Chapter 8: Nutrition and fluid balance
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Source: Adapted from Brady et al. ([24]), Brodsky et al. ([25]), Coffey and Tolley ([38]), Groher and Crary ([62]), Patterson et al. ([136]).
Evidence‐based approaches
Rationale
Indications
Patients who are at high risk of dysphagia are summarized in Box 8.5.
Box 8.5
Patient groups at high risk of dysphagia
- Head and neck cancer patients undergoing surgery and/or radiotherapy/chemoradiotherapy. The risk of dysphagia is increased with multimodal therapy. Swallow function may be affected by side‐effects of treatment, such as xerostomia (dry mouth), odynophagia (pain on swallowing), thick oral secretions, nausea, candidiasis, taste changes, mucositis, fatigue, fibrosis and trismus (reduced mouth opening). Nutritional support with enteral tube feeding may be required.
- Patients with neurological involvement including brain tumours or metastases, or other co‐morbid neurological disorders, for example cerebrovascular accident, multiple sclerosis, motor neurone disease, Parkinson's disease or myasthenia gravis. Such patients may also have cognitive or behavioural issues that can affect their mood, motivation, feeding and appetite.
- Patients with lung cancer and vocal cord paralysis and respiratory disorders such as chronic obstructive pulmonary disease, including mechanically ventilated patients.
- Tracheostomy patients may present with swallowing problems, although frequently their medical diagnosis is the primary cause of dysphagia.
- Gastrointestinal patients may present with oropharyngeal or oesophageal dysphagia.
- Any other patient with significant generalized weakness or other co‐morbidities, including critical care and palliative care patients.
- Patients with psychogenic dysphagia.
- Laryngectomy patients and particularly pharyngolaryngectomy and pharyngo‐laryngo‐oesophagectomy patients. Some patients may experience dysphagia due to altered anatomy after surgery.
Goals of clinical assessment
It is important to correctly ascertain the presence of dysphagia and the factors contributing to its possible aetiology. Such patients may be at risk of aspiration and subsequent chest infections and therefore require a referral to a speech and language therapist (SLT) for a full assessment (Roe [154]). These patients also require a nutritional assessment from a dietician to ascertain the need for enteral tube feeding if they are unable to maintain an adequate nutritional intake or are at risk of aspiration. A suitable swallowing rehabilitation programme should be developed. Patients undergoing surgery or radiotherapy for head and neck cancer should have a baseline clinical swallowing evaluation before treatment (Jones et al. [74]).
Principles of care
Care will be influenced by the timing of the patient's referral, depending on their disease and treatment status. Management of dysphagic patients will be tailored to individual needs and they will require regular reviews to ensure that intervention and management decisions remain appropriate. The nature of the dysphagia may persist, recur or worsen depending on the patient's treatment or disease.
Treatment options may include normal diet with specifically targeted therapy techniques, modified diet, combination of alternative feeding and limited oral intake, or nil by mouth. For patients with oropharyngeal dysphagia, dysphagia food texture descriptors have been developed and updated to provide industry and in‐house caterers with detailed guidance on categories of food texture, thereby enhancing patient safety (Cichero et al. [36]). For patients undergoing radiotherapy for head and neck cancer, it may be appropriate to implement a programme of prophylactic swallowing exercises (Cappell et al. [28], Paleri et al. [133]).
Close liaison between the nursing staff, dieticians and members of the multidisciplinary team is essential. The SLT may recommend that the patient adopts certain compensatory swallow techniques to reduce the risk of aspiration or eliminate discomfort. Exercises or swallow techniques may be given to the patient to rehabilitate their swallow (Groher and Crary [62]). It is important for nurses to participate in educational programmes for patients and carers in order to improve awareness of the implications of dysphagia. Nurses may be required to supervise patients with oral intake and encourage their participation with regard to therapy exercises, and reduce other risk factors by encouraging good mouth care and independent feeding.
Methods of assessment
Clinical swallow assessment
In any patient presenting with a new onset of dysphagia, a medical review is necessary as this may be the first indicator of a change in disease or condition. A subsequent specialist SLT referral is then necessary. The SLT will take a comprehensive case history including subjective reports as well as medical, physical and mental status. Surgical and/or disease details will be determined, including where the patient is on the care pathway, for example pre‐operative, post‐operative, or receiving treatment, medication or palliative care. An examination of the oral cavity and cranial nerve assessment will be carried out to evaluate motor and sensory function associated with swallowing (Figure 8.19). Food and drink trials may be carried out by the SLT. The clinical swallowing evaluation may include tests such as the 100 mL Water Swallow Test (Patterson and Wilson [135]).
Figure 8.19 The oral stage of swallowing.
Instrumental swallowing evaluation
Following an initial assessment, the SLT may recommend instrumental assessments to evaluate in detail the nature and extent of any swallowing disorder. Silent aspiration is a particular issue and, in the absence of any overt clinical signs of aspiration or relevant medical history (such as frequent chest infections), instrumental evaluation will be the most appropriate way to identify the problem and its cause. The SLT can implement a range of compensatory strategies during these assessments to optimize swallowing function and minimize the risk of aspiration where possible. By observing swallowing biomechanics, SLTs will be able to define rehabilitation targets. A number of instrumental assessments of swallowing are available but videofluoroscopy (modified barium swallow) and fibreoptic endoscopic evaluation of swallowing (FEES) are the most commonly used (Roe [154]). Videofluoroscopy takes place in the X‐ray department and involves the use of radio‐opaque contrast mixed with food (Logemann [87]). FEES involves the use of an endoscope passed transnasally, allowing a view of the swallow process while a patient eats and drinks (Langmore [80]). These assessments should be selected on a patient‐by‐patient basis and in the knowledge that each method has its own particular advantages and limitations (Roe [154]).
Anticipated patient outcomes
Early identification of dysphagia and appropriate management are essential parts of patient care. Appropriate management aims to reduce the incidence of aspiration and the risk of aspiration pneumonia and to help maintain adequate nutrition. Potential complications of poorly managed dysphagia include malnutrition, weight loss and dehydration, aspiration and aspiration pneumonia, low mood, reduced quality of life and increased length of hospital stay (Groher and Crary [62]). Ensuring the patient has a clear understanding of their swallowing difficulty is essential and may help them to become a motivated rehabilitation partner (Roe and Ashforth [155]).
