Swallowing after AcuteStroke:

How hard can it be?

Alex Harling B7 Speech Therapist

St Georges Hospital.

Learning Outcomes

How common is dysphagia post acute stroke?

What is Dysphagia?

National guidelines

How dysphagia is identified

How dysphagia is managed

Prognosis

Case Study

Questions

Incidence of dysphagia postAcute Stroke

13-94 % of stroke patients are diagnosed withdysphagia (Langdon et al 2010)

64-90% of patients have dysphagia post AcuteStroke (Martino et al 2004)

Although there are many variables, theincidence of dysphagia is mainly related tolesion size and location.

Cerebral, cerebellar, or brain stem strokes canimpair swallowing physiology

What is Dysphagia? Dysphagia is ……..

Difficulty eating and drinking

This could include:

Difficulties chewing

Difficulties controlling food/fluid in the mouth

Choking on food/fluids

This CAN result in…..

Aspiration

Pneumonia secondary to aspiration

Weight loss

Death

Poor longer term prognosis of recovery following stroke(Mann et al 1999, Smithard et al 2007)

The Complexities of Swallowing Over all 50 pairs of

muscles and 5 cranialnerves are involved inthe swallow process

4 Stages of swallowinginclude:

-Oral preparatorystage

-oral stage

- pharyngeal stage

-Oesophageal stage

The Normal Swallow:Oral preparatory phase

The Normal Swallow: Oral Stage

The Normal Swallow: PharyngealStage

Animation of Normal Swallow

National Guidelines

Importance of early identification of dysphagia is welldocumented. (National Stroke Strategy

The National guidelines for the assessment of dysphagiaare as follows:

Swallow screen within 4 hours of admission

SLT assessment within 72 hours for patients who havefailed the swallow screen

How do we identify Dysphagiafollowing a Stroke?

Stage 1: Nurse swallow screen. Nursing staffare trained to carry out a water swallow screento identify those at risk of aspiration

The water swallow test has been validated as agood predictor of aspiration risk even whencompared with videofluoroscopy andendoscopic examination. (Edmiaston et al 2010)

CAUTION:While some subjects pass the waterswallow test may require a modified diet toassist the oral stage of swallowing

Speech Therapy Assessment:Stage 2 - Bedside assessment

Oromotor assessment: Cranial Nerve exam focusing on V, VII,IX, X, & XII

Use of different tools to assist identification ofdysphagia/aspiration e.g.

Pulse oximetry

Cervical auscultation

Overt clinical signs (choking/coughing/wet voice)

Assessment using both fluids and solids

This may include modified consistencies as appropriate

CAUTION: Variable reliability. E.g. Sensitivity of 47%,specificity of 87% (Smithard et al 1997)

Instrumental assessment: Stage 3Videofluorscopy

Often deemed the ‘Gold’standard (Loggeman 1993)

Subjective visual judgement

Interrater reliability dependenton

-timing

-bolus consistency

- image quality

Instrumental assessment Stage 3:Fibreoptic Endoscopic Evaluation ofthe Swallow (FEES) FEES is a video- endoscopic tool that

is sensitive to detect residualmaterial in the pharynx, penetrationand aspiration

Limitations: it doesn’t showpharyngeal stripping, transit throughUES, oral stage or extent ofaspiration

Benefit: Does NOT involve exposureto radiation, therefore you can get alonger sequence of video. Also, theequipment can be moved to anyplace in the hospital

Management of Dysphagia inacute phase of care

Diet and fluid modification

E.g. Thickened fluids, Puree diet

Compensatory Maneuvers: e.g. chin tuck posture/ headturn to affected side

Swallow rehabilitation: Direct intervention may targetoral stage and/or pharyngeal stage.

Non-oral feeding: Naso- Gastric tube for the short-term

Recovery and prognosis

Swallow recovers in >80% within 2-4 weeks (Smithard et al1997)

25% - 50% of patients with dysphagia will havepersistent dysphagia at 6 months (Mann et al)

Measures of Stroke severity e.g. continence, largelesion size, reduced levels of consciousness are found tobe significantly associated with an increased likelihoodof prolonged dysphagia

Pre-morbid factors: e.g. any pre-existing progressive neurological

Age: The elderly post-stroke patient might no longer be ableto compensate for normal changes in skeletal muscle strengththat reduce mastication or diminish lingual pressure

Case Study:

Male; admitted to the Stroke unit at SGH followingacute Pontine infarct.

CT and MRI confirmed: Small vessel disease, old leftbasal ganglia infarct

Initial Videofluorscopy identified poor oral control,delayed initiation of the swallow and reduced laryngealelevation

Direct impairment based therapy commenced, targetingthese areas.

VIDEO

Video showing x-ray :

•Pre-rehab (approx 1 month poststroke)

•Post rehab – (1 month later)

•Post rehab phase: (3months post endof rehab)

QUESTIONS

References

References

Jeff Edmiaston, MS, CCC-SLP; Lisa Tabor Connor, PhD; Lynda Loehr, MA, CCCSLP; Abdullah Nassief, MD.Validation of a Dysphagia Screening Tool in Acute Stroke Patients. American Journal of CriticalCare. 2010;19(4):357-364