Nutrition In Critical
Dr. Doha Rasheedy
lecturer of geriatric medicine
Geriatrics Intensive care unit
Geriatric medicine department
Ain Shams University
Clinical scenario 1
• Female patient: 18-year-old
• No past medical history.
• She was admitted to ICU with suspected
• ventilated and requires complete nutritional
• Her temperature is 39ºC.
• Her height and weight have been recorded (1.60
• As far as is known, the patient has a stable
weight and has no history of weight loss.
Clinical scenario 2
• 61 year old white female.
• sharp pain in her stomach For the last 6 months. for the last 3
weeks the pain has become severe enough that she hasn't been
able to work. Her appetite has diminished and she noticed she is
losing weight. She finally went to the doctor.
• Height 5'3" weight 144Ibs. During her visit to the doctor, she
discovered she had lost 15 lbs and weighed 129 lbs.
• Some blood work and a UGI series were done. The UGI revealed
a tumor in her stomach. she was admitted into the hospital for
removal and biopsy of the tumor. It was found to be malignant
with metastases. she remained in the hospital while
chemotherapy and radiation therapy were begun. she could not
tolerate enteral feeding at this time.
Clinical scenario 3
• 84 year old man who was admitted with a
diagnosis of CVA. He is 70 inches tall and
weighs 153 lbs. with a usual weight of 180 lbs.
After the first 36 hours of admission, his
voluntary intake is reported to be very poor.
He is unable to communicate with caregivers
and family and has marked difficulty
Seven simple questions
• Why do we feed ICU patients?
• Which patients should we feed?
• When should we start to feed them?
• Which route should we feed by?
• How much feed should we give?
• What should the feed contain?
• How to monitor the patient?
1(Why feed ICU patients?
• Critically ill patients high risk for malnutrition.
Consequences of malnutrition:
• Increased morbidity and mortality.
• Prolonged hospital stay.
• Impaired tissue function and wound healing.
• Defective muscle function, reduced respiratory and
• Immunosuppression, increased risk of infection.
• CIPs lose around 2%/day muscle protein.
Reasons for feeding the critically
• To minimize the net negative balance and breakdown of the
• To provide precursors for the immune response, wound repair
and hepatic protein synthesis.
• Provision of nutritional support may increase the protein
synthesis rate even if it does not decrease the catabolic rate.
• Glucose administration is partly protein sparing , but this effect
is blunted by sepsis.
• Even low rates of enteral feeding limit gut mucosal atrophy.
2(Which patients should we
• all malnourished patients (assessment?)
• all patients who are unlikely to regain normal
oral intake within 5-7 days.
3(When should we start to
• early feeding usually defined as starting within
the first 48 hours of admission reduced
• ACCEPT study aimed to start within 24 hours of
• If EN will be delayed for 5-7 days , TPN should
start within 48 hours.
Indirect calorimetry: the gold
standard, particularly with critically
ill, obese, pts who do not respond
well to treatment. Not clinically
• Daily Energy Expenditure:
• The daily energy expenditure is expressed as the
basal energy expenditure (BEE), which is the heat
production of basal metabolism in the resting and
• Harris Benedict equation:
energy expenditure in hypermetabolic
• Fever: BEE * 1.1 (for each °C above the normal body
• Mild stress: BEE * 1.2
• Moderate stress: BEE * 1.4
• Severe stress: BEE *1.6
Total caloric requirement, approximates to
BEE + 30%.
Daily Protein Intake
Normal metabolism 0.8 to 1.0 g/kg
Hypercatabolism 1.2 to 1.6 g/kg.
•Another method is to calculate the nitrogen balance
following collection of a 24 hour urine specimen:
Nitrogen balance = nitrogen intake – nitrogen output
Nitrogen output = UUN + 4 grams + [1.9 * (liters of abdominal
Carbohydrates: approximately 70% of the nonprotein calories.
Lipids: exogenous lipids to provide approximately 30% of the daily energy
Fiber: should be added routinely as part of an enteral feed regimen. It
support normal gut flora, bind bile salts, absorb water, reduce gram negative
bacteria overgrowth and improve glucose intolerance. Reduces enteral
feeding associated diarrhea.
Micronutrients: most standard oral and enteral feeds contain enough
electrolytes, minerals, vitamins and trace elements to ensure that needs are
met if the patient is taking enough feed to meet their daily energy needs.
