MEDICAL PROBLEMS IN TBI: SWALLOWING (DYSPHAGIA) IN TRAUMATIC BRAIN INJURY: SWALLOWING IN TBI

     Brain injury frequently affects the skilled coordination of the nerves and 26 different muscles in the neck and esophagus that are used during the normal swallowing process. A set of symptoms can result, called dysphagia. Problems in any of the 4 stages of normal swallowing are classified as one of the 4 major classifications of dysphagia:

  • Oral preparatory dysphagia is characterized by difficulty in taking food, chewing it into small bits, mixing it with saliva, and forming it into a bolus

  • Oral dysphagia is characterized by difficulty in controlling the bolus of food and transporting it to the back of the mouth

  • Pharyngeal phase dysphagia is characterized by difficulty in swallowing due to the food being trapped at the top of the pharynx and at the very back portion of the mouth. This delays the pharyngeal stage until the bolus of food has entered the lower throat. This delay can cause significant aspiration or obstruction of the airway. (The gag reflex, which is triggered when an uncomfortable or foreign stimulus touches the back of the throat area or the base of the tongue, is the body's attempt to eject the stimulus from the mouth, and is not an indication of an individual's ability to swallow food.)

  • Esophageal stage dysphagia is characterized by swallowing difficulties when the food has entered the esophagus - the passageway to the stomach.

Some patients have more than one type of dysphagia at the same time, such as patients who have both oral and pharyngeal dysphagia.

Warning Signs of Dysphagia and Prognosis

  • Warning signs include:
    1. Coughing while eating or drinking
    2. Coughing after swallowing
    3. Choking
    4. Coughing up food particles
    5. Uncoordinated chewing or swallowing
    6. Pocketing of food between the cheek or gum
    7. Leakage of food or liquid through the nose
    8. Drooling/leakage of liquid or food from the mouth while eating or drinking
    9. Slow eating
    10. Labored or effortful swallowing
    11. Poor oral consumption of food or liquid
    12. Excessive saliva
    13. After eating, patient complains of pain behind the sternum, in the neck, or between the shoulder blades
    14. Gurgling voice or wet cough
    15. Complaints of food sticking in the throat
    16. Facial grimaces or reddening of the face
    17. Impulsive eating behaviors

Note: Cough is an unreliable index of aspiration, because the cough reflex can be absent in those patients with neurological impairments. About 40% of dysphagic patients have been shown to silently aspirate.

  • Positive prognostic indicators for recovery from dysphagia following TBI include:
    1. The patient's comprehension and understanding skills are intact
    2. The client can self-monitor and self-correct
    3. The client's family is active in the management of the dysphagia and follows through with the treatment plan
    4. Compensatory techniques used during videofluoroscopy assist the swallow
    5. There is little or no pharyngeal or esophageal dysphagia
    6. The client coughs when food is aspirated into the windpipe
    7. The client has a strong and protective cough
    8. The client has good lung power
    9. The client is able to satisfy all nutritional needs by mouth

Treatments for Dysphagia

  1. Non-Oral Feeding Methods - Also known as NPO (No Food by Mouth), these methods are for patients who cannot safely take any food or liquid orally due to severe impairments. Examples of alternative feeding measures include:

    • Intravenous - IV feedings involve placing a needle in a vein and infusing nutrients directly into the blood. This method is usually used for patients to maintain adequate nutrition for short periods.

    • Nasogastric Tube - N-G tubes are tubes that are passed through the nose and throat, down the esophagus, and into the stomach. The patient receives nutritional liquid through the tube either several times a day, or, on a continuous basis for several hours at night. Patients can still swallow, participate in dysphagia therapy, and, in some cases, take food by mouth with no interference from the tube. N-G tubes are used for patients who require alternative feedings for longer periods of time.

    • Percutaneous Endoscopic Gastrostomy - PEG s are tubes that are surgically placed through the abdominal wall and directly into the stomach. Patients then obtain nutrition in the same way as the nasogastric tube feedings. This method is used for patients who require alternate feedings for long periods of time, or, on a permanent basis. The tube can, however, be removed and the incision healed over if the patient regains the ability to take food by mouth.

