xRead - Swallowing Disorders in the Adult Patient (October 2024)
10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302, Wiley Online Library on [08/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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The development group likewise agreed that NPO status is not universally required for HNC patients ( Table 5 ; Statement 30). When aspiration is observed during a swallowing evaluation, common recommenda tions include dietary modi fi cations and avoidance of, or thickening of liquids. Although the use of free water protocols in HNC patients has not been speci fi cally studied, these data suggest that in carefully selected patients, it might be done safely under the supervision of a dysphagia specialist and could lead to improvements in QOL and hydration. 138 Education, Counseling, and Oral Care HNC patients and their caregivers should be alerted to recognize signs of aspiration, such as choking, throat clearing, or dif fi culty eating, and report them promptly to their dysphagia specialist. Choking that progresses to airway obstruction is a life ‐ threatening event. There was consensus that counseling for HNC patients and caregivers should include education regarding aspiration precautions and the Heimlich maneuver (Table 5; Statement 41). While most are familiar with the Heimlich maneuver as performed by a rescuer, patients can also be taught to self ‐ administer whereby gravity and a chair back (or railing) are used to provide thrust to the abdomen. 139 Pavitt and colleagues completed a study comparing the ef fi cacy of experimenter ‐ performed Heimlich compared to self ‐ performed Heimlich. Their limited study found that self ‐ administered Heimlich over a chair back resulted in greater peak esophageal pressures than the Heimlich maneuver performed by another individual. Concerns related to the injury should be considered against the risk of morbidity and mortality from airway obstruc tion, and those risks must be included in patient education. For patient safety and ef fi cacious medication delivery, there was consensus that HNC patients and caregivers be educated on the nuances of medication administration via feeding tube and that the expertise of clinical pharmacists should be utilized (Table 5; Statement 42). HNC patients with dysphagia may be reliant on feeding tubes for nutrition and medication administration. Incorrect medication administration through a feeding tube can lead to reduced drug ef fi cacy, increased risk for toxicity, increased adverse effects, and tube obstruction. 140 The American Society for Parenteral and Enteral Nutrition developed evidence ‐ based guidelines for safe medication admin istration. 129 Among medications that cannot be safely administered via feeding tube are sustained ‐ release medications, enteric ‐ coated medications, and most proton pump inhibitors. 141 A comprehensive “ Do Not Crush ” list may be found on the Institute for Safe Medication Practices website (https://www.ismp. org/recommendations/do-not-crush).
There was also a strong consensus that HNC patients and their caregivers should be instructed to self ‐ assess nutrition and hydration status throughout treatment and recovery (Table 5; Statement 43). Dysphagia, in combina tion with other acute toxicities, such as odynophagia, dysgeusia, and mucositis, can increase the risk for dehydration and malnutrition, especially during and immediately after chemoradiation. 142 Malnutrition and dehydration are associated with adverse outcomes such as lower tolerance for cancer treatment, unplanned treat ment interruptions, poor quality of life, and decreased survival. 143 Although self ‐ assessment of nutrition and hydration status is not precise, it may be useful in the early identi fi cation and intervention of adverse effects. Measuring hydration status is dif fi cult due to the complex systems involved in fl uid regulation. Although urine color monitoring may not be an accurate measure of hydration in clinical situations, it is a useful and readily apparent tool for patients and caregivers to use in the home environment. 144 The development group reached a consensus on the bene fi t of HNC patient and family education in oral care to reduce the adverse effects of dysphagia (Table 5; Statement 16). There was agreement on consistent daily oral care to reduce the risk of aspiration pneumonia in HNC patients with dysphagia (Table 5; Statement 44). Effective oral care routine for HNC patients extends beyond brushing and fl ossing the teeth. Reduced auto debridement of the oral cavity due to a texture ‐ modi fi ed diet can lead to an overgrowth of bacterial fl ora. The resultant bacterial fl ora is not typically seen in a healthy mouth, and usually consists of Gram ‐ negative bacteria common to phlegm and epithelial residue. 145 Mechanical debridement of the tongue and palate, in addition to brushing and fl ossing, has been shown to reduce pneumonia risk in HNC patients with dysphagia and may increase cough re fl ex. 146 Lymphedema Therapy Lymphedema is a pathologic accumulation of lymph fl uid in the interstitial tissue resulting from an inability of the lymphatic system to transport lymph fl uid from the tissue to the central circulatory system. 147 Among HNC patients, external lymphedema manifests as soft tissue swelling while internal lymphedema affects the mucosal ‐ lined structures of the aerodigestive tract. Both internal and external lymphedema is associated with greater patient perception of dysphagia, laryngeal penetration/ aspiration, and diet modi fi cation. 148,149 Preliminary stu dies suggest that manual lymph drainage, combined with stretching and swallowing exercises, may improve lym phedema and dysphagia symptoms in HNC survivors. Although prospective studies de fi ning best practices for the management of lymphedema and dysphagia related to internal lymphedema are lacking, 150 there was strong consensus among panel members that lymphedema
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