Water: 30–35 ml fluid/kg (with allowance for extra losses from drains and
enteral feeding is claimed to be superior because
it prevents gut mucosal atrophy .
it reduces bacterial translocation and multi-organ failure.
lipid contained in TPN appears to be immunosuppressive.
Head of bed to be elevated ≥ 30
degrees at all times
Indications for EN
CNS injury/disease with GCS ≤ 8
Burns ≥ 30% TBSA
Major Abdominal Surgery/Trauma ( Grade IV Liver,
Splenectomy with associated small or large bowel injuries,
perforated viscus with peritoneal soilage,
Major Thoracic Trauma or surgery in patient with chronic
Renal Failure patients requiring Renal Replacement
Malnourished or immune deficient patients expected to
be NPO > 72 hours.
– Total enteral nutrition is not advised in patients
with : partial mechanical bowel obstruction,
severe or unrelenting diarrhea, pancreatitis, or
high-volume (more than 500 mL daily)
– Partial (low volume) enteral support is, however,
possible in these conditions.
• In the case of pancreatitis, enteral feedings
can be delivered into the jejunum
How to prescribe EN
2. Type of formula.
Routes of Enteral feeding
■ Nasogastric tube (NGT)
■ Percutaneous endoscopic gastrostomy (PEG)
■ Nasal duodenal tube (NDT)
■ Low-profile gastrostomy device (LPGD)
Small Bowel Access
■ Nasal jejunal tube (NJT)
■ Percutaneous endoscopic jejunostomy (PEJ)
•Consider long term access (i.e. PEG or PEJ) for
patients who will require tube feedig > 4 weeks.
• gastric access relies on a functional stomach
free of delayed gastric emptying, obstruction,
• Small bowel feedings are most appropriate for
patients with gastric outlet obstruction,
gastroparesis, pancreatitis and in those with
known reflux and aspiration of gastric
• Insertion: The distance that the tube must be advanced to reach
the stomach can be estimated by measuring the distance from the
tip of the nose to the earlobe and then to the xiphoid process
(typically 50–60 cm).
• Checking Tube Placement:
– Aspirate gastric contents and check PH.
■ Gastric aspirate pH 1–4 but may be as high as 6 if patient
is on medication to reduce gastric acid.
■ Small intestine aspirate pH >6.
– Obtain chest x-ray.
• Mark the exit site of a feeding tube at the time of the initial radiograph; observe
for a change in the external tube length during feedings.
Types of Tube Feedings
■ Intermittent or bolus feedings: A set volume of
formula is delivered at specified times.
■ Continuous feedings: A set rate of formula is
delivered over a period of time.
■ Cyclic feedings: Similar to a continuous feeding
but the infusion is stopped for a specified time
within a 24-hour period, usually 6–10 hours.
• Initiate feeds at rate of 25 cc/hr and advance by 25 cc/h q 4 hr to goal.
• Checking for Residuals:
Assess every 4–6 hrs for continuous feeding and prior to bolus feeding.
2. Using a 30- to 60-mL syringe, withdraw gastric contents from the feeding
tube. Note volume of formula.
A review of medications that may cause gastric dysmotility is essential
• A 4-h rest period during the night is often recommended. Stomach
acidity during this period may limit bacterial growth in the stomach.
• Flush feeding tubes with 30 mL of water every 4 hours during
continuous feeding or before and after intermittent feedings in an
Types of formula:
•polymeric formulas (which contain nutrients in
high molecular weight forms and require normal
digestive and absorptive ability).
•predigested or elemental formulas (which contain
one or more partially digested macronutrients or
combinations of nutrients and can be absorbed in
patients with compromised GI tracts).
FIBER SUPPLEMENTED FORMULAS
• water soluble fibers, such as pectin and guar, are
fermented by colonic bacteria providing fuel for
the colonocyte, increased colonic sodium and
water absorption have been demonstrated with
soluble fiber, a potential benefit in the treatment
of diarrhea associated with EN.
• Insoluble fiber, such as soy polysaccharide,
increases fecal weight, thereby increasing
peristalsis and decreasing fecal transit time.
