metoclopramide on gastric emptying in traumatic brain injury. J Clin Neurosci, 14(4), 344-348.

Robertson, T., & Carter, D. (2013). Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients. Can J Neurosci Nurs, 35(2), 10-17.

Sacks, G. S., Brown, R. O., Teague, D., Dickerson, R. N., Tolley, E. A., & Kudsk, K. A. (1995). Early nutrition support modifies immune function in patients sustaining severe head injury. JPEN J Parenter Enteral Nutr, 19(5), 387-392.

Taylor, S., & Fettes, S. . (1998). Enhanced enteral nutrition in head injury: effect on the efficacy of nutritional delivery, nitrogen balance, gastric residuals and risk of pneumonia. J Hum Nutr Diet,, 11(5), 391-401.

Taylor, S. J., Fettes, S. B., Jewkes, C., & Nelson, R. J. (1999). Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med, 27(11), 2525-2531.

Twyman, D. (1997). Nutritional management of the critically ill neurologic patient. Crit Care Clin, 13(1), 39-49.

Yanagawa, T., Bunn, F., Roberts, I., Wentz, R., & Pierro, A. (2000). Nutritional support for head-injured patients. Cochrane Database Syst Rev(2), Cd001530.

Young, B., Ott, L., Haack, D., Twyman, D., Combs, D., Oexmann, J. B., . . . Dempsey, R. (1987). Effect of total parenteral nutrition upon intracranial pressure in severe head injury. J Neurosurg, 67(1), 76-80.

Young, B., Ott, L., Kasarskis, E., Rapp, R., Moles, K., Dempsey, R. J., . . . McClain, C. (1996). Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury. J Neurotrauma, 13(1), 25-34.

Zasler, N. D., Devany, C. W., Jarman, A. L., Friedman, R., & Dinius, A. (1993). Oral hygiene following traumatic brain injury: a programme to promote dental health. Brain Inj, 7(4), 339-345.

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L1. Assessment of Swallowing (Dysphagia)

P Priority F Fundamental New Level of evidence A B C
L 1.1 P B

Individuals with traumatic brain injury should be referred in a timely fashion to an appropriately trained and certified professional for a complete assessment of swallowing function when they present with one or more of the following risk factors for aspiration post-injury:

  • Presence of a tracheostomy

  • Poor cognitive functioning

  • Hypoactive gag reflex

  • Reduced pharyngeal sensation

  • Brainstem involvement

  • Difficulty swallowing oral secretions

  • Coughing / throat clearing or wet/gurgly voice quality after swallowing water

  • Choking more than once while drinking 50 ml of water

  • Weak voice and cough

  • Wet-hoarse voice quality

  • Recurrent lower respiratory infections

  • Unexplained low-grade fever or leukocytosis

  • Immunocompromised state

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p. 21-22, 5.6.4, table 5.10

L 1.2 C

Instrumental assessment (videofluoroscopic modified barium swallow [VMBS]) of dysphagia in post traumatic brain injury (TBI) individuals should be considered when:

  • Effectiveness of compensatory strategies and techniques for safe swallowing is being evaluated

  • Bedside assessment indicates possible pharyngeal stage problems (which would potentially include the aspiration of food and fluid into the lungs)

  • The risks of proceeding on the basis of the bedside assessment outweigh the possible benefits (the person with TBI is at very high risk of choking or aspiration if fed orally)

  • The bedside assessment alone does not enable a sufficiently robust clinical evaluation to permit the development of an adequate plan for swallowing treatment

(Adapted from SIGN 2013, 7.2.1, p. 30)

L 1.3 C

For individuals with traumatic brain injury (TBI) who are cognitively and physically able to tolerate it, videofluoroscopic modified barium swallow (VMBS) or modified barium swallow (MBS) studies should be used as a tool to assist in dysphagia management and identification of aspiration.

(INESSS-ONF, 2015)

Note: Aspiration can be seen in 30 to 50% of individuals with dysphagia post TBI.

  • Silent aspiration is not uncommon and requires videofluoroscopic modified barium swallow (VMBS) imaging studies to detect.

  • Aspiration is more common in more severe brain injuries.


REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p. 21-22, 5.6.4, table 5.10

L 1.4 P C

Individuals with traumatic brain injury who are tracheotomised and/or ventilator-dependent should have an assessment by an appropriately-trained and certified professional to determine appropriateness for Passy Muir Valve placement or capping of trachea tube in preparation for swallowing assessment to optimize swallow function.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.38, 5.6.8

L2. Management of Swallowing (Dysphagia)

P Priority F Fundamental New Level of evidence A B C
L 2.1 P B

Individuals with traumatic brain injury, and particularly those with dysphagia, should have access to specialized oral and dental care. Serial assessment and meticulous oral and dental care should be undertaken during both the acute and rehabilitation stages post brain injury.

