Dysphagia After Stroke: Incidence, Diagnosis, and Pulmonary Complications
Graduate Department of Speech Language Pathology, University of Toronto, Ontario, Canada. Stroke
(Impact Factor: 5.72).
01/2006; 36(12):2756-63. DOI: 10.1161/01.STR.0000190056.76543.eb
To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature.
Databases were searched (1966 through May 2005) using terms "cerebrovascular disorders," "deglutition disorders," and limited to "humans" for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration.
Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77).
The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.
Figures in this publication
Available from: Philip Michael Bath
- "Acute stroke is complicated by oropharyngeal dysphagia in up to 50% of patients and although it often resolves over the following weeks, 40% of these patients can remain dysphagic a year later. Dysphagia leads to aspiration and a 3-fold increase in pneumonia and malnutrition. Patients who remain chronically dysphagic require enteral feeding through a nasogastric tube (NG) or percutaneous endoscopically introduced gastrostomy tube (PEG) and are more likely to require long-term institutional care. "
- "Hyperglycaemia following stroke has been shown to increase infarct size (Allport, Baird, & Davis, 2008; Pulsinelli et al., 1983) and lead to poorer outcomes independent of the patient's prestroke history of diabetes (Pulsinelli et al., 1983; Weir et al., 1997). The incidence of dysphagia in the acute poststroke period ranges from 37% to 78% (Martino et al., 2005) and stroke patients with dysphagia are three times more likely to develop pneumonia than those without dysphagia (Doggett et al., 2001; Martino et al., 2005). Thus, optimal management of these three common physiological disturbances, namely, fever, hyperglycaemia and dysphagia are important elements of organised stroke care with potential to significantly influence outcomes. "
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ABSTRACT: The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia.
To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers.
Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke champions from intervention sites was conducted.
A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical champions, medical staff, nursing management and allied health staff; easy adaptation of current protocols, care-plans, and local policies; and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions; hyperglycaemic protocols could not be commenced without written orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor level of engagement of medical staff; and doctors' unawareness of the trial.
The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.
© 2015 Sigma Theta Tau International.
Available from: Maureen Musto
- "Aspiration pneumonia is defined as pneumonia typically bacterial in origin, occurring with patients who are at risk for increased oropharyngeal aspiration (Marik & Kaplan, 2003; Millns, Gosney, Jack, Martin & Wright, 2003). A systematic review of nine studies on dysphagia poststroke, demonstrated that the incidence of pneumonia in poststroke patients with dysphagia ranges between 7% and 33% (Martino et al., 2005). After a stroke, patients are at an increased risk for reduced frequency of oral care and increased oral colonization for various reasons: physical impairment limiting mobility and self-care, decreased coordination of movements , cognitive deficits, dysphagia resulting in decreased salivary and bolus clearance, and medication-related xerostomia (Fitzpatrick, 2000; Talbot, Brady, Furlanetto, Frenkel & Williams, 2005). "
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ABSTRACT: PurposeThe pilot study purpose was to determine the effects of a new standardized oral care protocol (intervention) to usual care practices (control) in poststroke patients.DesignThis study is a randomized controlled clinical trial.Method
Fifty-one subjects were enrolled. Subjects in the intervention group received oral care twice a day including tooth brushing, tongue brushing, flossing, mouth rinse, and lip care while control patients received usual oral care.FindingsSubjects in the control and intervention groups showed improvement in their oral health assessments, swallowing abilities and oral intake. There were no significant differences between the two groups. Although not statistically significant, overall prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitiveStaphylococcus aureus colonization in the control group almost doubled (from 4.8% to 9.5%), while colonization in the intervention group decreased (from 20.8% to 16.7%).Conclusions/Clinical RelevanceThese findings demonstrate the importance of oral care in the poststroke patient with dysphagia.
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