Introduction
In general, acute dysphagia is treated with active rehabilitation of dysphagia therapy (RDT). On the other hand, chronic dysphagia treatment tends to focus on minimizing complications rather than undergoing active RDT. For this reason, only few studies have been conducted on the effect of RDT in chronic dysphagia patients in Korea. This case is a chronic brain injury patient who successfully removed the nasogastric tube (NGT) after receiving persistent active RDT as a management of aspiration pneumonia due to exacerbated dysphagia. Through this, we would like to emphasize the situations where RDT is necessary and its importance in chronic brain injury patients with dysphagia.
Case presentation
In 2008, a 48-year-old man with insignificant past medical history came to our institution with traumatic brain injury accompanied by dysphagia after a vehicle-pedestrian crash. The patient started NGT feeding and underwent active RDT. In 2009, RDT was discontinued as the patient was able to tolerate a general diet. However, in March 2019, NGT was re-inserted into the patient due to aspiration pneumonia. On April 24, 2019, the patient was admitted in our institution to undergo RDT, judging that his dysphagia could improve as he had no difficulty eating prior to the incidence of aspiration pneumonia. On the 6th day of hospitalization (April 30, 2019), Video Fluoroscopic Swallowing Study (VFSS) was performed and revealed 20 seconds for oral phase and 1.5 seconds for pharyngeal transit time. In addition, aspiration was detected with 4/8cc of liquid, but unremarkable with semisolid food. Based on these findings, a level 1 dysphagia diet was attempted while maintaining the NGT along with balloon swallowing, compensatory therapy, and functional electrical stimulation (30min/6 times/week, at 6mA/6mA). After gradually intensifying RDT, the patient underwent another VFSS on May 21, 2020, which showed unremarkable findings in 4cc of liquid. The patient was also tolerable with level 1 dysphagia diet with sufficient oral intake, thus he was discharged from the hospital after removal of NGT.
Conclusion
This chronic brain injury patient with dysphagia showed marked improvement in dysphagia after active RDT and functional electrical stimulation, and was able to withstand the level 1 dysphagia diet after removal of the NGT. In the early stage of brain injury, active swallowing rehabilitation improved the patient's dysphagia, but aspiration pneumonia occurred as swallowing muscle function gradually deteriorated over time, which was once again improved by active RDT. Based on this case report, it is necessary to regularly evaluate dysphagia in patients with chronic brain injury, taking into account age-related changes in the swallowing mechanisms. It is also believed that early detection of dysphagia allows patients to undergo active RDT, thereby preventing complications such as aspiration pneumonia and further improving the patient's quality of life.
|
|
Figure 1. Bilateral lower lobe pneumonia was observed at Chest HRCT taken on May 22th, 2019
Figure 2. Aspiration was observed during VFSS with 4mL liquid diet on April 30th, 2019
Figure 3. No aspiration was observed during VFSS with 4mL liquid diet on May 21th, 2020
|
