Swallowing, nutrition and PEG feeding: deciding, doing and managing

Swallowing, nutrition and PEG feeding: deciding, doing and managing

Swallowing in MND Dysphagia disruption in the swallowing process In MND can be variable depending on type Bulbar MND - faster progression Other types difficulties later on/slow deterioration

SLT Role Baseline assessment of current ability Self management strategies Bolus size, sip size, specialist cups, positioning, mindful swallowing, medication Information on what to expect Joint working with Dietetics

Avoid Modify Continue Most difficult to swallow Lasagne Easiest to swallow

Promoting early decision making tube feeding MND team instigate early conversations Evidence base - ProGas study key recommendation early gastrostomy before substantial weight loss that might not be reversible Patient Information PEG feeding leaflet Difficult decision to make before swallowing becomes an issue Can be made too late if wait until have many difficulties Feeding at risk decision

Feeding at risk Patient usually has the capacity to make this decision early on patient choice Expect increased difficulty in swallowing No PEG/other tube feeding in the future Continue oral feeding accepting the risks involved

Feeding at risk Food or fluids can go down the wrong way due to a poor swallow - aspiration Choking episodes Chest infections and aspiration pneumonia Weight loss

Management in feeding at risk Advice and training for dysphagia management Continue dietary modifications, positioning, feeding techniques Good oral hygiene Management of choking seek medical advice and further training if necessary Resuscitation Council (UK) guidelines Regular monitoring by MDT of patient s weight, hydration, nutrition and occurrences of aspiration

Terminology for modified diet/fluid Currently - National Food and fluid descriptors Fluids Normal, Stage1 (syrup/slightly thick),stage 2(thick custard), Stage 3(very thick/jelly) Food Normal, Texture E (soft moist/fork mashable), Texture D (finely minced/ mashed), Texture C (thick puree), Texture B (thin puree)

Terminology for modified diet/fluid By April 2019 - International descriptors in use IDDSI International Dysphagia Diet Standardisation Initiative Watch this space!

IDDSI

PEGs (Percutaneous Endoscopic Gastrostomy) Deciding, Doing and Managing Karen Haigh Nutrition Nurse

What is a PEG? An opening created from abdominal wall into the stomach. PEG tube inserted to administer feed, fluid and medications. Indicated where longer term (> 4 weeks) nutrition support is required. Usually inserted in Endoscopy under sedation.

Consideration for procedure Early referral to Gastroenterologist:- What is a PEG How is it inserted: risks of procedure/contraindications Care of PEG tube post insertion Most appropriate environment for placement

Consideration for procedure Endoscopy or theatres; dependant on respiratory function: Assessment for PEG placement for patient with MND Low/Medium/High traffic light pathway to assess safest placement area: Low: endoscopy under sedation Medium:? Endoscopy /? Theatres dependant on respiratory Consultant opinion High: Theatres with anaesthetic cover

Pre-insertion prep Able to tolerate endoscopy Previous abdominal surgery MRSA screening: nose/groin/axilla Stop anticoagulation Clotting screen: INR <1.3 Pre-insertion antibiotic prophylaxis Consent Consider discharge arrangements

Procedure Endoscopy first to check anatomy. Position for PEG located by Consultant. Small incision to abdomen under local anaesthetic using aseptic conditions. Needle and wire inserted into stomach and snared by Endoscopist. PEG tube attached to wire and pulled via mouth, through oesophagus into stomach and out via abdomen. External fixator and y end attached.

Post insertion care Regular post procedure monitoring: TPR, NEWS and PEG insertion site Clean aseptically for first 48 hours. Feeding as per Dietetic regimen. 45 o angle for feeding episodes. Mouthcare. Analgesia once local anaesthetic has worn off. Daily cleaning of insertion site. Make sure external fixator maximum 5mm from abdominal wall After 4 weeks commence daily rotation and weekly advance and rotate to prevent buried bumper syndrome.

Complications On Insertion Aspiration After Insertion Blockage Infection Tube pulled out: see flowchart Perforation / peritonitis Leakage from around tube Bleeding Pressure damage from external fixator: weight gain / loss Buried bumper syndrome

Balloon Gastrostomy Tubes (BGT) Occasionally RIG. Most often used as replacement for PEG in MND patients. Internal bumper water filled balloon. Weekly water changes in balloon followed by position check. 3 monthly routine tube changes.

Resources for care of PEG tube Gastrostomy Pathway Guidelines PEG patient information leaflet PEG integrated care pathway Procedure for the unplanned replacement of gastrostomy tube Nutricia Nurse in community Hospital Nutrition Nurse Telemedicine

Nutrition and MND Nick Bergin Specialist Nutrition Support Dietitian and Acute Team Leader

Nutritional facts Nutrition support plays a key role in the management of MND Malnutrition in MND increases the risk of death by 7 fold 6-53% of MND patients found to have BMI <18.5 At time of diagnosis each 5% decrease in weight associated with a 30% increase in risk of death Nutritional status is an independent prognostic indicator

MND where dietary intervention can help Early referral to dietetics Modified textures specific to the individual Tube feeding Constipation Muscle weakness weakness Reassurance

Nutritional assessment and requirements Nutritional assessment: Weight/height/BMI Diet history Social and medical history Symptoms Nutritional requirements: Age, sex, activity levels, other comorbidities Hypermetabolic about 10% Increases as disease progresses

Nutritional management Specific and tailored to the individual Disease progression Food fortification - Texture appropriate - Nutrient dense - Wide variety of foods - Easy to prepare - Enjoyment and pleasure

Food and drink fortification Enriching the diet Making the most of each mouthful: - Full fat milk - Skimmed milk powder - Butter, cheese, cream, - Jam, honey, sugar - Milky puddings - Avoiding low fat products Airedale NHS Foundation Trust, Department of Dietetics, have a selection of dietary leaflets on Aireshare

Tube feeding Specific to individual needs Pump vs bolus Amend as needed Mouth care if NBM Consider who will be doing this? patient, carer, relative, District Nurses

Dietetics and MND at Airedale Works closely with other healthcare professionals Dietitian attends MND clinic Outpatient appointments Home visits for those patients with PEGs Early referral to dietetics is essential