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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Figure 13–4. Kendall™ Argyle™ Silicone
Salem Pump™ Tube, 16 Fr., 48-in. length (Tyco/
Healthcare). Dual lumen. Y- connector with
(1) suction drainage lumen/feeding port,
(2) suction vent lumen, and (3) closed-end
tip with multiple exit ports.
Figure 13–6. Kendall™ Entriflex™ Dual Port Feeding Tube with-
out stylet 12 Fr., 36-in. length (Tyco/Healthcare). Y- connector
with (1) feeding port, (2) irrigation/medication port, (3) exit
ports, and (4) weighted tip.
36 in. for other tubes). It also requires
radiographic confirmation of placement and may need to be placed with
endoscopic visualization. Its primary
advantage is that its further placement
into the GI tract minimizes dislodgment back into the stomach, and feeding can begin shortly after placement,
as feeding into the small intestine does
Figure 13–5. Kendall™ Kangaroo™ 12 Fr.,
36-in. length, unweighted (Tyco/Healthcare). Y -connector with (1) feeding port,
(2) irrigation/medication port, and (3)
open-end tip with exit ports in tubing.
not depend on a stomach to be emptying its contents (see Figure 13–7).
Gastrostomy tube (G-tube) placement from the surface of the abdomen
into the stomach is appropriate if the
nasal route is unavailable, long-term
feeding is required, or swallowing dysfunction is permanent. Location of tip
placement in stomach, duodenum, or
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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Figure 13–7. Kendall™ Entriflex™ Dual Port Feeding Tube with FLOW-
THROUGH™ Stylet, 12 Fr., 43-in. length (Tyco/Healthcare). Y- connector
with (1) feeding port, (2) irrigation/medication port, (3) stylet, (4) exit
ports, and (5) weighted tip.
305
jejunum would follow the same decision tree used with a nasally placed
tube. A prime advantage of gastrostomy is cosmetic, as the feeding tube
placed directly into the stomach from
the surface of the abdomen is covered
by clothing and is not outwardly visible
(Figures 13–8 and 13–9).
Some dual-lumen G-tubes have a
narrow lumen line that serves the duodenum or jejunum (see Figure 13–9). This
has the advantage of being able to access
both the stomach and intestine. Some
medications are better absorbed in the
stomach. If long-term jejunal feeding
is the goal and stomach access is not
required, placement directly as a J-tube
may be preferred. Tube length will be
shorter and possibly less inclined to
clogging. As with gastrostomy tubes, a
jejunostomy can be placed endoscopically (PEJ), which is less costly than
a surgical jejunostomy. A surgically
placed J-tube is indicated in the patient
with extensive gastroesophageal sur-
gery or disease. A caveat is that bypassing the duodenum also bypasses the
nutrient absorption sites of this part of
the intestine and may have longer-term
consequences for nutrition status.
The dysphagia etiology may also
play a role in determining the method
of feeding tube placement. For example, Rustom et al. (2006) reviewed 78
head and neck cancer patients to determine complication rates between three
methods of gastrostomy tube insertion: PEG, radiologically inserted gastrostomy (RIG), and surgically inserted
gastrostomy (open or laparoscopic).
The PEG group had fewer complications, and the authors recommended
PEG for head and neck cancer patients.
However, other researchers have found
cases of PEG site metastasis in head and
neck cancer patients, presumably due
to passing the endoscope through the
site containing cancer in the pharynx
and seeding of the abdominal wall with
cancerous cells during the gastrostomy
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Figure 13–8. Kimberly Clark™ MIC™ Gastrostomy Feeding Tube, 20 Fr., 7-
to 10
mL balloon (Ballard Medical Products). (1) Feeding port, (2) irrigation/medication port, (3) balloon valve port, (4) external retention disk,
(5) balloon, and (6) open-tip exit port.
Figure 13–9. MIC™ Gastro Enteric
Feeding tube, 20 Fr. (Medical Innovations, a division of Ballard Medical
Products). (1)Gastric port, (2) jejunal
port, (3)balloon valve, (4) dual-lumen
tube, (5)Secur
(7)tapered gastric exit port, (8) multiple
exit ports, and (9) weighted tip.
®
lok
ring, (6) balloon,
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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307
(Douglas et al., 2000; Mincheff, 2005).
Furthermore, if the G-tube placement is
performed after surgical resection of an
upper aerodigestive tract cancer, there
is the potential to disrupt the surgical
repair during passage of the endoscope
into the stomach. Likely institutional
preference, expertise, and equipment
will also play a role in selection of feeding tube placement methods. Asummary of advantages and disadvantages
of each feeding tube is presented in
Table 13–5.
The dietitian is a key resource in
assisting selection of the enteral formula
appropriate for each type of feeding
tube, with consideration given to suitability, availability, tolerance, and cost.
Generally, the cost of formula will be
lowest if one retains the ability to feed
into the stomach. The stomach acts as a
reservoir, and hypertonic solutions can
be fed directly into the stomach with
good results. The stomach also allows
for an intermittent bolus feeding schedule, which may allow the patient more
freedom and a feeling of normalcy by
engaging in feeding at meal periods.
