Swallowing Assessment in

Stroke Patients

Sharanya Kumar

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

Swallowing is often affected by stroke.

◦ The frequency of dysphagia has been documented to be as high as 81% in one study (1)

Dysphagia is a poor prognostic factor

◦ Therefore must be recognised early

Dysphagia in following stroke increases your risk of:

◦ Chest infection

◦ Aspiration Pneumonia

◦ Malnutrition

◦ Persistent Disability

◦ Prolonged Hospital Stay

◦ Institutionalisation on Discharge

◦ Mortality

Infection Post Stroke

Infection during the acute phase

following stroke reported in up to 40%

of patients (2)

Most common infection = Pneumonia

◦ Complicates 1 out of 3 cases of Acute

Stroke

◦ 50% of cases within first 48 hours of

admission

◦ Rest: all within the first 7 days of

admission

Why prevent infection?

Estimated 10% of deaths within 30

days of admission with stroke are due

to pneumonia (2)

Pneumonia is associated with poor

functional outcome at 3 months post

stroke

N.B. Dysphagia is a strong predictor

for Pneumonia

Prophylactic Antibiotics?

Currently there is no NICE guidance

recommendation for the use of

prophylactic antibiotics, as there is not

enough evidence proving its efficacy.

Evidence Base Van De Beek et al. 2009

Systematic review and meta – analysis of studies looking at preventative antibiotics for infections in acute stroke

Between 1996 – 2009: 4 RCTs were identified

Antibiotics regimens used:

◦ 2 : Fluoroquinolones

◦ 1: Tetracycline

◦ 1: Beta - lactam Abx + B - lactamase inhibitor

Therapy had to be started within 24 hours of stroke onset in all studies

The duration of antibiotic therapy varied between 3 and 5 days.

Results

Overall number of participants with infection: ◦ Significantly smaller in Antibiotic Group

NNT to prevent infection = 7

Mortality:

◦ Antibiotic group = 10 ( out of 210)

◦ Placebo / control = 13 (out of 216)

NNT to prevent death = 83

Van De Beek D et al. Preventive antibiotics for infections in acute stroke: a Systematic review and meta-analysis. Arch Neurol 2009;

66(9):1076-81.

Results

Van De Beek D et al. Preventive antibiotics for infections in acute stroke: a Systematic review and meta-analysis. Arch Neurol 2009;

66(9):1076-81.

Prophylactic Antibiotics?

Further evidence is required.

However, interestingly, there were no

complications with safety.

Choosing the right antibiotic for

prophylaxis

Needs to be effective against the common causative bacteria of aspiration pneumonia:

◦ Streptococcus pneumoniae

◦ Haemophilus Influenzae

◦ Staphyloccus aureus

◦ Enterbacteriaceae

Some antibiotics have been shown to also offer neuroprotective effects:

◦ Minocycline Reduces microglial activation

Inhibits apoptosis

◦ Ceftriaxone

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

Swallowing should be assessed by a trained Healthcare Professional

Before the patient takes any: ◦ Food

◦ Fluid (incl. water)

◦ Medications PO

Ideally within 24 hours of admission to hospital

Definitely within 3 days of admission to hospital

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

Swallowing “Process by which food and drink passes from the mouth to

stomach”

Complex series of neurologically controlled events.

Involves:

◦ Oral Cavity

◦ Pharynx

◦ Oesophagus

Allows individuals to SAFELY manage:

◦ Wide range of food and drink

◦ Varying volumes

◦ Varying textures

◦ Varying consistencies

Swallowing

Three main phases:

All reliant on both motor activity and sensory feedback

Real Time MRI

Normal Swallowing

http://upload.wikimedia.org/wikipedia/co

mmons/b/be/Real-time_MRI_-

_Swallowing_%28Pineapple_Juice%2

9.ogv

Swallowing – Oral Phase Function: Preparation of the bolus for safe transit.