(INESSS-ONF, 2015)

Note: Individuals should be provided with thorough oral care as a preventative treatment as defined by:

  • Oral care prior to each meal

  • Oral care that includes teeth, tongue, lips, buccal mucosa, and palate

  • Oral care done more frequently if individual is on a free water protocol

A dentist or dental hygienist should be consulted as needed.


REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.27

L 2.2 P B

Individuals with traumatic brain injury requiring enteral feeding should be converted from nasogastric feeding to gastrostomy feeding as soon as possible if the patient’s condition allows, as the risk of developing pneumonia is higher among ventilated individuals fed by a nasogastric tube than among those fed with a gastrostomy tube.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.50, 5.8.5

L 2.3 C

The dysphagia intervention plan for individuals with traumatic brain injury should incorporate an interdisciplinary approach and consider positioning, feeding strategies, medical status, pharmacological profile, cognitive impairments, behaviour, comfort and nutritional status.

(INESSS-ONF, 2015)

REFERENCE:

- College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) (2015)

L 2.4 C

Where possible, it is recommended that individuals with traumatic brain injury should be encouraged to self-feed.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.27, 5.5.1, table 5.13

L 2.5 C

To reduce the risk of aspiration pneumonia, education regarding proper oral care should be provided to the person with traumatic brain injury, healthcare professionals and family members.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.27, Table 5.13

L 2.6 C

Education on dysphagia, safe swallowing and safe feeding should be provided to individuals with traumatic brain injury (TBI), their family and caregivers. Additional focus should be placed on how cognitive impairments resulting from TBI can impact safe swallowing (e.g., impulsivity, neglect, verbosity, distractibility, fatigue, etc.).

(INESSS-ONF, 2015)

L3. Assessment and Management of Nutrition

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
L 3.1 P C

All individuals with traumatic brain injury should have their nutrition and hydration status assessed. Nutritional interventions should be initiated as soon as the condition of the patient allows it in order to prevent undernutrition and malnutrition.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.38

L 3.2 C

Where appropriate, a professional trained in low-risk feeding strategies should provide feeding assistance or supervision to individuals with traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.28, Table 5.14

L 3.3 B

Enteral nutrition and parenteral nutrition are recommended, as they have been shown to be effective in providing an increase in calories to individuals with traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.42, 5.8.1

L 3.4 B

Total parenteral nutrition (TPN) can be safely administered without causing serum hyperosmolality or influencing intracranial pressure levels (ICP) or ICP therapy in individuals with traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.42, 5.8.1

L 3.5 P A

Early enhanced enteral nutrition is recommended, when appropriate, to reduce the incidence of infection, reduce ventilator dependency and ICU stay, improve hormonal profile and potentially contribute to better outcomes of individuals with traumatic brain injury.

(INESSS-ONF, 2015)

Note: The diet should be started within the first 24 to 48 hours after admission, if the patient is hemodynamically stable. It should be withheld if high catecholamine doses are administered, alone or in combination with fluid or blood volumes, to restore cell infusion. (this note corresponds to level of evidence C)


REFERENCES:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.47, 5.8.2
- McClave et al. (2016)

L 3.6 B

Initiating enteral feeding for individuals with traumatic brain injury at goal rate is recommended to increase the percentage of prescribed energy and protein actually received.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.48, 5.8.3

L 3.7 A

Metoclopramide has not been shown to be effective as a gastric emptying aid and SHOULD NOT be used in individuals with traumatic brain injury.

(INESSS-ONF, 2015)


Suggested tool: Health Canada Indications of Use

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.51, 5.8.6

L 3.8 A

Individuals with traumatic brain injury (TBI) should be screened for zinc deficiencies. If needed, zinc supplementation should be considered within 15 days of the trauma to promote neurological recovery post TBI.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.52, 5.9.1

L 3.9 B

High nitrogen feedings of approximately 2 g protein/kg is recommended to restore the substantial nitrogen losses that occur post traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.55, 5.8.3

L 3.10 B

Supplementation of branched-chain amino acids (BCAAs) in individuals following traumatic brain injury is recommended to enhance recovery of cognitive function, without negatively effecting tyrosine and tryptophan concentrations.

(INESSS-ONF, 2015)

Note: Availability of BCAA supplements may be an issue in Canada


REFERENCE:

- ERABI Module 5- Dysphagia & Nutritional Interventions, p.56, 5.9.4

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