Arquivo da categoria: Dysphagia Diet

The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review

Steele CM, Alsanei WA, Ayanikalath S, Barbon CE, Chen J, Cichero JA, Coutts K, Dantas RO, Duivestein J, Giosa L, Hanson B, Lam P, Lecko C, Leigh C, Nagy A, Namasivayam AM, Nascimento WV, Odendaal I, Smith CH, Wang H.

Dysphagia. 2015 Feb;30(1):2-26. doi: 10.1007/s00455-014-9578-x. Epub 2014 Oct 25.

consistencia alimento

Abstract

Texture modification has become one of the most common forms of intervention for dysphagia, and is widely considered important for promoting safe and efficient swallowing. However, to date, there is no single convention with respect to the terminology used to describe levels of liquid thickening orfood texture modification for clinical use. As a first step toward building a common taxonomy, a systematic review was undertaken to identify empirical evidence describing the impact of liquid consistency and food texture on swallowing behavior. A multi-engine search yielded 10,147 non-duplicate articles, which were screened for relevance. A team of ten international researchers collaborated to conduct full-text reviews for 488 of these articles, which met the study inclusion criteria. Of these, 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration-aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries or other quantifiable material properties related to these clinical outcomes. With respect to food texture, the literature pointed to properties of hardness, cohesiveness, and slipperiness as being relevant both for physiological behaviors and bolus flow patterns. The literature suggests a need to classify food and fluid behavior in the context of the physiological processes involved in oral transport and flow initiation.

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Viscosity changes in thickened water due to the addition of highly prescribed drugs in geriatrics

N. Garin, J. T. De Pourcq, D. Cardona, R. Martín-Venegas, I. Gich, J. Cardenete, M. A. Mangues

Nutr. Hosp., Ago 2012, vol.27, no.4, p.1298-1303. ISSN 0212-1611

ABSTRACT

Introduction: Dysphagia is a swallowing disorder with a high incidence in the geriatric patient related with an increased risk for undernutrition and pneumonia due to bronchial aspiration. In this condition, it is usual to add commercial thickeners in liquids, as well as the addition of drugs in this mixture to improve their administration. However, there are no studies regarding the possible change in viscosity produced by their addition.
Objectives: To assess the change in viscosity of water thickened with commercial products by adding the drugs frequently used in elderly patients.
Methods: Samples of water mixed with the commercial thickener Resource® (modified corn starch) or Nutilis® (modified corn starch, maltodextrin, and gums: tara, xhantan, and guar) to achieve an intermediate consistence as “honey”. The viscosity of these samples was measured as well as for similar samples to which one of the following drugs was added: galantamine, rivastigmin, ciprofloxacin, cholecalciferol, memantine, fosfomycin, calcium, and amoxicillin/clavulanic acid.
Results: In the samples with Resource® thickener we observed decreased viscosity by adding galantamine, memantine, fosfomycin or calcium, and increased viscosity with amoxicillin/clavulanic acid. The viscosity of the samples with Nutilis® decreased with galantamine, rivastigmine, amoxicillin/clavulanic acid, fosfomycin and calcium.
Conclusion: The viscosity of water with commercial thickeners may be affected by some drugs or their preservatives, which may influence the swallowing capability. It is recommended to perform further in vitro and in vivo studies in order to adjust these formulations if necessary.

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Cambios en la viscosidad del agua con espesantes por la adición de fármacos altamente prescritos en geriatría

N. Garin, J. T. De Pourcq, D. Cardona, R. Martín-Venegas, I. Gich, J. Cardenete, M. A. Mangues

Nutr. Hosp., Ago 2012, vol.27, no.4, p.1298-1303. ISSN 0212-1611

RESUMEN

Introducción: La disfagia es una alteración de la deglución con una elevada incidencia en el paciente geriátrico relacionada con un aumento del riesgo de desnutrición y neumonía por broncoaspiración. La adición de espesantes comerciales en líquidos es frecuente en esta situación, así como la adición de fármacos en esta mezcla para facilitar su administración. Sin embargo, no existen estudios referentes al posible cambio de viscosidad producido por la adición de los mismos.
Objetivos: Evaluar la variación ejercida sobre la viscosidad del agua espesada con preparados comerciales al añadir fármacos frecuentemente utilizados en pacientes de edad avanzada.
Métodos: Se prepararon muestras de agua con espesante comercial Resource® (almidón de maíz modificado) o Nutilis® (almidón modificado de maíz, maltodextrina y gomas: tara, xantana y guar) para conseguir consistencia intermedia tipo “miel”. Se midió la viscosidad de estas muestras y para muestras similares a las que se había añadido alguno de los siguientes fármacos: galantamina, rivastigmina, ciprofloxacino, colecalciferol, memantina, fosfomicina, calcio y amoxilina/clavulánico.
Resultados: En las muestras con espesante Resource® se observó una disminución de la viscosidad al añadir galantamina, memantina, fosfomicina o calcio, y un aumento de la viscosidad con amoxicilina/clavulánico. La viscosidad de la muestras con Nutilis® disminuyó con galantamina, rivastigmina, amoxicilina/clavulánico, fosfomicina y calcio.
Conclusión: La viscosidad del agua con espesantes comerciales puede verse afectada por algunos fármacos o sus excipientes, lo que puede incidir en la capacidad de deglución de los mismos. Es aconsejable realizar más estudios in vitro e in vivo para valorar ajustar dichas pautas en caso necesario.

