xRead - Swallowing Disorders in the Adult Patient (October 2024)

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Otolaryngology – Head and Neck Surgery 168(4)

reactively versus proactively, proactively managed co horts demonstrate reduced feeding tube use during treatment, shorter duration of feeding use posttreatment, maintenance of some oral intake at the conclusion of treatment, and more favorable swallowing func tion. 12,77,121,122 The development group recognized that a variety of devices designed to augment the intensity of behavioral swallowing hold promise (Table 5; Statement 48). Many such devices are available and include expiratory muscle strength training, electromyography, resistive tongue ‐ strengthening apparatuses, and electrical stimulation among others. The widespread use of these devices requires supporting evidence from trials that address underlying dysphagia pathophysiology (Table 5; Statement 49). Diet Allocation and Feeding Tubes The development group agreed that nutrition supplemen tation via a feeding tube is appropriate in certain HNC patients. There was strong consensus supporting enteral feeding in HNC patients who are unable to safely maintain adequate oral nutrition (Table 5; Statement 12). The optimal timing of feeding tube placement (prophylactic vs reactive) is debated due to a lack of high ‐ quality randomized controlled trials. 123,124 The NCCN Clinical Practice Guidelines in Oncology recom mend pretreatment prophylactic feeding tube placement for HNC patients undergoing chemoradiation therapy who have severe weight loss, dehydration, dysphagia, or other conditions impacting safe and adequate oral intake because it may lessen the negative impacts of treatment. 88 Pretreatment feeding tube placement is not suggested for those at lower risk, but thorough monitoring for nutritional decline is strongly encouraged. 88 As such, there was strong consensus supporting pretreatment feeding tubes for HNC patients with baseline malnutri tion or signi fi cant swallowing impairment (Table 5; Statement 26). An important added bene fi t of a prophy lactic feeding tube 125 is the reduction in treatment breaks for reactive placements, which may lead to an adverse oncologic outcome. 125 Concerns exist that prophylactic placement may delay tube removal and return to eating, resulting in worse quality ‐ of ‐ life and even worse long ‐ term dysphagia. 126 However, studies generally rebuke this theory, neither fi nding a signi fi cant difference in long ‐ term feeding tube dependency nor an increased risk of long ‐ term dysphagia. 126 ‐ 128 A randomized study of prophylactic versus reactive feeding tubes from Sweden showed no difference in any patient ‐ reported quality ‐ of ‐ life or functional endpoints 1 to 8 years following HNC treatment. Still, additional high ‐ quality randomized trials are needed to more de fi nitively answer this question. 125 There was agreement among the expert development group that HNC patients' ability to maintain their weight and hydration via oral diet was essential prior to

discontinue enteral feeding (Table 5; Statement 47). Practical recommendations for transitioning from enteral nutrition to an oral diet are provided by the Enteral Nutrition Safe Practices Consensus Recommendations of the American Society of Parenteral and Enteral Nutrition. 129 A long ‐ accepted algorithm recommends that HNC patients consume 75% of their nutrition requirements orally for 3 days before enteral nutrition is ceased. 130 Incremental decreases in both enteral nutrition volume and administered hours help support acceptable nutrient intake during the transition. Documentation of intake helps ensure the patient can completely wean from enteral nutrition to an oral diet. Key parameters for ongoing monitoring are nutrition and hydration status with weight and oral intake measured weekly. Fostering a patient ‐ centered approach to the feeding transition by involving the HNC patient and/or caregivers can assist with achieving goals, and multidisciplinary collaboration ensures that patients can consistently and safely meet their needs through oral nutrition in the context of the overall oncology plan. There was a strong consensus that oral intake is encouraged in HNC patients if judged by a dysphagia specialist to be low risk for consequences of aspiration (Table 5; Statement 23). While data demon strate an increased risk of development of aspiration pneumonia in patients with HNC compared to controls, the proportion of HNC survivors developing aspiration pneumonia remains low when compared to the number of patients with dysphagia. 131,132 Furthermore, prolonged NPO status has been shown to increase both dysphagia severity and risk of death. 133,134 Factors associated with an elevated risk of developing aspiration pneumonia include age >80 years, hypopharyngeal primary, ad vanced tumor stage, and chemoradiation. Additionally, comorbid conditions like neuromuscular disease and esophageal disorders may be associated with an elevated risk of pneumonia. 135 There was strong consensus among the development group that the identi fi cation of appropriate textures and liquids for safe consumption is critical for HNC patients with dysphagia (Table 5; Statement 25). Determining the most appropriate diet by dysphagia specialists often requires instrumental assessment of swallowing phy siology, safety, and ef fi ciency. 43 Although there is limited data on the HNC patient population, the impact of diet modi fi cations on outcomes has been shown to reduce pulmonary complications and length of stay in other dysphagic populations. 136 Appropriate diet modi fi cation may contribute to less patient fear and anxiety about choking. 137 The International Dysphagia Diet Standardization Initiative diet levels describe a continuum of 8 levels from a thin liquid to regular solids. 116 Use of these descriptors is suggested to improve communication between clinicians as patients move across levels of care and facilities.

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