Best Practices for Best Practices for Dysphagia Management Dysphagia Management

Post StrokePost Stroke

Kari ClarkKari Clark

Speech-Language Pathologist (c)Speech-Language Pathologist (c)

Dr. Everett Chalmers Regional HospitalDr. Everett Chalmers Regional Hospital

OutlineOutline

Summary of current evidence related to Summary of current evidence related to dysphagia post strokedysphagia post stroke

Anatomy and physiology of the swallowAnatomy and physiology of the swallow Types of dysphagia with MBS samplesTypes of dysphagia with MBS samples Swallowing screens for CVA patientsSwallowing screens for CVA patients Importance of Oral HygieneImportance of Oral Hygiene

Summary of EvidenceSummary of Evidence

Estimate 55% of acute stroke Estimate 55% of acute stroke survivors have some degree of survivors have some degree of dysphagiadysphagia

Only approx. 50% of those affected Only approx. 50% of those affected recover their normal swallowing ability recover their normal swallowing ability by 6 mths post onset.by 6 mths post onset.

Summary of EvidenceSummary of Evidence

Increased risk for pneumonia in stroke Increased risk for pneumonia in stroke patients with dysphagia.patients with dysphagia.

Even greater risk for pneumonia in pts Even greater risk for pneumonia in pts who aspirate.who aspirate.

Dysphagia may lead to poor nutrition and Dysphagia may lead to poor nutrition and dehydrationdehydration

Summary of EvidenceSummary of Evidence

Systematic program for screening, Systematic program for screening, diagnosis & treatment of dysphagia in diagnosis & treatment of dysphagia in acute CVA may yield dramatic decrease acute CVA may yield dramatic decrease in:in:

rate of pneumoniarate of pneumonia

feeding tube dependencyfeeding tube dependency

length of hospital staylength of hospital stay

Summary of EvidenceSummary of Evidence

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

Swallowing Anatomy 101Swallowing Anatomy 101

Physiology of the Normal SwallowPhysiology of the Normal Swallow

4 Stages4 Stages

1. Oral preparatory phase1. Oral preparatory phase

2. Oral-propulsive phase2. Oral-propulsive phase

3. Pharyngeal phase3. Pharyngeal phase

4. Esophageal phase4. Esophageal phase

Causes of Dysphagia in StrokeCauses of Dysphagia in Stroke

Swallowing is a rapid and complicated Swallowing is a rapid and complicated physiological act.physiological act.

Any disruption in the timing or strength of Any disruption in the timing or strength of the movement of any of the structures the movement of any of the structures involved can cause dysphagia.involved can cause dysphagia.

Oral DysphagiaOral Dysphagia

Affects the voluntary stage of swallowing Affects the voluntary stage of swallowing during which the bolus movement can be during which the bolus movement can be controlled.controlled.

Hemiparesis and apraxia can affect this Hemiparesis and apraxia can affect this volitional movement.volitional movement.

CVA can affect underlying oral processes CVA can affect underlying oral processes and sensations (salivary flow, taste & and sensations (salivary flow, taste & temperature sensitivity)temperature sensitivity)

Oral DysphagiaOral Dysphagia

Oral Preparatory deficits:Oral Preparatory deficits:

- difficulties manipulating food and - difficulties manipulating food and forming a bolus forming a bolus

Oral Propulsive deficits:Oral Propulsive deficits:

- - > 2 seconds transferring bolus from oral > 2 seconds transferring bolus from oral cavity to pharynxcavity to pharynx

Pharyngeal DysphagiaPharyngeal Dysphagia

More difficult to detect because structures More difficult to detect because structures and processes are not easily seen.and processes are not easily seen.

Difficulty moving food/liquids into the Difficulty moving food/liquids into the esophagus.esophagus.

- penetration/aspiration- penetration/aspiration

- pharyngeal residue- pharyngeal residue

Esophageal DysphagiaEsophageal Dysphagia

Bolus takes longer than normal to travel to Bolus takes longer than normal to travel to the stomach the stomach

Retention of food in the esophagus Retention of food in the esophagus caused by mechanical obstruction, motility caused by mechanical obstruction, motility disorder or impaired LES function.disorder or impaired LES function.

AspirationAspiration

Occurs when food or liquid (including Occurs when food or liquid (including saliva) enter the trachea.saliva) enter the trachea.

Silent aspiration – occurs in individuals Silent aspiration – occurs in individuals with reduced laryngeal sensation (no with reduced laryngeal sensation (no coughing, throat clearing or changes in coughing, throat clearing or changes in vocal quality)vocal quality)

Not everyone who aspirates develops Not everyone who aspirates develops aspiration pneumonia (AP).aspiration pneumonia (AP).

AspirationAspiration Factors affecting AP:Factors affecting AP:

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

AspirationAspiration

- - oral hygieneoral hygiene

- dependency on others for oral care/- dependency on others for oral care/

feedingfeeding

- dental caries- dental caries

- tube feeding- tube feeding

- medical conditions (COPD, cancer, - medical conditions (COPD, cancer, malnutrition, cardiac disease, DM, malnutrition, cardiac disease, DM,

multiple strokes)multiple strokes)

Modified Barium Swallow StudiesModified Barium Swallow Studies

Clinical Approach to DysphagiaClinical Approach to Dysphagia

Swallowing screen of all CVA Swallowing screen of all CVA patientspatients

Oral HygieneOral Hygiene Clinical swallowing assessmentsClinical swallowing assessments Instrumental assessmentInstrumental assessment Nutrition assessmentNutrition assessment Rehab/compensatory strategiesRehab/compensatory strategies

Stroke survivors NPO

Swallowing team screening for dysphagia

NEGATIVE POSITIVE

Eat or be fednormally

SLP assessmentof swallow

RD assessmentof nutrition

Low risk High Risk

Monitoring byany dysphagiateam member

Monitoring by SLP

Swallowing screening toolsSwallowing screening tools

Several screening tools exist but some are Several screening tools exist but some are better than others.better than others.

Toronto Bedside Swallowing Screening Test Toronto Bedside Swallowing Screening Test (TOR-BSST©) only one with research (TOR-BSST©) only one with research supporting its reliability and validity.supporting its reliability and validity.

Stroke unit at the DECRH has approx. 10 RNs Stroke unit at the DECRH has approx. 10 RNs trained to complete TOR-BSST© with new CVA trained to complete TOR-BSST© with new CVA admissions.admissions.

Our goal is to have all new CVA admissions Our goal is to have all new CVA admissions screened prior to any po intake. screened prior to any po intake.

Oral HygieneOral Hygiene

Link between lack of provision of adequate oral Link between lack of provision of adequate oral care/presence of oral bacteria and the care/presence of oral bacteria and the development of aspiration pneumonia.development of aspiration pneumonia.

Evidence for what constitutes effective oral care Evidence for what constitutes effective oral care in dysphagia: in dysphagia:

Pink swabs don’t cut it!!Pink swabs don’t cut it!!

Toothbrush and toothpaste, use of Toothbrush and toothpaste, use of antimicrobial agents are a must!!antimicrobial agents are a must!!

Oral HygieneOral Hygiene

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

Oral HygieneOral Hygiene

Negative impact on ability to chew, Negative impact on ability to chew, swallow, digest which can lead to swallow, digest which can lead to malnutrition and weight loss.malnutrition and weight loss.

Stroke survivors experience numerous Stroke survivors experience numerous sources of stress that negatively impact sources of stress that negatively impact oral health/hygieneoral health/hygiene

Questions?Questions?

Thank you!Thank you!