DISEASE SPECIFIC FORMULAS
• renal formulas are lower in protein, calorically dense and have
lower levels of potassium, magnesium and phosphorus when
compared to standard formulas. In patients undergoing renal
replacement therapy, especially continuous venovenous
hemodialysis (CVVHD), renal formulas are not always necessary.
These patients typically do not require fluid restriction and have
higher protein requirements of 1.5–2.0 gm/kg/day.
• Hepatic formulas offer increased amounts of branched chain
amino acids (BCAA): valine, leucine, and isoleucine; and reduced
amounts of aromatic amino acids (AAA): phenylalanine, tyrosine
and tryptophan, compared to standard products.
• Formulas designed for patients with DM have lower amount of
total carbohydrate and a higher amount of fat than standard
formulas as well as a variation in type of carbohydrate.
Carbohydrate sources generally consist of oligosaccharides,
fructose, cornstarch and fiber.
• formula designed for the COPD patient. Substituting a
portion of carbohydrate calories with fat calories was
thought to limit carbon dioxide production resulting in
improved ventilatory status.
• formula for ARDS. This formula contains fish oils, sources
of g-linolenic and eicosapentanoic acids as well as
increased amounts of antioxidants. The increased
presence of these fatty acids, through metabolic
alterations known to occur in ARDS, lead to an increased
production of prostaglandins of the 1 series and
leukotrienes of the 5 series, metabolites associated with
an anti-inflammatory and vasodilatory state.
Immune-modulating enteral formulations
• (supplemented with agents such as arginine, glutamine, ω-
3 fatty acids, and antioxidants) should be used in this case
(critically ill patient on mechanical ventilation)
• Glutamine, considered a conditionally essential amino
acid, exerts various beneficial effects on antioxidant
defences, immune function, production of heat shock
proteins, and nitrogen retention. The addition of enteral
glutamine (0.3–0.5 g/kg/d) to an enteral nutrition regimen
(not already containing supplemental glutamine) should
be considered in thermally injured, trauma, and mixed ICU
• Addition of agents such as selenium, vitamin C and
vitamin E provides further antioxidant protection.
• Typically formulas contain 1 kcal/mL and 37 to 62 g
protein/1000 kcal and are 85% water.
• Concentrated formulas are 2 kcal/mL, approximately
36 g protein/1000 kcal and are 70% water.
• The RDI for vitamins and minerals is delivered in 1000
to 1800 kcal of formula.
• Enteral feedings range from < 300 – 700 mOsm/kg
• Formulas with high osmolality (Hydrolyzed protein or
amino acids and Disaccharides) may cause shift of
water into intestinal space = rapid transit, diarrhea
• Medications tend to be hypertonic, particularly elixirs;
may need to be diluted to decrease hypertonicity
when given via tube
– Calculate free water:
• 1kcal/ml = ~85% free water (850mL per 1,000 mL
• 1.2-1.5 kcal/mL = 69% - 82% (690-820)
• 1.5-2.0 kcal/mL = 69% - 72% (690-720)
• Exact water content on label
• Provide additional water via flushes
•Wt (at least 3 times/week)
•Signs/symptoms of edema (daily)
•Signs/symptoms of dehydration (daily)
•Fluid I/O (daily)
•Adequacy of intake (at least 2x weekly)
•Nitrogen balance: becoming less common (weekly, if
•Serum electrolytes, BUN, creatinine (2 –3 x weekly)
•Serum glucose, calcium, magnesium, phosphorus
(weekly or as ordered)
•Stool output and consistency (daily)
• TPN is an IV Nutrition Support using a formulation of amino acids,
carbohydrates, lipids, electrolytes, MVI, minerals, and supplemental
medications (Insulin or H2 blockers).
• Patient Selection: Inability to use the gut at goal feeds with in 5 days.
• Patient Exclusion: Ability to use the gut at goal feeds or oral intake within 5
• Components of PN are in elemental or “pre-
– Protein as amino acids
– CHO as dextrose
– Fat as lipid emulsion
– Electrolytes, vitamins and minerals
Indications for TPN in the ICU
• Massive bowel resection if nutritional requirements cannot be met by oral or
• High-output fistula refractory to elemental diet
• Unable to meet > 60% of nutritional needs via enteral route by ICU day 6
• Persistent ileus or bowel obstruction.
