15. Dysphagia and Aspiration Post Stroke
Robert Teasell MD, Norine Foley MSc, Rosemary Martino, PhD, Sanjit Bhogal MSc, Mark Speechley PhD
There is a high incidence of dysphagia and aspiration following acute The Evidence-Based
stroke. Review of Stroke
VMBS studies are the only sure way of diagnosing dysphagia and practices in stroke
The incidence of silent aspiration following acute stroke is high. Contacts:
Dr. Robert Teasell
The risk of developing pneumonia following stroke is proportional to 801 Commissioners
the severity of aspiration.
All stroke survivors should remain NPO until a trained assessor has
assessed swallowing ability.
Following a failed screening, a referral to a Speech-Language
Pathologist should be made for further assessment and management. www.ebrsr.com
Feeding assistance should be provided by an individual trained in low-
risk feeding strategies. Individuals with dysphagia should feed ndon.on.ca
themselves whenever possible.
Dysphagia diets, consisting of texture-modified solid foods and
partially thickened fluids may help to reduce the incidence of
Treatments with Nifedipine, transcranial magnetic stimulation and
head rotation techniques can be used to improve swallowing
mechanics, while thermal stimulation may not.
Enteral tube feeding may be necessary when stroke patients fail to
meet their nutritional needs orally. There is no difference in the
outcomes of death or poor outcome associated with the use of either
nasogastric or gastro-enteric feeding tubes.
It is uncertain if the use of electrical stimulation improves swallowing
function post stroke.
Last updated August 2010
15. Dysphagia pg. 1 of 60
Table of Contents
Key Points .......................................................................................... 1
Table of Contents ................................................................................. 2
15. Dysphagia and Aspiration Post Stroke.................................................. 3
15.1 Normal Swallowing .................................................................................3
15.2 Pathophysiology of Dysphagia..................................................................4
15.3 Aspiration Associated with Dysphagia ........................................................4
15.3.1 Silent Aspiration Post Stroke ................................................................. 5
15.4 Incidence of Dysphagia Post Stroke ...........................................................5
15.4.1 Acute Phase of Stroke......................................................................... 5
15.4.2 Incidence of Aspiration Following Stroke ................................................... 7
15.4.3 The Prevalence of Dysphagia in the Rehabilitation Stage Post Stroke ............... 9
15.5 Pneumonia and Aspiration Post Stroke .................................................... 10
15.5.1 Defining Aspiration Pneumonia ............................................................ 11
15.5.2 Relationship Between Pneumonia and Dysphagia/Aspiration ........................ 12
15.6 Non-Instrumental Methods for Screening and Assessment of Dysphagia Following
Stroke ...................................................................................................... 14
15.6.1 Clinical Screening Methods................................................................. 14
15.6.2 The Water Swallowing Test ................................................................ 17
15.6.3 Swallowing Provocation Test (SPT) ....................................................... 19
15.6.4 The Bedside Clinical Examination for Assessment of Dysphagia..................... 20
15.6.5 Other Methods................................................................................ 21
15.7 Instrumental Methods Used in the Detection of Dysphagia/Aspiration.............. 22
15.7.1 VMBS Examination .......................................................................... 22
15.7.2 Flexible Endoscopic Evaluation of Swallowing (FEES)................................. 23
15.7.3 Pulse Oximetry ............................................................................... 25
15.8 Management of Aspiration Post Stroke ..................................................... 26
15.8.1 Management Strategies for Dysphagia ................................................... 27
15.8.2 Best Practice Guidelines for Managing Dysphagia...................................... 27
15.8.3 Dysphagia Screening Protocols............................................................ 29
15.8.4 Low-Risk Feeding Strategies for Dysphagia ............................................ 29
15.9 Specific Interventions to Manage Dysphagia .............................................. 31
15.9.1 Dietary Modifications........................................................................ 31
15.9.2 Swallowing Treatment Programs ......................................................... 34
15.9.3 Non-Oral Feedings........................................................................... 37
15.9.4 Selection of Feeding Tubes ................................................................ 39
15.9.5 Alternative Interventions .................................................................... 43
15.10 Summary .......................................................................................... 51
15. Dysphagia pg. 2 of 60
in stroke survivors was associated
15. Dysphagia and Aspiration with the length of hospitalization.
Detection of aspiration, both silent and
Post Stroke audible, and subsequent adaptive
Dysphagia is defined as difficulty with management strategies are regarded
swallowing and is a common as important in the prevention of
complication of stroke. The incidence pneumonia (Horner and Massey
rates are reported to be between 29- 1988a, Horner et al. 1988b,
67% in acute stroke patients (Martino Logemann 1983, Teasell et al. 1996,
et al. 2005). Some of the variability is Tobin 1986, Veis and Logemann
related to differences in the timing 1985). Management of dysphagia
and method of swallowing largely focuses on strategies to avoid
assessment. The presence of aspiration following stroke.
dysphagia can be identified on the
basis of clinical or radiographic 15.1 Normal Swallowing
examinations, or both.