In addition, a feeding regimen that is
intermittent avoids a chronic elevation
of insulin that occurs in patients on continuous feeding (Gonzalez et al., 2020).
Occasionally, however, patients experience a “dumping syndrome” with
hypertonic bolus feeding into the stomach. These patients suffer symptoms of
nausea, gas, diarrhea, and dizziness
with or shortly after their tube feeding
has been administered. If the feeding
solution is sufficiently hypertonic, it
will pull fluid from the vascular system
into the stomach, inducing hypotension
and the associated symptoms. Adding
water to the tube feeds and slowing the
delivery rate should help manage and
can potentially eliminate “dumping”
symptoms. Alternatively, patients can
administer diluted tube feeds slowly
with a pump at night while asleep.
Jejunal feeding usually requires an
isotonic formula and a feeding pump.
Care must be taken to avoid the development of a dumping syndrome with
jejunal feeding due to the relative
hypertonic load of the formula directly
into the gut. These symptoms can often
also be managed by increasing the
water content of the formula and gradually increasing the feeding rate.
Medications delivered via the feeding tube must be liquid or crushed and
sustainable in a slurry. A bolus of water
before and after the medication administration will prevent interaction of the
medication with the feeding that may
result in clumping of the feeding, which
could clog the tube. No sustainedrelease medications can be fed through
the feeding tube, as crushing will ruin
the sustained-release property.
TEAM APPROACH
The benefit of a team approach to dysphagic patients is the opportunity it
provides for synergism. The dovetailing of the skills and experience of each
individual professional in the assessment and treatment of the patient is
an enormous advantage, for both the
patient and team members. Members
of the team should have a healthy
regard for the individual skills and
backgrounds represented by each participant, and this translates to a broad,
comprehensive approach to patient
management. The team approach also
provides opportunities to reinforce the
message of other team members or of
Table 13 – 5. Diets for People with Difficulty Chewing and Swallowing (NDD)
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Dysphagia Advanced
(DYSPHAGIA III DIET)
OLD NAME:
REGULAR SOFT
Regular food that is
easy to chew.
Meat:
Thin-sliced, tender, or
ground meats and poultry.
Well-moistened fish. Eggs
prepared in any way. Yogurt
without nuts or coconut.
Casseroles with small chunks
of meat, ground meats, or
tender meats. NO nuts
All soups except
Soups:
strained corn or clam
chowder. (May need to be
thickened to appropriate
consistency if soup is thinner
than prescribed liquid
consistency.)
If thin liquids allowed, also
may have: All thin soups
except broth and bouillon.
Dysphagia Ground Or
“Mechanically-Altered”
(DYSPHAGIA II DIET)
OLD NAME:
MECHANICAL SOFT
Soft-cohesive food
with ground meat and
extra gravy to make
the meat moist.
All meat is ground, with gravy.
Poached, scrambled, soft-
cooked eggs.
Scoop of tuna fish, egg salad
(NO large chunks or celery).
Soft salad sandwich/white
bread (NO crusts)
Pureed soups
NO mixed consistencies
(i.e., cold cereal moistened
with little texture allowed, NO
soup with thin liquid broth
and solids)
Dysphagia Puree
(DYSPHAGIA I DIET)
OLD NAME:
PUREE
All foods must be
pureed smooth.
Pureed scrambled eggs
Pureed meats with gravy
Smooth hot cereal (pureed
oatmeal or Cream of
Wheat)
Order may specify NO
oatmeal
Pureed soups
Starches:
Breads:
Any well-moistened
breads, biscuits, muffins,
pancakes, waffles, etc.
Need to add adequate
syrup, jelly, margarine,
butter, etc. to moisten well.
NO dry crusty bread.
All well-moistened cereals
(cereals may have ¼ cup
milk or just enough milk to
moisten if thin liquids are
restricted).
All potatoes and starches
okay, including rice, wild
rice, moist bread dressing,
and tender-fried potatoes.
Fruits and vegetables:
All canned and cooked
fruits. Soft, peeled fresh
fruits such as peaches,
nectarines, kiwi, mangoes,
cantaloupe, honeydew,
watermelon (without seeds).
Soft berries with small seeds
such as strawberries.
Toast, French Toast (NO
crusts), muffins, pancakes
okay
Soft breakfast cakes okay
NO bagels, NO English
muffins, NO breadsticks, NO
dinner rolls
Pasta, noodles with sauce
okay
American Chop Suey
Macaroni and cheese okay
NO RICE
Well-cooked, soft vegetables
okay
Well-cooked, soft potatoes
okay (i.e., potatoes sliced
with cheese)
NO salads or raw vegetables.
Cottage cheese okay.
Mashed potatoes (whipped
smooth with gravy, sour
cream, and/or butter to
keep moist and smooth)
Well-cooked, pureed pasta
Vegetables pureed smooth
without lumps, chunks,
seeds
Pureed fruits without pulp,
seeds, chunks
NO cottage cheese
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Table 13 – 5. continued
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Dysphagia Advanced
(DYSPHAGIA III DIET)
OLD NAME:
REGULAR SOFT
Regular food that is
easy to chew.
