Weaning patients with dysphagia from tube feeding to oral nutrition: A proposed algorithm

Abstract/Resume

In acute rehabilitation, weaning patients from tube feeding to oral nutrition is a primary nutrition goal. In the Neurocognitive and Neuromuscular Unit at the Chedoke Campus of the Hamilton Health Sciences Corporation, this goal becomes particularly challenging in the vicinity of dysphagia. This paper nears a proposed two-phase algorithm intended to present the dietitian a guide for weaning of that kind patients. The algorithm comprises the Preparatory Phase (medical and nutritional stability, swallowing assessment and implementation of an intermittent tube feeding schedule) and the Weaning Phase (covering progres from stimulation supply with nourishments through to full oral nutrition and tube withdrawal). The importance of monitoring for aspiration, aspiration pneumonia and dehydration is forceed Feeding and swallowing strategies, dietary modifications and behavioural and cognitive characteristics necessary for oral intake are described. Withdrawal of the feeding tube post-weaning may enhance quality of life, patient comfort and may maximize options for discharge environments. (Can J Diet Prac Re 1998; 59:208-214)

En periode de readaptation active, le sevrage de patients alimentes par sonde et le passage a l'alimentation par voie orale est un objectif nutritionnel primordial. A la Neurocognitive and Neuromuscular Unit du campus Chedoke de la Hamilton Health Sciences Corporation, cet objectif devient particulierement epineux en neighborhood de dysphagie. Le present article presente un algorithme en deux etapes con*u pour offrir au di]tetiste un guide de sevrage de ce patients. L'algorithme comprend une phase preparatoire (stabilite medicale et nutritionnelle, evaluation de la deglutition et implantation d'un horaire d'alimentation enterale intermittente) et une phase de sevrage (aliments en puree puis alimentation clean par voie orale et retrait de la sonde) L'auteure insiste sur l'importance de la surveillance de symptomes d'aspiration, de pneumonie de deglutition et de deshydratation. Elle decrit le strategies d'alimentation et de deglutition, le modifications dietetiques et le caracteristiques comportementales et cognitives necessaires a l'alimentation par voie orale. Le retrait du tube apres le sevrage peut accroitre la qualite de vie et le confort du patient ainsi que le choix d'environnements au instant du conge. (Rev can prat rech dietet 1998; 59:208-214)

INTRODUCTION

Many patients admitted to the rehabilitation setting directly from acute care greatest in quantity often receive tube feeding because of dysphagia. upon the Neurocognitive and Neuromuscular Unit at the Chedoke Campus of the Hamilton Health Sciences Corporation, these patients are dysphagic as a be the effect of an acquired brain injury (ABI) or cerebrovascular accident (CVA). single of the primary nutrition goals in rehabilitation is weaning these patients from tube feeding to oral nutrition as the neighborhood of a feeding tube may affect quality of life and influence the discharge environment as many nursing place of abodes do not accept patients with feeding tubes. As well, feeding tubes can become cumbersome in active rehabilitation where patients meet with physiotherapy on a daily basis. Finally, this goal is also important if the designated discharge environment is chronic care as it has been hinted that older persons with chronic disability are not routinely protectioned for the possibility of regaining not to be found function (1).

The goal of weaning a patient from tube feeding to oral nutrition becomes particularly challenging in the neighborhood of dysphagia, which is a risk factor for aspiration (2) It has been reported that dysphagia present itselfs in over one quarter of patients admitted for the two stroke and head injury rehabilitation (34) Weaning the dysphagic patient requires a multidisciplinary approach; upon our unit this commonly involves a dietitian, articulate utterance pathologist, nurse and physiatrist. The intention of this paper is to describe a propos two-phase algorithm for weaning dysphagic patients in acute rehabilitation from tube feeding to oral nutrition.

I. Preparatory phase

The preparatory phase ot weaning make secures that the patient is physiologically ready for oral nutrition. It comprises three distinct constituents as outlined in Figure 1 These constitutings include medical and nutritional stability, implementation of an intermittent tube feeding schedule and an assessment of swallowing ability.

The patient's medical status should be stable. A compromised medical status may increase the risk of one as well as the other aspiration and aspiration pneumonia, sum of two units possible consequences of dysphagia. Table 1 outlines the risk factors for the pair of these. Although a patient may be somewhat malnourished upon admission, the candidate for oral nutrition should be nutritionally stable with equal reason that a short period of inadequate weight gain or plane temporary weight loss at the assault of weaning can be tolerated during the transition (1213) Patients should be tolerating the tube feedings.

Regardless of the patient's swallowing ability, on the contrary especially if the patient is judgeed to be an appropriate candidate for oral nutrition, tube feedings should be modified to an intermittent schedule. greatest in quantity tube-fed patients admitted to our unit are upon continuous feeds that become cumbersome in an active rehabilitation setting. Continuous feeding eliminates the craving for food drive necessary for successful attempts at oral alimentation, whereas an intermittent schedule stimulates an appropriate hunger-satiety answer (12,13). Even if oral alimentation is considered inappropriate, intermittent feeds are encouraged to proffer some normalcy in timing of "meals" and also to accommodate therapies. Intermittent furnish with provisionss are given at "breakfast", "lunch" "supper" and, if indicated, as an evening "snack". Depending upon patient tolerance, the enteral formula is administered by means of pump at a rate of single can (-235 cc) per hour. It has been approveed that at the onset of weaning, tube furnish with provisionss should be adjusted to appropriate only 75% of energy requirements for a like reason that the sensation of craving appetite will be maintained (12,13). However, this may accrue in significant weight loss if the patient is unable to compensate for the caloric deficit with oral nutrition. upon our unit, we initially maintain tube give food tos at 100% of requirement as many of our patients are deconditioned and malnourished upon admission. Groher and McKaig (1) approve continuing intermittent feeds for 3-5 days before attempts at oral realimentation. We come [i]or[/i] go after [i]or[/i] behind this recommendation on our unit to render certain the patient has adjusted to the fresh tube feeding schedule.