Commentary

Safe feeding methods in stroke patients

Swallowing dysfunction after stroke is common, but there is little reliable evidence for how the disorder should be managed. This study compared standard low-intensity and high-intensity behavioural interventions with usual care for dysphagia.

306 patients with clinical dysphagia admitted to hospital with acute stroke were randomly assigned to receive usual care (n=102), prescribed by the attending physician; standard low-intensity intervention (n=102), comprising swallowing compensation strategies and diet prescription three times weekly for up to a month; or standard high-intensity intervention and dietary prescription (n=102), at least daily for up to a month. The primary outcome measure was survival free of an abnormal diet at 6 months. Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00257764.

60 patients died and three patients were lost to follow up before the 6-month analysis. Of patients randomly allocated usual care, 56% (57/102) survived at 6 months free of an abnormal diet compared with 67% (136/204) allocated standard swallowing therapy (relative risk 1·19, 95% CI 0·98–1·45). Standard swallowing therapy was associated with a non-significant trend toward a reduction in death (0·80, 0·5–1·3), institutionalisation (0·69, 0·4–1·1), and dependency (1·05, 0·8–1·3); a significant reduction in swallowing-related medical complications (0·73, 0·6–0·9), chest infection (0·56, 0·4–0·8), and death or institutionalisation (0·73, 0·55–0·97); and a significant rise in the proportion of patients regaining swallowing function (1·41, 1·03–1·94) by 6 months. Compared with usual care and low-intensity therapy, high-intensity therapy was associated with an increased proportion of patients who returned to a normal diet (p=0·04) and recovered swallowing (p=0·02) by 6 months.

These data show a consistent trend towards more favourable outcomes in dysphagic stroke patients who are assigned a standard programme of early behavioural swallowing intervention, including active therapeutic approaches and dietary modification.

Offering and recommending PEG tube placement to patients has been a topic of considerable interest in the medical literature. The role of individual health care professionals in the decision making process is poorly defined. PEG tubes are often placed inappropriately because of unrealistic and inaccurate expectations of what they can accomplish in patients unable to tolerate adequate oral intake. We have developed an algorithm for PEG placement for the geriatric, oncology, and neurology patients based on a critical review of current literature.

An extensive review of the literature was performed focusing on PEG tube placement in oncology, neurology, and geriatric patients. This algorithm was developed to provide both the primary care provider and the specialist with appropriate indications for PEG placement in these patient populations.

Appropriate indications for PEG placement are 1) Esophageal obstruction (e.g., esophageal cancer), 2) Neurologic etiology of dysphagia without obstruction (e.g., status post cerebrovascular accident, pseudobulbar palsy), 3) Prolonged refusal to swallow without evidence of concomitant terminal illness (e.g., protracted pseudodementia due to severe depression), 4) Supplemental nutrition for patients undergoing chemotherapy or radiation therapy.

If no physiologic benefit is expected with PEG placement (anorexia-cachexia syndrome), the health care team has no obligation to offer or perform an intervention. This same principle would apply if intervention improves physiologic states but has no effect on quality of life (e.g., permanent vegetative state). Small-bore feeding tubes are cost effective and relatively safe for enteral feedings of up to 6–8 weeks. This is especially pertinent in the population with acute neurological deficits, in which prognostication on extent of impairment is best estimated by communication with neurologist. In the geriatric population there is no proved benefit in weight gain or markers of nutrition (albumin, prealbumin) in patients with malnutrition due to impaired oral intake.