• Diffuse peritonitis
• Intractable vomiting
• Intractable diarrhea
• GI ischemia
• Perceived high risk for non occlusive bowel necrosis (shock resuscitation, α-
agonists, persistent severe distention or cramping)
• Patients with pancreatitis who have demonstrated intolerance to enteral
• Patients with inflammatory bowel disease who have demonstrated intolerance to
enteral nutrition .
• Crohn’s disease with fistulae.
• Functional and accessible GI tract
• Patient is taking oral diet
• Prognosis does not warrant aggressive
nutrition support (terminally ill)
• Risk exceeds benefit
• Patient expected to meet needs within 14(7?)
How to prescribe parenteral nutrition
2. Type of formula.
– Central Parenteral Nutrition: often called Total Parenteral
Nutrition (TPN); delivered into a central vein.
– Peripheral Parenteral Nutrition (PPN): delivered into a
smaller or peripheral vein. Therapy is expected to be short
term (10-14 days)
CV lines include:
• Patients identified as likely to require PN for a period of more than 2 weeks
• Patients already having suitable central venous access with a lumen which
can be used solely for feeding (e.g. post-op from theatre)
• Patients with no suitable veins for peripheral feeding
• Patients requiring specialised PN feeds that cannot be given into smaller
peripheral veins (e.g. hypertonic feeds (>1300-1500 mosmol/l such as fat
free or restricted volume solutions).
•Peripheral route if Formulation osmolarity is <600-900
Parenteral Base Solutions
– Available in concentrations from 5% to 70%
– D30, D50 and D70 used for manual mixing
• Amino acids
– Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions
– 8.5% and 10% generally used for manual mixing
• Fat :The triglycerides are derived from vegetable oils (safflower or
soybean oils) and are rich in linoleic acid, an essential polyunsaturated
fatty acid that is not produced by the human body.
– 10% emulsions = 1.1 kcal/ml
– 20% emulsions = 2 kcal/ml
– 30% emulsions = 3 kcal/ml (used only in mixing TNA, not for direct
• Give lipids continuously with peripheral TPN. With central TPN, lipids
may be given on a continuous or intermittent basis. Maximum lipid
infusion rates:20% = 60 ml/hr
• Fluid—30 to 50 ml/kg (1.5 to 3 L/day)
– Sterile water is added to PN admixture to meet
– Use acetate or chloride forms
• Vitamins, Trace elements : parenteral
vitamins and trace elements do not go
recommendations are lower than DRIs
• Total nutrient admixture (TNA) or 3-in-1
– Dextrose, amino acids, lipid, additives are mixed
together in one container
– Lipid is provided as part of the PN mixture on a
daily basis and becomes an important energy
• 2-in-1 solution of dextrose, amino acids,
– Typically compounded in 1-liter bags
– Lipid is delivered as piggyback daily or
intermittently as a source of EFA
Creating a TPN Regimen
•the daily calorie requirement will be 25 kcal/kg
and the daily protein requirement will be 1.4 g/kg.
take a standard mixture of 10% amino acids (500 mL)
and 50% dextrose (500 mL) and determine the
volume of this mixture that is needed to deliver the
estimated daily protein requirement
•the final mixture actually represents 5% amino acids
(50 grams of protein per liter) and 25% dextrose (250
grams dextrose per liter).
•infused continuously over 24 hours,
• Step 3:
determine the total calories that will be provided by
the dextrose in the mixture. Using an energy yield of
3.4 kcal/g for dextrose, the total dextrose calories
can be determined .
• Step 4:
These remaining calories can be provided by an
intravenous lipid emulsion. If a 10% lipid emulsion
• volume can be infused at half the maximum
recommended rate (50-60 mL/hour)
Because the estimated requirement for calories is 1750 kcal/day, the dextrose will
provide all but 135 kcal/day. These remaining calories can be provided by an
intravenous lipid emulsion.
Acute Inpatient PN Monitoring
Glucose Initially √
Electrolytes Initially √
BUN, Cr, Ca
Fluid/Is & Os √
T. Bili, LFTs Initially √
Adapted from K&M, p. 549
Inpatient Monitoring PN
Body Weight Initially √
Nitrogen Balance Initially
HGB, HCT √
Catheter Site √
Lymphocyte Count √
Clinical Status √
Calculating the Osmolarity of a
Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5. Example: 100
g of dextrose x 5 = 500 mOsm/L
2. Multiply the grams of protein per liter by 10. Example: 30 g
of protein x 10 = 300 mOsm/L
3. Multiply the grams of lipid per liter by 1.5.
Example: 40 g lipid x 1.5 = 60.