  2. Food Textures - The following diets refer only to the texture of the food. Any of the diets may also have restrictions, such as "low sodium", "low fat", etc. Crushing medication may be recommended to aid in bolus propulsion and reduce the risk of aspiration with patients who have oral and/or pharyngeal stages dysphagia. Medical clearance must be obtained when recommending crushed medication, because some medications may not be as effective if crushed, such as time released medications, and/or a liquid form of medication can be prescribed as an alternative.

    • Pureed - A pureed diet is prescribed primarily to patients with weakness in the mouth and tongue muscles, who cannot manage food items that are difficult to chew or difficult to clear out of the mouth. This diet may also be recommended for patients with weakness in the throat muscles, who are at risk of choking or obstructing the airway on more advanced food textures. Examples: mashed potatoes, applesauce, and strained vegetables

    • Mechanical Soft - A mechanical soft diet is prescribed to patients with weakness in the mouth muscles, who have difficulty chewing regular textured foods and who may be at risk of choking on large pieces of food that are not chewed properly. The diet consists of items that do not require excessive chewing to break down foods. Examples: grounds meats, cut-up pasta, and cut-up cooked vegetables

    • Soft - A soft diet is prescribed to patients with some weakness in the mouth muscles, who have difficulty chewing "tough" or "regular" foods. Chewing may not be refined enough to safely handle all food textures. This diet consists of all food items except items such as streak, bagels, and raw vegetables

    • Soft Cut-Up - A soft cut-up diet consists of the same food textures found on a "soft" diet, except the food is already cut for the patients before leaving the kitchen. This diet is prepared for patients who are unable to cut their foods, due to upper extremity weakness or lack of judgment to cut appropriate bite sizes.

    • Regular - A regular diet has no restrictions and consists of all food textures.

  3. Liquids
    • Thin Liquid
      • Thin liquids are fluids that have low viscosity and are thin in nature. Examples: water, coffee, and orange juice.
      • Some thin liquids are a little thicker, but not thick enough to be considered think. Examples: nectar, buttermilk, and tomato juice.
      • Any fluid that melts into a think liquid is also considered thin even it starts out appearing thick. Examples: ice cream, frozen yogurt, and jello.

    • Thick Liquid - Thick liquids are any thin fluids that are thickened to the proper consistency using a food thickening agent, such as gelatin, Thixx, Thicken-Up, or Thick-It. The amount of thickener needed to obtain proper consistency will vary by product and the liquid you are thickening. When you have mixed the fluid to the proper consistency, a plastic spoon will stand in an 8 oz. glass for a split second and then fall to the side of the cup.

    • Extra-Thick Liquid - Extra-thick liquids are liquids that are mixed with a thickening agent to a pudding consistency and that require spoon feeding. These liquids are used for patients who cannot safely take thin or thick fluid, but cannot have (or in some cases, refuse) alternative hydration (tube feeding). Extra-thick liquids are not, however, an option for all patients who cannot tolerate other fluids. Each case is reviewed on an individual basis.

  4. Therapeutic Feedings are oral "feedings" used to rebuild the patient's swallowing skills.  They are used in cases of severe dysphagia, where the patient can safely swallow food only under carefully controlled circumstances. The patient's nutritional needs will probably be met through alternative feeding measures, such as tube feedings, or Non-Oral Feeding Methods.

Based on Brain Injury Patient Care and Education Manual, by Pinecrest Rehabilitation Hospital; Neuro section of the Trauma Manual, Jackson Memorial Hospital; and Recovering from Head Injury; a Guide for Patients, by Nova University Neuropsychology Service, and edited for PoinTIS by the Louis Calder Memorial Library of the University of Miami School of Medicine and the PoinTIS Advisory Committee, and on Rehabilitation of Persons with Traumatic Brain Injury, NIH Consensus Statement 1998 Oct. 26-28.