Swallowing has four sequential
The presence of dysphagia in stroke coordinated phases: the oral
survivors has been associated with preparatory phase, the oral propulsive
increased mortality and morbidities phase, the pharyngeal phase and the
such as malnutrition, dehydration and esophageal phase. Each of the phases
pulmonary compromise (Smithard et of a normal swallow is described below
al. 1996, Barer 1989, Kidd et al. 1995, (Jean et al. 2001).
Finestone et al. 1995, Teasell et al.
1994, Gordon et al. 1987, Schmidt et Oral Preparatory Phase. During this
al. 1994, Sharma et al. 2001). phase, food in the oral cavity is
Evidence indicates that detecting and manipulated and masticated in
managing dysphagia in acute stroke preparation for swallowing. The back
survivors improves outcomes such as of the tongue controls the position of
reduced risk of pneumonia, length of the food, preventing it from falling
hospital stay and overall healthcare into the pharynx.
expenditures (Smithard et al. 1996).
Oral Propulsive Phase. During the
Aspiration following stroke, the most oral propulsive, the tongue transfers
clinically significant symptom of the bolus of food to the pharynx,
dysphagia, has long been associated triggering the pharyngeal swallow.
with pneumonia, sepsis and death.
Silver et al. (1984) and Bounds et al. Pharyngeal Phase. During the
(1981) reported that pneumonia was pharyngeal phase, complex and
the second most common cause of coordinated movements of the tongue
death during the acute phase of a and pharyngeal structures propel the
stroke, with up to 20% of individuals bolus from the pharynx into the
with stroke-related dysphagia dying esophagus. The closing of the vocal
during the first year post stroke from cords and the backward movement of
aspiration pneumonia (Schmidt et al. the epiglottis prevents food or liquid
1988). Steele (2002) found that the from entering the trachea.
number of swallowing difficulties seen
Esophageal Phase. During the
esophageal phase of swallowing,
15. Dysphagia pg. 3 of 60
coordinated contractions of the of dysphagia include: Choking on
esophageal muscle move the bolus food, coughing during meals, drooling
through the esophagus towards the or loss of food from mouth, pocketing
stomach. on food in cheeks, slow, effortful
eating, difficulty swallowing pills,
15.2 Pathophysiology of Dysphagia avoiding food or fluids, complaining of
food sticking in throat, problems
Dysphagia post stroke has long been swallowing, reflux or heartburn
attributed to pharyngeal muscular (Schmidt et al. 1994). Table 15.1
dysfunction and incoordination, summarizes the results of studies
secondary to central nervous system assessing the pathophysiology.
loss of control. Signs and symptoms
Table 15.1 Pathophysiology of Dysphagia Post Stroke
Author Methods Results
Veis and 38 stroke patients consecutively 50% of patients demonstrated reduced lingual
Logemann referred for VMBS examination for control, 82% a delayed reflex, 58% reduced
1985 suspicion of swallowing disorders pharyngeal peristalsis, 5% reduced laryngeal
USA within 4 months of stroke. VMBS adduction, 5% crichopharyngeal dysfunction.
No Score studies were used to assess oral and 76% of patients demonstrated more than one
pharyngeal functioning and to identify swallowing disorder. 32% of patients aspirated.
motility disorders. 3 consistencies
were tested: liquid, paste and cookie.
Robbins et The swallowing patterns of 20 first - Patients with left hemisphere strokes had
al. 1993 ever MCA stroke patients were longer pharyngeal transit duration times
USA compared with 40 control subjects. compared to controls. Patients with right
No Score hemisphere strokes demonstrated longer
pharyngeal stage durations and higher
incidences of laryngeal penetration and
aspiration of liquid. Anterior lesion subjects
demonstrated significantly longer swallowing
durations on most variables compared to both
normal and posterior lesion subjects.
Conclusions Regarding the
Pathophysiology of Dysphagia 15.3 Aspiration Associated with
Dysphagia post stroke is characterized Dysphagia
by a delay and reduced function in the Aspiration is defined as "entry of
pharyngeal phase of swallowing. material into the airway below the
Although the incidence of dysphagia is level of the true vocal cords". Since
more common following brainstem or many stroke patients with dysphagia
bilateral hemispheric stroke, it do not aspirate, the two terms are not
frequently occurs following unilateral
synonymous, although they are closely
associated. The diagnosis of aspiration
should be suspected when the stroke
Dysphagia is characterized by reduced patient has any of the following: a
coordination of pharyngeal muscles. subjective complaint of trouble
15. Dysphagia pg. 4 of 60
swallowing, an abnormal chest x-ray, minimal amount of fluid, a small cup of
congested voice quality, or a delay in water is carefully introduced. The full
voluntary initiation of the swallow assessment is described elsewhere
reflex and coughing during or after (Smithard et al. 1996). While all
swallowing (Horner et al 1988b). stroke patients are potential
Diagnosis is initially established aspirators, there are certain
through clinical assessment involving identifiable risk factors that have been
an oral motor examination followed by recognized as greatly increasing the
the introduction of one or several likelihood of aspiration. These clinical
teaspoons of water. If patients are risk factors are listed in Table 15.2.