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Viscosity changes in thickened water due to the addition of highly prescribed drugs in geriatrics

Garin N, de Pourcq JT, Cardona D, Martín-Venegas R, Gich I, Cardenete J, Mangues MA.

Nutr Hosp. 2012 Aug;27(4):1298-303. doi: 10.3305/nh.2012.27.4.5838. Spanish.

Abstract

Introduction: Dysphagia is a swallowing disorder with a high incidence in the geriatric patient related with an increased risk for undernutrition and pneumonia due to bronchial aspiration. In this condition, it is usual to add commercial thickeners in liquids, as well as the addition of drugs in this mixture to improve their administration. However, there are no studies regarding the possible change in viscosity produced by their addition. Objectives: To assess the change in viscosity of water thickened with commercial products by adding the drugs frequently used in elderly patients. Methods: Samples of water mixed with the commercial thickener Resource® (modified corn starch) or Nutilis® (modified corn starch, maltodextrin, and gums: tara, xhantan, and guar) to achieve an intermediate consistence as “honey”. The viscosity of these samples was measured as well as for similar samples to which one of the following drugs was added: galantamine, rivastigmin, ciprofloxacin, cholecalciferol, memantine, fosfomycin, calcium, and amoxicillin/clavulanic acid. Results: In the samples with Resource® thickener we observed decreased viscosity by adding galantamine, memantine, fosfomycin or calcium, and increased viscosity with amoxicillin/clavulanic acid. The viscosity of the samples with Nutilis® decreased with galantamine, rivastigmine, amoxicillin/clavulanic acid, fosfomycin and calcium. Conclusion: The viscosity of water with commercial thickeners may be affected by some drugs or their preservatives, which may influence the swallowing capability. It is recommended to perform further in vitro and in vivo studies in order to adjust these formulations if necessary.

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Tratamiento nutricional de la disfagia orofaríngea

La disfagia orofaríngea es un síntoma que aparece en diferentes patologías, habitualmente infravalorado, y que puede tener repercusiones graves para la salud y la calidad de vida de las personas que la presentan.

Es importante conocer su diagnóstico y su gravedad para establecer el plan terapéutico adecuado, cuyo objetivo es que el enfermo esté bien nutrido e hidratado con el mínimo riesgo de aspiración y el máximo bienestar.

El tratamiento nutricional (líquidos espesados, dietas con diferentes consistencias y texturas, nutrición enteral por sonda nasogástrica o gastrostomía) depende de la causa, las expectativas vitales, el nivel de conciencia y la calidad de vida del paciente.

Aunque es necesario conocer más y unificar criterios acerca de la disfagia, se sabe que los programas multidisciplinarios de evaluación y tratamiento reducen los riesgos y mejoran la calidad de vida de los pacientes.

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Consumo alimentar de crianças e adolescentes com disfagia decorrente de estenose de esôfago: avaliação com base na pirâmide alimentar brasileira

MARCIANO, Renata; SPERIDIAO, Patrícia da Graça Leite  e  KAWAKAMI, Elisabete.

Rev. Nutr. [online]. 2011, vol.24, n.2, pp. 233-241.

OBJETIVO: Avaliar o consumo alimentar de pacientes com disfagia decorrente de estenose de esôfago, comparando a dieta de consistência líquida com a dieta de consistência pastosa e sólida, com base na Pirâmide Alimentar Brasileira. MÉTODOS: Estudo de corte transversal, no qual foram incluídos consecutivamente 31 pacientes com estenose esofágica, sendo 18 (58,0%) cáustica, 7 (22,6%) pós-cirúrgica, 3 (9,7%) péptica e 3 (9,7%) sem causa definida. Empregou-se o recordatório de 24 horas; os alimentos foram transformados em porções em função dos oito grupos de alimentos, conforme recomendado por Philippi. Utilizou-se o teste Kruskal-Wallis e Exato de Fisher, fixando em 5% o nível de rejeição da hipótese de nulidade. RESULTADOS: A idade variou entre 15 e 176 meses (mediana, 56 meses), sendo 28 crianças e três adolescentes, e 18 do sexo masculino. Vinte e nove pacientes (93,5%) apresentavam disfagia, sendo grave em 34,4% (10/29), moderada em 41,3% (12/29), e leve em 24,1% (7/29). O consumo mediano de porções de cereais, leguminosas, e óleos e gorduras foi menor no grupo com dieta líquida (p<0,005), o qual também apresentou maior proporção de pacientes cujo consumo foi abaixo do proposto pela pirâmide alimentar quando comparado ao grupo com dieta pastosa e sólida, com diferença estatisticamente significante (p<0,05). CONCLUSÃO: O suporte nutricional é de extrema importância no tratamento de pacientes com estenose esofágica, principalmente na disfagia grave, cuja dieta deve ser adaptada à consistência líquida, devido ao risco nutricional que se atribui à limitada ingestão alimentar, e para que o tratamento dietético seja precocemente instituído.