1. Multiply the (mEq per L sodium + potassium + calcium +
magnesium) X 2
Example: 80 X 2 = 160
1. Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L
Cessation of TPN
• Rebound hypoglycemia is a potential
• Decrease the volume by 50% for 1-2 hours
before discontinuing the solution to minimize
• PPN can be stopped without concern for
Complications of PN
• Refeeding syndrome: Results from intracellular
electrolyte shift. Reduced serum levels of magnesium,
potassium, and phosphorus, Hyperglycemia and
hyperinsulinemia, Interstitial fluid retention ,Cardiac
decompensation and arrest
• Acid-base disorders
• Hepatobiliary complications (fatty liver, cholestasis)
• Metabolic bone disease
• Vascular access sepsis
• Day 1
At 22:30 a 55-year old female is involved in a high-speed motor vehicle accident and
admitted to intensive care from the emergency department for ventilator
She has several high rib fractures with associated major lung contusion and a
haemothorax that has been drained. She also has a fractured left humerus, left
femur and collapsed pelvis. She has no cerebral injury. There are no abdominal
signs and a computed tomography (CT) scan could not demonstrate any major
She has type-2 diabetes mellitus, is known with coronary artery disease (on
treatment for angina) and has a body mass index (BMI) of 29. She is sedated
with propofol and alfentanyl.
She is orally intubated and has a large bore nasogastric tube (NGT) on free
drainage. A triple-lumen central venous catheter is inserted.
You are satisfied with her current haemodynamic status and, although she has to go
to theatre to externally fix the pelvis and pin the femur, no set theatre time has
Question 1: What are your decisions regarding her maintenance fluids and
• This polytrauma patient had no marked abdominal problems.
Early enteral nutrition (EN) was recommended since the
patient was haemodynamically stable.
• A polymeric feed was recommended as there was no
indication for the use of elemental enteral feeding solution.
• A global fluid allowance of 30–35 ml/kg was suggested,
divided between maintenance fluids and enteral feeds.
• Supply of enteral glutamine of 0.5 g/kg was recommended. A
total energy target of 20–25 kcal/kg actual bodyweight with
1.2–1.5 g protein/kg ideal bodyweight was suggested.
• Day 3
• Early in the morning increased ventilator and circulatory problems
dictate more detailed cardiac output and lung water monitoring,
deeper sedation and neuromuscular blockade to tolerate the
necessary ventilator strategy.
• A restricted fluid regimen is introduced, but she also requires
blood products because of coagulation disorders.
• She is requiring inotrope support and has marked peripheral
oedema. Her albumin is 26 g/L and her blood glucose is 170 mg/dL.
The nurse feels that she is tolerating her enteral feeding but during
turning feed is regurgitated.
• Question 3: A new nurse asks whether there is a problem with feed
tolerance. What could be happening? What additional information
do you need to make your judgement? What can you do?
• Question 4: Do you need to do anything about the low albumin,
oedema or her blood glucose?
• A chest X-ray (CXR) is required to check and confirm the position of
the NGT. An abdominal X-ray (AXR) should be taken to check
whether the patient is developing ileus. Prokinetics could be
considered and the administration rate of the feeding solution might
be reduced to increase tolerance.
• There is no indication for the administration of IV albumin to relieve
the peripheral oedema.
• The blood glucose is high, but is managed without insulin at this
• One could consider mixed nutrition in terms of supplemental
parenteral nutrition (PN) to help aim for target energy goals at Day 3.
• One could consider elemental feeding solution in the presumed
presence of gut oedema (assuming that peripheral oedema is a
reflection of the presence of gut oedema). There is no evidence that
the patient is not absorbing feeds; however, the patient might have
problems with motility.
• Day 6
• She undergoes a percutaneous tracheotomy as prolonged ventilator support is
• During the night a rise in her temperature and rising white cell count suggests a
new infection and antibiotics were started. All her vascular lines were changed.
She has passed a loose stool. Liver and renal function is moderately impaired.