able to successfully swallow this
Table 15.2 Risk Factors for Aspiration Post-Stroke
• Brainstem Stroke
• Difficulty swallowing oral secretion
• Coughing/throat clearing or wet, gurgly voice quality after swallowing water
• Choking more than once while drinking 50 ml of water
• Weak voice and cough
• Wet-hoarse voice quality
• Recurrent lower respiratory infections
• Low-grade fever or leukocytosis
• Auscultatory evidence of lower lobe congestion
• Immunocompromised state
15.3.1 Silent Aspiration Post Stroke developing complications. Since the
In addition to overt signs of aspiration, condition was not diagnosed,
such as chocking or coughing, a precautions to decrease aspiration risk
substantial number of patients would often not be employed. Silent
experience silent aspiration, aspiration should be suspected in the
highlighting the utility of using VMBS stroke patient with recurrent lower
studies. "Silent aspiration" is defined respiratory infections, chronic
as "penetration of food below the level congestion, low- grade fever or
of the true vocal cords, without cough leukocytosis (Muller-Lissner et al.
or any outward sign of difficulty" 1982). Clinical markers of silent
(Linden and Siebens 1983). Detailed aspiration may include a weak voice or
clinical swallowing assessments were cough or a wet-hoarse quality after
shown to under-diagnose or miss these swallowing.
cases of aspiration (Horner and Massey
1988a, Horner et al. 1988b, Splaingard
15.4 Incidence of Dysphagia Post
et al. 1988, Terre & Mearin 2006). In Stroke
particular, the presence or absence of 15.4.1 Acute Phase of Stroke
a gag reflex failed to distinguish
Table 15.3 presents results from a
aspirating from non-aspirating stroke
variety of studies that used clinical
patients (Horner and Massey 1988a,
methods to assess swallowing among
Horner et al. 1988b, Splaingard et al.
acute and rehabilitating stroke
1988). Silent aspirators were
considered to be at increased risk of
15. Dysphagia pg. 5 of 60
Table 15.3 Incidence of Dysphagia Post Stroke (Acute)
Author Methods Results
Gordon et al. 91 consecutive stroke patients were evaluated 41 (45%) of the patients had
1987 with a standardized swallowing test for the evidence of dysphagia.
UK presence of dysphagia. 82/90 (92%) were
No Score evaluated within 4 days of stroke onset.
Wade et al. 452 consecutive, conscious acute stroke 194 (43%) of patients were
1987 patients were evaluated within 7 days of onset considered dysphagic.
UK of symptoms. Their ability to swallow water
No Score from a cup was evaluated.
Barer 1989 357 stroke patients selected from a stroke 105 (29%) patients initially presented
UK registry participating in the “BEST” study with with dysphagia. By 1 month, 6/277
No Score onset of symptoms within 48 hrs, single- (2%) of survivors were still dysphagic.
hemisphere involvement, able to take oral At 6 months, 1/248 (0.4%) of those
medications, no pre-stoke impairments and no assessed remained dysphagic.
cardiac conditions were followed. Ability to
swallow 10 mL of water from a cup was
Odderson et 124 consecutive, ischemic stroke patients 48 (39%) of patients failed the initial
al. 1995 were assessed within 24 hours using a clinical swallow screen. 21 of patients with
USA swallowing screen, assessing voice quality, dysphagia recovered their swallowing
No Score ability to handle oral secretions and ability to function by discharge.
swallow ice chips or water briskly.
Nilsson et al. 100 consecutive, acute stroke patients were Only 72 patients were able to reliably
1998 assessed for dysphagia within 24 hours of respond to questions. 14 patients
Sweden admission. Patients were questioned about (19%) complained of dysphagia.
No Score swallowing complaints and examined with a
repetitive oral suction swallow test (ROSS).
Daniels et al. 55 stroke patients consecutively admitted to a Dysphagia was present in 36 (65%) of
1998 VA medical centre. All patients received a patients. Aspiration occurred in 21
USA bedside and VMBS evaluation within 5 days of (38%) patients.
No Score admission.