Voluntary phase

Food and drink detected and recognised by taste, texture, consistency

◦ Cranial Nerve XI1

Lips and cheek muscles contract to retain food (orbicularis oris, buccinator)

◦ Cranial Nerve VII

Tongue manipulates food to aid mastication

Submental, Suprahyoid muscles at floor of mouth contract to elevate soft palate

◦ CN V, XII

At the end:

◦ Bolus is formed and held midline by tongue

◦ Then propelled towards the pharynx

Swallowing – Oral Phase

Therefore it requires functioning:

◦ Trigeminal Nerve

◦ Facial Nerve

◦ Glossopharyngeal Nerve

◦ Vagus Nerve (esp sup. Laryngeal branch)

◦ Hypoglossal Nerve

◦ Afferent fibres

Swallowing – Pharyngeal

Phase Function: Ensuring airway is protected during swallowing

Involuntary, Reflex

◦ Medulla – Swallowing Centre

Initiated by

◦ Backward movement of tongue (CNXII)

◦ Detection of bolus in pharynx

Series of well controlled, timed steps:

◦ Elevation of soft palate Therefore cannot enter nasal cavity

◦ Cessation of breathing & Closure of the airway Vocal cords in larynx draw together

◦ Opening of Upper Oesophageal Sphincter Upward forward movement of larynx

◦ Epiglottis closes over larynx Diverting food towards oesophagus

◦ Pharyngeal muscles contract Forcing food into oesophagus (CN X)

Swallowing – Pharyngeal

Phase Therefore it requires functioning:

◦ Medulla

◦ Vagus Nerve (esp the sup. Laryngeal branch)

◦ Hypoglossal Nerve

◦ Afferent fibres

Swallowing – Oesophageal

Phase Function Movement of bolus through

oesophagus into stomach

Active Transport ◦ Muscular contractions

◦ (Peristaltic waves)

Opening of Lower Oesophageal Sphincter ◦ Reflex on detection of bolus in oesophagus

Therefore requires functioning: ◦ Vagus Nerve

◦ Glossopharyngeal Nerve

◦ Sympathetic Nervous System

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

Dysphagia

“Any difficulty which disrupts the safe delivery of a food bolus to the stomach”

Either due to:

Structural dysfunction

Neurological dysfunction

N.B. Neurological Control is bilateral, therefore pathology may be unilateral / bilateral

Dysphagia

As the oral phase and pharyngeal phases are closely linked, dysphagia is commonly classified as being either:

Oropharyngeal Dysphagia ◦ Commonly due to nerve and muscle

pathology e.g. stroke

Oesophageal Dysphagia ◦ Commonly due to obstruction from

strictures / tumours

What can go wrong? Any Stroke lesion can affect swallowing, whether it be cerebral,

cortical, cerebellar or in the brain stem

Cerebral

◦ Interrupt voluntary control of mastication

◦ Bolus transport

◦ Cognitive impairment

Reduced concentration

Selective attention

Cortical Lesions (esp Pre Central Gyrus)

◦ Contralateral impairment in required facial / lip / tongue motor control

◦ Contralateral impairement of pharyngeal muscles required for peristalsis

Brain Stem

◦ Loss of sensation in mouth / tongue/ cheek

◦ Impaired timing of pharyngeal phase sequence

Laryngeal elevation, Closure of epiglottis etc

What can go wrong?

Oral Phase

◦ Sensory / Cognitive Disturbance Failure to detect material in mouth

◦ Motor Control Impairment Disrupting retention / preparation of bolus

Reduced power of muscles involved in mastication

Inappropriate drools / spills into unprepared

pharynx

Pharyngeal Phase

◦ Loss of sensation in pharynx Failure to initiate pharyngeal phase

Aspiration before swallow

◦ Incomplete closure of vocal cords Aspiration during swallow

◦ Incomplete elevation of larynx Failure to clear all material from pharynx

Aspiration after swallow

Oesophageal Phase

◦ Loss of Peristalsis

N.B.

