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Dysphagia: Management Approach in Stroke

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Presentation on theme: "Dysphagia: Management Approach in Stroke"— Presentation transcript:

1 Dysphagia: Management Approach in Stroke
Marlís González Fernández, MD, PhD Associate Professor Physical Medicine and Rehabilitation April 25, 2017

2 Disclosures I have no conflicts of interest to disclose 4/25/2017

3 Outline Epidemiology Neural control Screening Evaluation Treatment
4/25/2017

4 Dysphagia Common after stroke Affects about 50% of stroke patients
Improves within 7-14 days 11-13% still dysphagic at 6 months 4/25/2017

5 Consequences Malnutrition Dehydration Pneumonia Higher mortality
Increased length of hospital stay 4/25/2017

6 Outcomes Formal dysphagia screen prevents pneumonia1
Aspiration on VFSS associated with lower respiratory tract infection2-3 Clinically unsafe swallow predictive of outcome including lower respiratory tract infection4 4/25/2017 1 Hinchey et al., 2005; 2 Holas et al. 1994; 3 Kidd et al. 1995; 4 Smithard et al., 1998)

7 Location Brain stem stroke Bilateral stroke Rostral medulla
Severe dysphagia Less likely to improve Bilateral stroke Pseudobulbar palsy Recurrent strokes 4/25/2017

8 Procedure Screen Evaluate Treat Clinical evaluation
Instrumental Examination VFSS FEES Treat 4/25/2017

9 Screening goal Detect dysphagia and determine the possibility of aspiration (overt or silent) before developing: Pneumonia Dehydration Malnutrition Airway Obstruction 4/25/2017

10 Screening NPO until completed Screen as early as possible
Trained personnel is critical Choose a standardized tool 4/25/2017

11 Screening Tools Burke Dysphagia Screening Test (BDST)1
Standardized Swallowing Assessment (SSA)2 Timed tests of Hinds and Wiles3 Bedside swallow assessment (BSA)4 Toronto Bedside Swallowing Screening Test (TOR-BSST)©5 Clinical examination (CE) – any two of a list of clinical features6 4/25/2017 1 DePippo et al. 1994; 2 Ellul et al. 1993; 3 Hinds and Wiles, 1998; 4 Smithard et al., 1996; 5 Martino et al., 2009; Daniels et al., 1997

12 Screening Tools They rely on: A few clinical features Swallowing water
4/25/2017

13 Clinical Examination (Screening)
Positive if any two of the following clinical findings present: Dysphonia Dysarthria Abnormal Gag Abnormal Volitional Cough Cough after swallow Voice changes after swallow 4/25/2017 Daniels et al., 1997

14 Screening Tests Summary
Std. Clinical Eval. Sensory Water Se Sp BDST VFSS Yes No 3oz Water swallow 88 22 SSA 5ml X 3 Cup drinking 68 86 Timed Test Symptom Quest. 5-10 ml ml 73 67 BSA VFSS/CE 5 ml X 3 60 ml 70 66 TOR-BSST© 5ml swallow X 10 Cup sip 91.3 66.7 CE N/A 92 MMASA MASA 93

15 Formal Clinical Evaluation
Performed by specialist Speech Therapist or SLP Clinical Assessment Determine aspiration risk Unable to detect silent aspiration 4/25/2017

16 Silent Aspiration Aspiration without signs of material passage into the respiratory tract. 4/25/2017

17 Silent Aspiration Daniels et al. - 13/19 subjects aspirated silently
Holas et al % of patients admitted for rehabilitation after stroke aspirated; 39% of those silently Kidd et al. – 8% of subjects aspirated silently 4/25/2017

18 Instrumental Evaluation
Videofluoroscopic swallowing study (VFSS) Fiberoptic endoscopic evaluation of swallowing (FEES) 4/25/2017

19 When to obtain instrumental exam?
Silent Aspiration is a concern Effective treatment program needs to be determined Deficit etiology is unclear Oral vs. pharyngeal vs. esophageal dysfunction and diagnoses. 4/25/2017

20 VFSS Identify abnormalities of swallowing
Determine the circumstances for safe swallowing Trials of therapeutic and compensatory maneuvers 4/25/2017

21 FEES Directly visualize the pharynx and larynx before and after swallowing. Identify aspiration and pharyngeal retention of food before or after swallowing. Cannot visualize during swallowing. Cannot evaluate esophagus or sphincters. 4/25/2017

22 Principles of Therapy Therapy is directed at the underlying pathophysiology Use therapeutic exercise to improve range of motion, strength and coordination “Swallowing is the best exercise for swallowing” Recreate the circumstances for safe and efficient swallowing Prevent complications 4/25/2017

23 Therapeutic interventions
Swallowing Maneuvers Exercises Diet Modifications 4/25/2017

24 Swallowing Maneuvers Neck Flexion Head turn Head tilt
Supraglottic swallow Mendelsohn Maneuver Effortful swallow 4/25/2017

25 Diet Modifications Thickened liquids Solids Nectar Honey Chopped
Mechanical soft Pureed 4/25/2017

26 Exercises Shaker Exercises Tongue strengthening
Laryngeal elevation and vocal cord adduction exercises 4/25/2017

27 Novel Therapies Neuromuscular electrical stimulation (NMES)
Tongue strengthening devices 4/25/2017

28 ? 4/25/2017


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