Mann et al. The swallowing function of 128 hospital- Using VMBS a median of 10 days
1999 referred patients with acute stroke was following stroke, 82 (64%) of patients
Australia evaluated clinically and with VMBS studies. were diagnosed with dysphagia, 28
No Score Patients were followed for 6 months. (22%) aspirated. Using a clinical
exam administered a median of 3
days following stroke, the incidence of
dysphagia and aspiration were 51%
and 50%, respectively.
Gosney et al. 203 patients with first ever stroke were On admission 58 (29%) were
2006 recruited from the acute stroke assessment considered to be dysphagic.
UK units from 3 hospitals within 24 hours of onset
6 (RCT) of symptoms. Patients were evaluated by
either a bedside evaluation or a water-
Smithard et A population-based long-term follow-up of 567 (44%) patients were determined
al. 2007 1,288 persons with first time stroke. to be dysphagic at the point of first
15. Dysphagia pg. 6 of 60
UK Dysphagia was assessed by clinical exam assessment.
No Score within 1 week of stroke. Patients were
followed up at 3 months and yearly for 5
The studies reviewed above assessed sample studied and the assessment
swallowing status in the acute phase method used.
of stroke assessed using both clinical
and VMBS examination. Among these There is a high incidence of
studies, the incidence of dysphagia dysphagia following acute stroke.
ranged from 19% to 65%.
15.4.2 Incidence of Aspiration
Conclusions Regarding the Incidence Following Stroke
of Dysphagia (Acute)
Several studies have estimated the
The incidence of dysphagia appears to incidence of aspiration and silent
be quite high following acute stroke
aspiration post stroke using a
with between one third and two-thirds
combination of clinical and
of patients affected, depending on the
(see Table 15.4)
Table 15.4 Incidence of Aspiration and Silent Aspiration Post Stroke
Author Methods Results
Veis and 38 stroke patients consecutively 50% of patients demonstrated reduced lingual
Logemann referred for VMBS studies for control, 82%, a delayed reflex, 58% reduced
1985 suspicion of swallowing disorders pharyngeal peristalsis, 5% reduced laryngeal
USA within 4 months of stroke. VMBS adduction, 5% crichopharyngeal dysfunction.
No Score studies to assess oral and 76% of patients demonstrated more than one
pharyngeal functioning and to swallowing disorder. 32% of patients aspirated.
identify motility disorders. 3
consistencies were tested: liquid,
paste and cookie.
Horner et al. 47 stroke patients referred for 51% of patients aspirated on at least one
1988 (b) swallowing evaluation on suspicion consistency. 54% of the aspirators were silent
USA of dysphagia. To evaluate the aspirators. Aspiration was not limited to
No Score clinical correlates of dysphagia, brainstem or bilateral lesions. Medical-clinical
patients received both a clinical and
abnormalities appeared to be more frequent in
videofluoroscopic evaluation of patients who aspirated although no statistical
swallowing function. Liquid, paste analysis was performed. The presence of a
and cookie consistencies were delayed swallow reflex and reduced peristalsis
tested. 33 patients were tested frequently resulted in aspiration. Poor oral
within the first month post stroke.motility did not.
Chen et al. 46 consecutive patients with clinical
Dysphagia was confirmed by VMBS examination
1990 symptoms of dysphagia within one- in all cases. Mild swallowing impairment was
USA month of stroke were referred for identified in 18 (39%) patients, moderate
No Score VMBS examination. dysfunction in 23 (50%) and severe problems in
5 (11%) patients. There were 24 episodes of
Splaingard et 107 patients referred for evaluation 40% of patients aspirated during VMBS study.
15. Dysphagia pg. 7 of 60
al. for possible swallowing dysfunction Bedside evaluations identified only 42% of proven
1988 from a general rehabilitation ward, aspirators. Silent aspiration, not detected on
USA including 87 stroke patients. The bedside evaluation was noted in 20% of patients.
No Score results of a bedside swallowing Bedside assessments identified 58/64 (90%) of
evaluation were compared with non-aspirators.
VMBS results by blinded evaluators.
Kidd et al. 60 consecutive stroke patients 42% of patients aspirated on initial VMBS.
1995 admitted to a teaching hospital. 42% of patients were unable to complete the
UK Patients received a water- water-swallowing test. Of these, 80% were
No Score swallowing test and VMBS study aspirators. 32% of patients developed a
within 72 hrs of stroke onset and respiratory tract infection (RTI) within 14 days.
were re-evaluated at 3 months. 89% of RTIs occurred in aspirating patients. 42
patients were re-examined at 3 months. 14% of
patients continued to experience impaired
pharyngeal sensation. An abnormal water-
swallowing test was reported in 7% of the
remaining patients. 8% of patients initially
presenting with a positive VMBS result also had a
positive follow-up test. These same patients
developed a respiratory tract infection between
days 14 and 90. 5 patients were silent aspirators,
accounting for 20% of all aspirators.
