Best Practices for Dysphagia Management Post Stroke Kari Clark Speech-Language Pathologist (c) Dr. Everett Chalmers Regional Hospital

Outline Summary of current evidence related to dysphagia post stroke Anatomy and physiology of the swallow Types of dysphagia with MBS samples Swallowing screens for CVA patients Importance of Oral Hygiene

Summary of Evidence Estimate 55% of acute stroke survivors have some degree of dysphagia Only approx. 50% of those affected recover their normal swallowing ability by 6 mths post onset.

Summary of Evidence Increased risk for pneumonia in stroke patients with dysphagia. Even greater risk for pneumonia in pts who aspirate. Dysphagia may lead to poor nutrition and dehydration

Summary of Evidence Systematic program for screening, diagnosis & treatment of dysphagia in acute CVA may yield dramatic decrease in: rate of pneumonia feeding tube dependency length of hospital stay

Summary of Evidence Not enough evidence to conclusively recommend one screening/treatment program over another.

Swallowing Anatomy 101

Physiology of the Normal Swallow 4 Stages 1. Oral preparatory phase 2. Oral-propulsive phase 3. Pharyngeal phase 4. Esophageal phase

Causes of Dysphagia in Stroke Swallowing is a rapid and complicated physiological act. Any disruption in the timing or strength of the movement of any of the structures involved can cause dysphagia.

Oral Dysphagia Affects the voluntary stage of swallowing during which the bolus movement can be controlled. Hemiparesis and apraxia can affect this volitional movement. CVA can affect underlying oral processes and sensations (salivary flow, taste & temperature sensitivity)

Oral Dysphagia Oral Preparatory deficits: - difficulties manipulating food and forming a bolus Oral Propulsive deficits: - > 2 seconds transferring bolus from oral cavity to pharynx

Pharyngeal Dysphagia More difficult to detect because structures and processes are not easily seen. Difficulty moving food/liquids into the esophagus. - penetration/aspiration - pharyngeal residue

Esophageal Dysphagia Bolus takes longer than normal to travel to the stomach Retention of food in the esophagus caused by mechanical obstruction, motility disorder or impaired LES function.

Aspiration Occurs when food or liquid (including saliva) enter the trachea. Silent aspiration – occurs in individuals with reduced laryngeal sensation (no coughing, throat clearing or changes in vocal quality) Not everyone who aspirates develops aspiration pneumonia (AP).

Aspiration Factors affecting AP: - stroke severity - level of consciousness - premorbid pulmonary function - ability to cough - mobility - posture - cognition - acidity of the aspirate - amount and frequency of aspiration

Aspiration - oral hygiene - dependency on others for oral care/ feeding - dental caries - tube feeding - medical conditions (COPD, cancer, malnutrition, cardiac disease, DM, multiple strokes)

Modified Barium Swallow Studies

Clinical Approach to Dysphagia Swallowing screen of all CVA patients Oral Hygiene Clinical swallowing assessments Instrumental assessment Nutrition assessment Rehab/compensatory strategies

Swallowing team screening for dysphagia Stroke survivors NPO Swallowing team screening for dysphagia NEGATIVE POSITIVE Eat or be fed normally SLP assessment of swallow RD assessment of nutrition Low risk High Risk Monitoring by any dysphagia team member Monitoring by SLP

Swallowing screening tools Several screening tools exist but some are better than others. Toronto Bedside Swallowing Screening Test (TOR-BSST©) only one with research supporting its reliability and validity. Stroke unit at the DECRH has approx. 10 RNs trained to complete TOR-BSST© with new CVA admissions. Our goal is to have all new CVA admissions screened prior to any po intake.

Oral Hygiene Link between lack of provision of adequate oral care/presence of oral bacteria and the development of aspiration pneumonia. Evidence for what constitutes effective oral care in dysphagia: Pink swabs don’t cut it!! Toothbrush and toothpaste, use of antimicrobial agents are a must!!

Oral Hygiene For patients who cannot tolerate managing secretions/expectorating, there are suction toothbrushes available (or brush and suction with Yankauer simultaneously).

Oral Hygiene Negative impact on ability to chew, swallow, digest which can lead to malnutrition and weight loss. Stroke survivors experience numerous sources of stress that negatively impact oral health/hygiene

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