Normally when you aspirate, you cough

to try and expel the material, however

loss of sensation can lead to a weak

cough / loss of coughing reflex:

Silent Aspiration

Objectives

Why is it important?

NICE Guidelines Advice

Normal physiology of swallowing.

Pathophysiology of swallowing in

Stroke.

The Swallowing Assessment

The Swallowing Assessment

Can be assessed by the bedside

Instrumental investigations can

provide more detailed information

Videofluroscopy is the gold standard

test for assessing swallowing

Bedside Swallowing

Assessment 1. Detailed History

From Patient and Care Giver

Onset

Duration

Severity (Solids / Liquids / Both)

Regurgitation, Coughing before / during / after swallow

Associated:

◦ Change in breathing pattern whilst eating

◦ Pain

◦ Hoarseness

◦ Weight Loss

Past Medical History

◦ Other causes, such as strictures secondary to GORD

Medications

◦ Certain drugs, such as anti-epileptics, can affect swallowing

SCREEN FOR RISK OF ASPIRATION

Risk of Aspiration

From: Kedlaya D, Brandstater ME. Swallowing, nutrition and hydration during acute stroke care. Top Stroke Rehabil 2002; 9 (2): 23 - 38

Bedside Swallowing

Assessment II. Examination

General Inspection

Gross Oro – Motor Examination

◦ Voice Quality Assessment

◦ Effect of compensatory strategies

Direct Test of Swallowing Safety

II. Examination

General Inspection

Posture (Able to sit up etc)

Cognitive Status

Ability to co – operate with test

Nutritional & Resp Status

Gross Oro – Facial Motor Assessment

Test Structure & Function & Sensation of Face, Lips, Tongue and Palate

Reflexes – abnormal gag reflex?

Reduced laryngo – pharyngeal sensation

Weak voluntary cough?

Wet Voice?

Safety of Swallow

1. Test with small sips of water

Monitoring for: ◦ Coughing

◦ Respiratory distress

◦ Voice changes

◦ Laryngeal movement

◦ Prolonged swallow

2. If no difficulties, test with larger volumes of water / yoghurt / normal foods

Monitoring as above.

Deemed Safe?

Yes

Watch oral intake and respiratory status for 48 hours.

Effort

Soft smooth diet

Referral to Speech and Language Therapy

Fail

NBM

Site NGT and request CXR to check site

Refer to Speech and Language Therapist for detailed assessment

Swallowing Assessment

Video of Swallowing Assessment from

SLT

Videofluroscopy

VFS image illustrating the anatomy of the oropharynx.

Singh S , Hamdy S Postgrad Med J 2006;82:383-391

Copyright © The Fellowship of Postgraduate Medicine. All rights reserved.

Serial VFS images showing the normal passage of a barium bolus through the pharynx.

Singh S , Hamdy S Postgrad Med J 2006;82:383-391

Copyright © The Fellowship of Postgraduate Medicine. All rights reserved.

References 1. NICE. Diagnosis and Initial Management of Acute Stroke and

Transient Ischaemic Attack (TIA). Clinical Guidelines, CG68. Issued: July 2008

2. Ertekin C, Aydogdu I. Neurophysiology of Swallowing. Clin Neurophysiol. Dec 2003; 114 (12): 2226 – 44.

3. Kedlaya D, Brandstater ME. Swallowing, nutrition and hydration during acute stroke care. Top Stroke Rehabil 2002; 9 (2): 23 - 38

4. Ramsey DJC, Smithard DG, Kalra L. Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients;

5. Singh S, Hamdy S. Dysphagia in Stroke Patients [Review]. Postgrad Med J 2006; 82: 383 – 391

6. Palmer JB, Drennan JC, Baba M. Evaluation and Treatment of Swallowing Impairments. Am Fam Physician. 2000 Apr 15; 61 (8): 2453 – 2462

7. Blue Book

8. Van De Beek D et al. Preventive antibiotics for infections in acute stroke: a Systematic review and meta-analysis. Arch Neurol 2009; 66(9):1076-81.