Management of dysphagia
=======================

* Roy M. Preshaw

Hillel Finestone and Linda Greene-Finestone1 note that “if the risk of aspiration is high, enteral nutrition (tube feeding) should be provided.” Unfortunately, there is little evidence to support the implication that enteral nutrition through a tube reduces the risk of aspiration pneumonia. Tube feeding does not afford protection against aspiration of oropharyngeal secretions, which may be colonized. The incidence of aspiration pneumonia is similar in subjects fed by nasogastric tube, gastrostomy or postpyloric tube.2,3,4,5,6 None of the cited studies compared the incidence of aspiration pneumonia among subjects receiving enteral nutrition with that among patients fed intravenously.

Finestone and Greene-Finestone1 identify complications of enteral nutrition in their online Appendix 2,7 noting that several of these may be life-threatening. There appears to be a need for good quality-of-life studies of stroke subjects with dysphagia randomly assigned to various feeding and hydration techniques. As the authors have already shown,8 such studies are made more difficult by the spontaneous recovery of swallowing in almost two-thirds of subjects within 2 to 4 months.

**Roy M. Preshaw** Lady Minto Hospital Salt Spring Island, BC

## References

1.  1.Finestone HM, Greene-Finestone LS. Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. CMAJ 2003;169(10):1041-4.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY5LzEwLzEwNDEiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTcwLzcvMTA3OS4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2.Park RH, Allison MC, Lang J. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persistent neurological dysphagia. BMJ 1992; 304:1406-9.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMDQvNjgzOS8xNDA2IjtzOjQ6ImF0b20iO3M6MjM6Ii9jbWFqLzE3MC83LzEwNzkuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  3.Baeten C, Hoefnagels J. Feeding via nasogastric or percutaneous endoscopic gastrostomy: a comparison. Scand J Gastroenterol Suppl 1992;194:95-8.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1298056&link_type=MED&atom=%2Fcmaj%2F170%2F7%2F1079.2.atom) 

4.  4.Strong RM, Condon SC, Solinger MR, Nahimas BN, Ito-Wang LA, Leuty JE. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. JPEN J Parenter Enteral Nutr 1992;16:59-63.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BwZW4iO3M6NToicmVzaWQiO3M6NzoiMTYvMS81OSI7czo0OiJhdG9tIjtzOjIzOiIvY21hai8xNzAvNy8xMDc5LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

5.  5.Spain DA, DeWesse RC, Reynolds MA, Richardson JD. Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications. J Trauma 1995;39:1100-2.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00005373-199512000-00015&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7500401&link_type=MED&atom=%2Fcmaj%2F170%2F7%2F1079.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995TL90500015&link_type=ISI) 

6.  6.Fox KA, Mularksi RA, Sarfati MR. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg 1995;170:564-6.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0002-9610(99)80016-6&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7492001&link_type=MED&atom=%2Fcmaj%2F170%2F7%2F1079.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995TH94200008&link_type=ISI) 

7.  7.Finestone HM, Greene-Finestone LS. e-Appendix 2: Enteral nutrition (tube feeding) [online]. *CMAJ* 2003;169(10). Available: [www.cmaj.ca/cgi/data/169/10/1041/DC1/1](http://www.cmaj.ca/cgi/data/169/10/1041/DC1/1) (accessed 2004 Jan 23).
    
    

8.  8.Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW. Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors. Arch Phys Med Rehabil 1995;76:310-6.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0003-9993(95)80655-5&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7717830&link_type=MED&atom=%2Fcmaj%2F170%2F7%2F1079.2.atom)