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

2. 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

3. 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.

4. 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

5. 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

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

7. Swallowing Anatomy 101

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

9. 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.

10. 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)

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

12. 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

13. 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.

14. 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).

15. 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

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

17. Modified Barium Swallow Studies

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

19. 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

20. 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.

21. 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!!

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

23. 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

24. Questions?

25. Thank you!