Swallowing disorders in severe brain injury: risk factors affecting return to oral intake

OBJECTIVE: To determine the incidence and type of swallowing disorders that accompany severe brain injury and to identify factors that affect oral intake. DESIGN: Inception cohort study. SETTING: Level I trauma center. PATIENTS: Consecutively admitted patients with severe brain injury who achieved cognitive levels during admission to assess swallowing and who did not sustain injuries preventing swallowing assessment (n = 54). MAIN OUTCOME MEASURES: Type of swallowing abnormalities and presence of aspiration evident on videofluoroscopic swallow studies (VFSS), days to initiation and achievement of oral feeding, ventilation days, presence of a tracheostomy, and cognitive levels at initiation and achievement of oral feeding. RESULTS: Sixty-one percent of subjects exhibited abnormal swallowing. Loss of bolus control and reduced lingual control occurred most commonly. Aspiration rate was 41%. Normal swallowers achieved oral feeding in 19 days versus 57 days for abnormal swallowers. Rancho Los Amigos (RLA) Level IV was needed for initiation of oral feeding; Level VI was needed for total oral feeding. Risk factors for abnormal swallowing included: lower admission Glasgow Coma Scale (GCS) and RLA scores, presence of a tracheostomy, and ventilation time longer than 2 weeks. Risk factors for aspiration were lower admission GCS and RLA scores. CONCLUSIONS: Swallowing disorders and behavioral/cognitive skills are frequently present in patients with severe brain injury and significantly affect oral intake of food. Persons who swallow abnormally take significantly longer to start eating and to achieve total oral feeding, and they require nonoral supplementation three to four times longer than those who swallow normally.