Palavras-chave : Consumo alimentar; Estenose esofágica; Pirâmide alimentar; Transtornos de deglutição.

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Interventions for dysphagia and nutritional support in acute and subacute stroke

Geeganage C, Beavan J, Ellender S, Bath PM.

Cochrane Database Syst Rev. 2012 Oct 17;10:CD000323. doi:

Abstract

BACKGROUND:

Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome.

OBJECTIVES:

To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke.

SEARCH METHODS:

We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers.

SELECTION CRITERIA:

Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment.

DATA COLLECTION AND ANALYSIS:

Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial.

MAIN RESULTS:

We included 33 studies involving 6779 participants.Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I(2) = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I(2) = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I(2) = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I(2) = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I(2) = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I(2) = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I(2) = 92%).

AUTHORS’ CONCLUSIONS:

There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.

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Risk of aspiration in patients on enteral nutrition: frequency, relevance, relation to pneumonia, risk factors, and strategies for risk reduction

Mizock BA.

Curr Gastroenterol Rep. 2007 Aug;9(4):338-44.

Abstract

Upper digestive feeding intolerance, as evidenced by high gastric residual volume and vomiting, is the most common complication among hospitalized patients receiving enteral nutrition. These patients are at high risk of developing aspiration pneumonia, which in turn is associated with prolonged hospital stay and increased mortality. Most episodes of aspiration are small in volume and do not lead to pneumonia. The likelihood of pneumonia increases with multiple aspirations. Pneumonia is also more common in critically ill patients who have bacterial colonization of the oropharynx. Gastric residual volume is commonly used as a means to assess aspiration risk during tube feeding. However, recent studies have demonstrated that this measurement has limited sensitivity. The approach to minimizing the frequency of aspiration during tube feeding involves assessment of the patient’s degree of risk and initiation of appropriate measures directed at risk reduction.

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Are we testing a true thin liquid?

 

Fink TA, Ross JB.

Dysphagia. 2009 Sep;24(3):285-9. Epub 2009 Feb 21.

Abstract

The purpose of this study was to examine the effects on a patient’s swallowing of diluting E-Z-EM’s Varibar® Thin liquid barium product (which is often used in videofluoroscopic swallow studies) to achieve a consistency closer to water. Forty patients who were 18 years and older participated in this study. Their varied medical diagnoses included stroke, pneumonia, TBI, and cancer as well as diagnoses not usually associated with dysphagia such as abdominal pain and rhabdomyolysis. To screen for aspiration, E-Z-EM’s Varibar Thin liquid was presented to patients to swallow as 2 cc, 5 cc, cup, and straw drinking trials. If no aspiration occurred, the patient was given the Varibar Thin liquid diluted by 50% using water (referred to as Ultrathin) to swallow in the same amounts. Then occurrence of aspiration with the Ultrathin liquid was compared to the occurrence of aspiration when the patient swallowed the Varibar Thin liquid. Fifty percent of patients aspirated on the Ultrathin liquid but not on the Varibar Thin liquid, across at least one of the test conditions. From these results we suggest that although E-Z-EM Varibar Thin liquid may have a low-viscosity range, it still may not be “thin enough” to identify all patients who aspirate or who are at risk for aspiration on thin liquids.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

Gomes CA; Lustosa SA; Matos D; Andriolo RB; Waisberg DR; Waisberg J

Gastrointestinal Surgery, UNIFESP, Sao Paulo, Sao Paulo, Brazil.

Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

Abstract

BACKGROUND:

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES:

To evaluate the effectiveness and safety of PEG as compared to NGT for adults with swallowing disturbances.

SEARCH STRATEGY:

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to August 2009, as well as contacting main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA:

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failures (feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS:

Review authors performed selection, data extraction and evaluation of methodological quality of studies. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I(2) > 50%.

MAIN RESULTS:

We included nine randomised controlled studies. Intervention failure occurred in 19/156 patients in the PEG group and 63/158 patients in the NGT group (RR 0.24 (95%CI 0.08 to 0.76, P = 0.01)) in favour of PEG. There was no statistically significant difference between comparison groups in complications (RR 1.00, 95%CI 0.91 to 1.11, P = 0.93).

AUTHORS’ CONCLUSIONS:

PEG was associated to a lower probability of intervention failure, suggesting the endoscopic procedure is more effective and safe as compared to NGT. There is no significant difference of mortality rates between comparison groups, and pneumonia irrespective of underlying disease (medical diagnosis). Future studies should include previously planned and executed follow-up periods, the gastrostomy technique, and the experience of the professionals to allow more detailed subgroup analysis.