Smithard et 121 stroke patients consecutively 50% of the patients were considered to have an
al. 1996 admitted to an urban hospital. unsafe swallow based on bedside evaluation
UK Patients received both bedside and alone. 94 patients had a VMBS study. Of these,
No Score VMBS evaluations within 3 days of 20 (16.5%) patients aspirated. Increased
stroke, when feasible. mortality, lower Barthel scores and increased
frequency of discharge to institutionalized care at
6 months were reported more often in patients
with an unsafe swallow. However, these
outcomes were not associated with a positive
VMBS study result. 22 patients did not receive a
Daniels et al. 59 consecutively admitted ischemic 44/59 patients (74.6%) were dysphagic based on
1997 stroke patients received a clinical VMBS results. Dysphonia, dysarthria, abnormal
USA and VMBS swallowing evaluation volitional cough and cough after swallow were all
No Score within 5 days of admission. significantly predictive of dysphagia severity.
Daniels et al. 55 stroke patients consecutively Dysphagia was present in 65% of patients.
1998 admitted to a VA medical centre. All Aspiration occurred in 21 (38%) patients. Of
USA patients received a bedside and these, 14 aspirated silently (67% of aspirators).
No Score VMBS evaluation within 5 days of Dysphagia was present in 65% of patients.
admission. Both abnormal volitional coughing and cough with
swallow were highly predictive of aspiration. One
patient developed aspiration pneumonia during
Mann et al. The swallowing function of 128 Using VMBS a median of 10 days following stroke,
1999 hospital-referred patients with 82 (64%) of patients were diagnosed with
Australia acute stroke was evaluated dysphagia, 28 (22%) aspirated. Using a clinical
No Score clinically and with VMBS studies. exam administered a median of 3 days following
Patients were followed for 6 stroke, the incidence of dysphagia and aspiration
months. were 51% and 50%, respectively.
Kim et al. 23 patients with isolated medullary Ten (44%) of the 23 patients manifested
2000 infarctions were assessed using aspiration on swallowing. Using criteria including
15. Dysphagia pg. 8 of 60
USA VMBS studies within two weeks of dysphonia, soft palate dysfunction, and facial
No Score stroke. From the results of the hypesthesia were used to discriminate between
VMBS studies, 2 patient groups those with and without aspiration with 95.7%
were formed: one with aspiration accuracy.
and the other without aspiration.
The clinical variables related to
aspiration and outcome measures
were also explored.
Discussion only reliably detectable through VMBS
studies. Between one-third and one-
The incidence of aspiration identified half of aspirators are “silent”
using VMBS studies, assessed during aspirators.
the acute stage of stroke, ranged from
30% to 51%. The incidence of silent Aspiration following stroke is very
aspiration was reported in five studies. common.
The incidence of silent aspirators The incidence of silent aspiration
ranged from 8% (Kidd et al. 1995) to following acute stroke is high.
27% (Horner et al. 1988b).
Conclusions Regarding the Incidence
of Aspiration Using VMBS 15.4.3 The Prevalence of Dysphagia
in the Rehabilitation Stage Post
The incidence of aspiration in the acute Stroke
phase of stroke varies from 30% to
51%. Few studies have examined the
prevalence of dysphagia that may
Conclusions Regarding Silent
persist past the acute stage of stroke.
The results from 5 studies that were
9 to 27% of acute stroke patients are identified, specific to the rehabilitation
silent aspirators, a condition which is period are presented in Table 15.5.
Table 15.5 Prevalence of Dysphagia at Admission to Rehabilitation Post Stroke
Author Methods Results
DePippo et al. 139 consecutive patients admitted to an 82 (59%) of patients failed the
1994 inpatient rehabilitation unit a mean of 5 weeks screening tests.
USA following stroke. Patients were evaluated
No Score using the Burke Dysphagia Screening test (a
water swallowing test).
Gottlieb et al. 180 consecutive rehab patients assessed an Dysphagia was diagnosed in 28% of
1996 average of 14 days post stroke using a patients.
Israel bedside technique, which included a water
No Score swallowing test (50 mL). A cough during
drinking was considered positive.
Terre & 138 consecutive patients admitted to a Dysphagia was clinically suspected in
Mearin 2006 rehabilitation hospital recovering from a 64 (46%) of patients. Clinical
Spain severe, first-ever strokes were evaluated examination showed that 44% had
No Score clinically and through videofluoroscopy. impaired gag reflex, 47% coughed
15. Dysphagia pg. 9 of 60
Evaluations were conducted a mean of 3 during oral feeding, and 13%
months following stroke demonstrated changes in voice after
swallowing. 42 (30%) patients
demonstrated pharyngeal aspiration
on VMBS. Of these, 21 (50%) were
episodes of silent aspiration.
