‘time is of the essence’: proactive vs reactive tube feeding and swallowing outcomes with head...

‘Time is of the essence’: Proactive vs Reactive Tube

feeding and swallowing outcomes with

Head and Neck Cancer Patients

Rachelle Robinson(Prince of Wales Hospital)

Anne Spencer(Liverpool Hospital)

On behalf of NSW H&N EBP Group

EBP Showcase Dec 2014

New EBP Group in the Network

H&N Speech Pathology EBP Group Newly formed EBP group in 2014 that is part of NSW Speech Pathology EBP Network2 EBP Leaders and 1 Academic Link from Sydney Uni & 18 speech pathologists as members12 sites in NSW critiqued papers (8 sites in Sydney; Also in Tweed Heads, Coffs Harbour, Wollongong, Newcastle)Conducted over 7 Teleconference meetings in 2014 organised through TelstraFunding of these TC meetings rotated between members


In head and neck cancer patients having chemo-radiation therapy, does

prophylactic vs reactive tube feeding result in improved functional oral intake?


What does a typical H&N patient look like

(on the inside) who speech pathology would

manage?


Barriers to Oral Intake: Needs Multi-Disciplinary

Management

• Odynophagia• Dysphagia• Poor appetite / nausea• Xerostomia/ saliva changes• Impaired/ altered taste• Impaired dentition• Trismus• Fatigue


Timing of feeding tube placement is challenged

Traditionally mainly Reactive Feeding Tubes

Previous belief re prophylactic PEGs:-Stop swallowing/NBM “Learned non use of swallowing” & the patients end up with long term dysphagia and worse swallowing outcomes.

When reactive NGTs are used: Remember that tube in area of radiation therapy fields and impacts on swallow/patient comfort


Do prophylactic feeding tubes (vs reactive) have a

positive or negative impact on swallowing/oral intake

outcomes?

Group identified and read 27 papers.

10 suitable to critique & include in CAT.


Clinical Bottom LineNO conclusive evidence of improved functional oral intake in the short or long term with use of a prophylactic feeding tube placement compared to reactive feeding tube.


Weaknesses in Methodology

Eligible studies for this review were wrought with methodological weaknesses, such as:

Group selection bias (i.e. prophylactic tubes placed for patients with more severe swallowing problems at baseline)

Lack of descriptive criteria for patient selection and timing of reactive feeding tubesInconsistent reporting of dysphagia intervention and speech pathology involvement Use of very generalised or ‘crude’ measures of dysphagia and oral intake


Clinical Bottom Line (ctd)

There is no reported deterioration in functional oral intake for patients who continued oral intake and/or continue swallowing exercises, while feeding tubes were insitu.

Placement of a prophylactic or reactive tube does not negatively impact functional oral intake.

Instead the severity of dysphagia at baseline, tumour staging, field of RTx and other factors determine swallow


What does this mean for our clinical

practice??

We cannot say that putting in prophylactic feeding tubes improves functional oral intake in short or longer term


What does this mean for our clinical practice???

Patients with prophylactic feeding tubes must continue to eat and drink throughout their

treatment

And/Or a range of exercises implemented pro-actively to prevent any further dysphagia


Implications for Service Delivery

• Being mindful that pts with prophylactic feeding tubes, need to be seen during and after their RT +/- CT

• Impacts of service delivery in metropolitan, rural and remote hospitals.


Where to from here?We completed a review of our newly established EBP Group using Survey Monkey at end of 2014 meetings

Key Findings: Meeting:-

Day & time, (70%) duration (100%) and frequency (90%) suited the majority


Key Findings from survey (ctd)

New styles of:-Service delivery method for meeting (teleconference, 100%) Information dissemination (Wiki, 90%) were liked by the majoritySome small teething issues (cost of teleconference issue for 1 member and issues with Wiki access for 2 members)

>75% of members saw Academic Link’s role in the group included completion of CATs, CAPs and in the provision of education to membersOnly those going on leave were those planning not to be members in 2015


Clinical Question 2015We are planning on revisiting our 2009 clinical question around:- Prophylactic exercises in patients having radiation +/- chemotherapy? There is more recent research emerged and also potentially looking at:

Benefits of swallow therapy in the H&N CRT population?Prophylactic versus reactive swallowing exercisesRegimes and compliance ratesSpecific exercises of focus


Thanks to our group members who were all

‘Active’ and Wonderful!!Molly BarnhartSophie ChandlerVirginia SimmsKatrina BlythEmma ChartersDanielle StoneElise Hamilton-FosterJessica Cooke

Katherine KellyArmalie MullerJessica BoehmTherese DoddsDr Hans BogaardtAmanda BaileyAsta FungJenna BinsteadElizabeth Walker


References of papers included in CAT

Sheth, C. H, Sharp, S., & Walters, E. R. (2013) Enteral feeding in H&N cancer pts at a UK cancer centre. Journal of Human Nutrition & DieteticsMorton, Crowder et al (2009) . Elective gastrostomy, nutritional status and QOL in advanced H&N Ca pts receiving CRT. ANZ J SurgLangmore, Krisciunas et al (2011) Does PEG use cause dysphagia in H&N Cancer? Dysphagia Ames, Karnell et al (2011) Outcomes after the use of gastrostomy tubes in patients whose H&N cancer was managed with RT. Head & NeckCorry, Poon et al (2009). Prospective study of PEG tubes vs. NGT for enteral feeing in patients with H&N Cancer undergoing (C)RT. Head & NeckSilander, Nyman et al. (2012) Impact of PEG on malnutrition and QOL in patients with H&N cancer – a randomised study. Head & NeckOozer, Corsar et al. (2011) The impact of enteral feeding route on patient-reported long term swallowing outcome after CRT for H&N cancer. Oral OncologyWilliams & Teo et al (2012) Enteral feeding outcomes after CRT for oropharyngeal cancer: a role for a prophylactic gastrostomy. Oral oncologyPrestwich & Teo et al. (2014). Long-term swallow function after CRT for oropharyngeal cancer: the influence of prophylactic gastrostomy or reactive nasogastric tube. Clinical oncologyChen et al (2009). Evaluating the role of prophylactic gastrostomy tube placement prior to definitive CRT for H&N Cancer. Head & Neck


‘time is of the essence’: proactive vs reactive tube feeding and swallowing outcomes with head...

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