Fruits and vegetables
continued
If thin liquids allowed, also
may have: any fruit juices.
NO dried fruits
NO popcorn
All cooked, tender vegetables
okay. Shredded lettuce okay.
Desserts: All okay, except:
NO nuts, seeds, coconut, or
chewy caramel. If thin liquids
allowed, also may have:
Malts, milk shakes, frozen
yogurts, ice cream, and other
frozen desserts. Nutritional
supplements, gelatin, and
any other desserts of thin
liquid consistency when in
the mouth.
Dysphagia Ground Or
“Mechanically-Altered”
(DYSPHAGIA II DIET)
OLD NAME:
MECHANICAL SOFT
Soft-cohesive food
with ground meat and
extra gravy to make
the meat moist.
NO corn, peas, beans,
asparagus, or non-tender
veggies
Canned peaches, pears,
stewed tomatoes okay, but
DRAIN OUT liquid
NO raw fruit, except banana
Soft desserts okay:
Soft Pies with whipped
cream, soft cookies, cakes
with icing, donuts okay
No sticky food items,
popcorn, corn chips, nuts,
seeds, coconut, chewy
caramel or dried fruit
Dysphagia Puree
(DYSPHAGIA I DIET)
OLD NAME:
PUREE
All foods must be
pureed smooth.
Pudding, smooth yogurt,
custards, applesauce,
pureed desserts, soufflés,
smooth chocolate.
Ice cream*, sherbet*, fruit
ice*, Jello* if NOT on a thick
liquid
NO pickles or garnish NO pickles or garnish NO pickles or garnish
LIQUIDS:
Thin liquid
Nectar Thick liquid
Honey Thick liquid
Pudding Thick liquid
(also known as spoon-thick)
Prepare with thickener
powder or purchase prethickened liquids for Nectar
and Honey.
Beverages:
Any beverages, depending
on recommendations for
liquid consistency.
Ice chips.
If thin liquids allowed, also
may have: Milk, juices, coffee,
tea, sodas, carbonated
beverages, alcoholic
beverages if allowed,
nutritional supplements.
Source: © 2017 Academy of Nutrition and Dietetics, Nutrition Care Manual® [Accessed October 2017].
Adapted and reprinted with permission.
WATCH OUT:
Cream of wheat and soups
should be thick and smooth
if patient is on a thickened
liquid.
If in doubt, don’t give it to the
patient.
* If a patient is on a
thickened liquid:
• NO Ice cream, sherbet,
fruit ice, popsicles, and
Jello.
• NO mixed consistencies
(cold cereals, broth-based
soups, fruit cocktail cups)
• Ensure is thin liquid.
Make frappes in blender
•
with the liquid supplement
plus banana or yogurt to
thicken.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
e.
the collective “team,” while individual
specialists deliver their own expertise.
The patient benefits from multiple
exposures to variations of the same
treatment theme and begins to incorporate successful adaptations for their
individual condition.
Patients with dysphagia, with or
without aspiration, may experience a
change in normally established eating
habits. Issues related to safe nutrition,
eating with friends and family, eating
in public, alteration of normal routines, and the need for increased time
for feeding may become pressing. The
relationship between food and eating
to quality of life, perhaps universally, is
significant. Television has many advertisements emphasizing food; eating is
a major part of holiday or just social
activities. But for the dysphagic patient,
and others in their environment, eating
may be a stressful chore, not a pleasure.
Coping skills can be sorely challenged
during this time. Strategies for coping
with the changes and the stressors they
induce are a part of the patient education process, and the responsibility of
all dysphagia team members who have
contact with the patient working toward
the resolution of issues that can separate
rather than unite a family during a time
of illness. The goal is success with nutrition, whether it be oral or enteral.
STUDY QUESTIONS
1. What is the dietitian’s role in the
treatment of dysphagia?
a. Nutritional management
b. Oral and tube feeding recom-
mendations
c. Weight management
d. All of the above
a and c
2. Which of the below are indications
for placing a gastrostomy feeding
tube?
a. Progressive neurologic condition
with feeding difficulties leading
to compromise of nutrition
b. Head-injured patient who is ex-
pected to need tube feeding for
2 to 3 months who keeps pulling
and removing nasogastric tube
c. Patient who is expected to regain
safe and effective swallow function in 2 to 3 weeks and dislikes
how they look with a feeding
tube
d. All of the above
e. a and b
f.
b and c
3. When evaluating whether percentage of weight change is significant
or severe, both the rate of a person’s
weight change and the amount of
weight change are considered. True
or False.
4. Specific guidelines define whether
a patient’s percentage of ideal body
weight characterizes them as having mild, moderate, or severe malnutrition. True or False.
5. The following elements compose a
nutritional assessment:
a. Anthropometric data
b. Laboratory data
c. Nutrition history
d. Clinical and physical finding
e. Financial analysis
f. All of the above
g. a, b, c, and d.
6. There is clear agreement among
dysphagia professionals concerning which food fluids are thin,
nectarlike, or honey-like and how
to describe textural diets. True or
False.
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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311
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