Poels et al. 69 stroke patients without aphasia admitted to Eating difficulties (including
2006 stroke rehabilitation an average of 34 days swallowing difficulties) were present
The following acute stroke. Dysphagia was in 30 (43%) of patients.
Netherlands assessed using structured observations of
No Score eating difficulties.
Falsetti et al. 151 consecutively-admitted patients admitted 62 (41%) of patients were dysphagic,
2009 to a neurorehabilitation unit an average of 14 based on the results from the clinical
Italy days following stroke received a 3-step clinical exam. 49/151 patients, 79% of whom
No Score exam, which included 2 water swallowing were identified as dysphagic based on
components (bolus of differing amounts) clinical exam, received a VFS study.
within one day of admission and a VFS exam Aspiration and silent aspiration were
for those who failed any portion of the detected in 21 (43%) and 13 (26.5%)
screening test. patients, respectively.
Discussion (Chua et al. 1996- 40%, Teasell et al.
2002-55%, Meng et al. 2000-81%).
Among five samples of unselected
patients entering stroke rehabilitation, Conclusions Regarding the Prevalence
the prevalence of dysphagia ranged of Dysphagia in the Rehabilitation
from 28-59%, using different Stage of Stroke
assessment techniques. If studies
which limit patient selection to those A high percentage of patients enter
recovering from brainstem stroke, the rehabilitation with persistent
percentages are significantly higher dysphagia.
the immune state or general health of
15.5 Pneumonia and Aspiration the stroke patient. Sellars et al.
(2007) prospectively evaluated 412
Post Stroke stroke patients for up to 3 months
Those patients who aspirate over 10% following stroke. Over this period,
of the test bolus or who have severe there were 160 cases of either
oral and/or pharyngeal motility confirmed or suspected pneumonias.
problems on VMBS studies are Independent predictors of pneumonia
considered at high risk for pneumonia were age >65 years, dysarthria or no
(Logemann 1983, Milazzo et al. 1989). speech due to aphasia, a modified
In many cases, it is difficult to Rankin Scale score ≥4, an Abbreviated
practically assess whether 10% or Mental Test score <8, and failure on
more of the test bolus has been the water swallow test. The presence
aspirated. Nevertheless, the degree of 2 or more of these risk factors
of aspiration seen on VMBS study is a carried 90.9% sensitivity and 75.6%
critical determinant of patient specificity for the development of
management. Predicting whether a pneumonia.
patient will develop pneumonia post
aspiration is, to some extent, The importance of the diagnosis and
dependent on other factors such as management of aspiration post stroke
15. Dysphagia pg. 10 of 60
has been driven by the purportedly in almost half of normal subjects
causal relationship between aspiration (Finegold 1991, Huxley et al. 1978).
and pneumonia (Brown and Aspiration pneumonia is thought to
Classenberg 1973, Hanning et al. occur when the lung's natural
1989, Holas et al. 1994, Johnson et al. defences are overwhelmed when
1993). In turn, mortality following a excessive and/or toxic gastric contents
stroke as a consequence of pneumonia are aspirated, leading to a localized
(presumably due to aspiration) has infection or a chemical pneumonitis.
been reported as high as 3% within Factors associated with an increased
the first 3 months (Kidd et al. 1995) risk of aspiration pneumonia include:
and 6% within the first year (Hanning dysphagia related factors due to
et al. 1989). Aspiration pneumonia stroke (see Table 15.6), as well as
has therefore been regarded as reduced levels of consciousness, a
important because of its significant tracheostomy, gastric reflux or
contribution to morbidity and mortality emesis, nasogastric tubes (due to
(Arms et al. 1974, Gordon et al. 1987, mechanical interference with the
Hanning et al. 1989, Johnson et al. cardiac sphincter), and a compromised
1993, Logemann 1983, Silver et al. immune system (Finegold 1991).
1984, Veis and Logemann 1985). However, it remains uncertain to what
degree the aspiration of colonized
Aspiration alone is not sufficient to oropharyngeal contents contributes to
cause pneumonia. Aspiration of small pneumonia (Langdon et al. 2009).
amounts of saliva occurs during sleep
Table 15.6 Factors More Likely to be Associated with Aspiration Pneumonia
• Brainstem stroke
• Aspiration on VMBS (risk greater if aspirates over 10% of barium laced test material)
• Aspiration of thick fluids or solids
• Slower pharyngeal transit time on VMBS
15.5.1 Defining Aspiration Pneumonia pneumonia influences its incidence.
Much of the variability in incidence of
Clinical criteria for aspiration aspiration among studies can be
pneumonia across studies have proven accounted for by differences in the
to be variable (Table 15.7). Obviously inclusion criteria for the diagnosis of
the criteria used for defining pneumonia.