Contrary to what you might have decided she has remained only on NG feeding
and despite the best of intentions, the review of her energy intake since
admission shows less than 50% of target achievement.
• Question 5: Why less than 50% energy target achieved? What are the common
reasons and are they avoidable? Do you have systems in place to monitor and
• Question 6: Is this amount of feed sufficient? What is the evidence for and
against this? Can you catch up for the missing feed by giving more?
• Question 7: Will her nutritional requirements have altered since admission in
composition and/or amount? What should you do now?
• Several factors potentially limit enteral intake in critically ill
patients, including lack of feeding protocols, gastrointestinal
intolerance of enteral tube feedings, displacement or obstruction
of the feeding tube, and interruption of tube feedings for tests and
• Gastrointestinal intolerance of tube feedings (e.g. large gastric
residual volumes, nausea and vomiting, ileus, abdominal
distension, and diarrhoea) is a major factor limiting adequate
enteral intake in patients. In order to reduce the risk of aspiration
of enteral formula, feeding is routinely withheld in patients with
unstable haemodynamic parameters and in preparation for
surgical or diagnostic procedures, weaning, and various nursing
• Supplementary PN should be considered since EN is not meeting
energy requirements. The addition of immunonutrients such as
glutamine and ù-3 fatty acids should be considered.
• Day 10
• She is now more awake and self-triggering the ventilator on
pressure support ventilation. Her chest drains are out. She is
complaining of upper abdominal discomfort, nausea and vomiting.
You attempt to assess the extent of her catabolism. Later that day
she suffers a circulatory collapse and undergoes urgent
laparotomy. A retro-peritoneal duodenal rupture is diagnosed and
treated. The surgeon asks if you want a feeding route via the
• Question 8: What type of approach would you suggest –
nasojejunal or jejunostomy tube? On return from theatre you are
asked for advice on her nutrition.
•The patient might benefit from a double-lumen jejunostomy tube
(ideally placed during the laparatomy procedure).
•It is believed that the patient will be able to tolerate a polymeric feed.
A semi-elemental feeding solution is only prescribed if there is
documented evidence of malabsorption of the polymeric feed.
•Critically ill patients should be fed via an enteral access tube placed in
the small bowel if at high risk for aspiration or after showing
intolerance to gastric feeding (high gastric residual volumes).
• Day 13
• She has deteriorated gas exchange with fever and purulent
excretions. Her renal function is deteriorating and she has a septic
dynamic circulation. Despite fluids and inotropes, renal support is
required and continuous veno-veno haemofiltration is commenced.
She regurgitates a large volume of bile stained fluid. There are no
• Question 9: It is Friday and the pharmacy request nutrition orders
for the weekend. Do you need to make any specific requests or
restrictions? How much will you feed?
• Energy intake should be increased to 30–40 kcal/kg/ day (Stage 5
level of kidney failure patient receiving haemodialysis requires 35
kcal/kg/d <60 years of age) and enough total parenteral nutrition
(TPN) should be ordered to meet the patient’s nutritional needs
over the weekend.
• If significant electrolyte abnormalities exist or develop, a specialty
formulation designed for renal failure (with appropriate electrolyte
profile e.g. reduced phosphate and potassium) may be considered
for the ICU patient with acute renal failure. Patients receiving
haemodialysis should receive formulations with 1.5–2.0 g/kg/d of
protein, up to a maximum of 2.5 g/kg/d to achieve positive
• Day 18
• She is now improving and breathing spontaneously through her
tracheostomy on continuous positive airway pressure (CPAP). She
has been sitting out of bed, propped in a chair. She still requires
intermittent haemodialysis that she has late in the afternoon and
is off all inotropic support and antibiotics. She is being prepared to
move from the ICU to high care. She is having large loose bowel
movements and also mentions to you that she wants something
• Question 10: What do you suggest? What are the risk-benefits?
Do you have any concerns? What might compromise her eating?
• The patient is likely to be exhausted with muscle
weakness and may be suffering from ICU neuropathy.
Patient needs support in terms of physiotherapy,
rehabilitation and psychotherapy.
• Patient’s jejunostomy should ideally remain intact to
enable nursing staff to administer overnight feeds for an
additional 2–3 days. This should meet some nutritional
needs in case the patient has dysphagia due to muscle