Table 15.7 Criteria For Defining Pneumonia in Stroke
Author/ Year Criteria
Johnson et al. 1993 Aspiration pneumonia was defined by either segmental consolidation or infiltrate on
USA chest x-ray or clinical diagnosis which included an episode of respiratory difficulty with
No Score segmental moist rales on auscultation and two other symptoms including temp
>100 °F, WBC >10,000 or hypoxia.
DePippo et al. 1994 Pneumonia was diagnosed by a positive chest x-ray or the presence of at least three
USA of the following: temp > 100 °F, drop in PO2 > 10 torr, presence of WBC in sputum
No Score and/or positive sputum culture for pathogen.
15. Dysphagia pg. 11 of 60
Holas et al. 1994 Pneumonia was diagnosed by a positive chest x-ray or the presence of at least three
USA of the following: temp > 100 °F, drop in PO2 > 10 torr, presence of WBC in sputum
No Score and/or positive sputum culture for pathogen.
Kidd et al. 1995 Diagnosis of pneumonia was based on the production of sputum in conjunction with
UK the development of crackles on auscultation, with or without the presence of fever or
No Score leucocytosis.
Smithard et al. Chest infection was diagnosed on the presence of at least two of the following:
1996 tachypnea (> 22/min), tachycardia, aspiratory crackles, bronchial breathing or
UK antibiotic usage.
Teasell et al. 1996 The criteria for pneumonia included radiological evidence of consolidation, and at least
Canada one other clinical feature including granulocytosis, temp >38°C and/or shortness of
No Score breath.
Dziewas et al. 2004 Pneumonia was diagnosed on the basis of 3 of the following indicators: temp >38°C,
Germany productive cough with purulent sputum, abnormal respiratory exam including
No Score tachypnea, (> 22 breaths/min), tachycardia, inspiratory crackles, bronchial
breathing, abnormal chest x-ray, arterial hypoxemia (PO2 < 9.3 kPa) and a positive
Carnaby et al. 2006 Pneumonia was diagnosed on the basis of 3 of the following indicators: temp >38°C,
USA productive cough, abnormal respiratory exam including tachypnea, (> 22
8 (RCT) breaths/min), tachycardia, inspiratory crackles, bronchial breathing, abnormal chest
x-ray, arterial hypoxemia (PO2 < 9.3 kPa), culture of a relevant pathogen; positive
swallowing response, assessed by
15.5.2 Relationship Between EMG activity and direct observation
Pneumonia and Dysphagia/Aspiration was greater than 20 sec. In contrast,
the latency of response was less than
A relationship between pneumonia and 4 seconds among patients without
dysphagia/aspiration has been dysphagia. The association between
reasonably well established despite pneumonia and both dysphagia and
variability among studies. Nakajoh et aspiration is examined among a series
al. (2004) have suggested that of studies using odds ratios. The
attenuated cough reflexes also results are presented in tables 15.8
increases a patients’ risk of And 15.9 and graphically in figures
pneumonia. The incidence of 15.1 and 15.2. In all cases the
pneumonia among dysphagic, incidence of pneumonia was higher
bedridden patients who had suffered among patients with dysphagia and/or
from a stroke for at least 6 months aspiration
was 9/14 (63%). The latency of the
15. Dysphagia pg. 12 of 60
Table 15.8 Relationship Between Dysphagia and Pneumonia
Study Incidence of Pneumonia Among Patients with OR (95% CI, fixed effects model)
and without Dysphagia
Gordon et al. 1987 7/37 vs. 4/50 2.63 (0.72 to 9.96)
De Pippo et al. 1994 10/82 vs. 1/57 7.78 (0.97 to 62.6)
Gottlieb et al. 1996 9/50 vs. 9/130 2.95 (1.10 to 7.94)
Smithard et al. 1996 20/60 vs. 9/57 2.67 (1.09 to 6.50)
Reynolds et al. 1998 18/69 vs. 3/33 3.53 (0.96 to 12.99)
Teasell et al. 2002 5/11 vs. 0/9 -
Falsetti et al. 2009 1/89 vs. 8/62 13.04 (1.44 to 286)
Combined estimate 70/398 vs. 34/398 2.28 (1.44 to 3.61)
Figure 15.1. Comparison of Pneumonia Frequency in Stroke Patients between
Dysphagic and Non-Dysphagia
Table 15.9 Relationship Between Aspiration and Pneumonia
Study Incidence of Pneumonia Among Patients with OR (95% CI, fixed effects model)
and without Aspiration
Holas et al. 1994 8/61 vs. 1/53 7.85 (0.95 to 65)
Schmidt et al. 1994 5/26 vs. 1/33 7.62 (0.83 to 70)
Kidd et al. 1995 17/25 vs. 2/35 35.06 (6.69 to 184)
Smithard et al. 1996 7/20 vs. 12/74 2.78 (0.92 to 8.42)
Teasell et al. 1996 10/84 vs. 2/357 24 (5.15 to 112)
Reynolds et al. 1998 12/35 vs. 9/68 3.53 (0.87 to 16.5)
Ding & Logemann 61/175 vs. 40/203 1.88 (1.18 to 2.99)
Meng et al. 2000 3/7 vs. 0/13 21 (0.90 to 490)
Lim et al. 2001 5/26 vs. 0/24 12.53 (0.65 to 240)
Combined estimate 128/468 vs. 67/850 6.53 (2.91 to 14.64)
15. Dysphagia pg. 13 of 60
Figure 15.2. Comparison of Pneumonia Frequency in Stroke Patients between
Aspirators and Non-Aspirators
From the pooled results presented
above (Figures 15.2 & 15.3) the Dysphagia and aspiration are both
presence of aspiration was associated with an increase in the odds
associated with a 4.5-fold increased of developing pneumonia. The risk of
risk of pneumonia while dysphagia developing pneumonia appears to be
(with or without aspiration) was proportional to the severity of the
associated with a 3-fold increase in aspiration.
The risk of developing pneumonia
Conclusions Regarding the following stroke is proportional to the
Relationship Between Aspiration and severity of aspiration.
can be assessed, preferably before the
15.6 Non-Instrumental Methods third day after the stroke. On the
for Screening and Assessment of other hand, screening describes the
problem in detail, determines the
Dysphagia Following Stroke severity of the swallowing problem
Stroke survivors should be screened and identifies optimal management
for dysphagia as soon as possible after strategies, including the need for a
acute stroke has been diagnosed and modified diet or enteral feeding.
emergency treatment has been given Assessment includes a clinical bedside
and before any oral intake is allowed. examination and, if warranted by the
Ideally, screening should take place as clinical signs, an instrumental
soon as the stroke survivor is awake examination, such as
and alert. Stroke survivors who pass videofluoroscopy. (Heart and Stroke
the screening are unlikely to have Foundation of Ontario 2002). Some
significant swallowing difficulties and common methods for screening and
have a minimal risk of dysphagic assessment of dysphagia are
complications. Individuals who fail the described in the following sections.
screen are maintained NPO until they
The Agency for Healthcare Research
15.6.1 Clinical Screening Methods and Quality published “Evidence
Report/Technology Assessment on
15. Dysphagia pg. 14 of 60
Diagnosis and Treatment of developed. Most of these screening
Swallowing Disorders in Acute-Care tests are comprised of two (or more)
Stroke Patients” in 1999. One of the components. Typically, there is some
conclusions reached by this group was form of swallowing trial, which is
that no screening tool has yet been preceded by a questionnaire or
developed that will accurately detect preliminary examination. A description
patients with dysphagia who require of the most familiar of these tools is
more extensive testing. Nevertheless, presented in Table 15.10.
many screening tools have been
Table 15.10 Description of Screening Tests Used to Identify Dysphagia Post Stroke
Author/Name of test Components of test Results
Details of validation study
DePippo et al. 1992 44 consecutive patients on a stroke The sensitivity and specificity of
rehabilitation unit with suspected dysphagia the WST to detect aspiration were
The Burke Dysphagia were studied. Patients were given 3 oz of 76% and 59%, respectively
Screening Test water from a cup and asked to drink without
interruption. Coughing for up to 1 minute
after the test or a wet-horse voice was
considered abnormal. Patients also received
a VMBS study and the results from the 2
tests were compared.
Daniels et al. 1997 59 acute stroke survivors were studied. Six 44/59 patients (74.6%) were
clinical features-dysphonia, dysarthria, dysphagic based on VMBS results.
“Any Two” abnormal volitional cough (includes water- The presence of 2 clinical features
swallowing test), abnormal gag reflex, correctly distinguished between
cough after swallow and voice change after subjects with normal swallow of
swallow were assessed. All subjects mild dysphagia from those with
received a VMBS study in addition to a moderate or severe dysphagia as
clinical exam and water swallowing test. determined by VMBS examination:
Hinds & Wiles 1998 Standardized questionnaire (11 questions) The ability of the 11 questions to
Timed test of swallowing: subject is given predict the need for a SLP referral:
“Timed test” small amount of water from a teaspoon. If Sensitivity: 0% - 69%
successful, 100-150 mL of water is given Specificity: 62%- 94%
with the instruction to drink as quickly as The ability of the water swallowing
possible. A test is considered abnormal if test to predict the need for a SLP
wet hoarse voice or coughing are noted, or referral:
if volume of water consumed are below Sensitivity: 100%
population norms. Specificity: 52%
115 consecutive subjects with acute stroke.
The tool was used to predict the need for
Logemann et al. 28 items divided into 5 categories: Aspiration: Throat clearing was
1999 i) 4 medical history variables best single predictor.
ii) 6 behavioural variables Sensitivity:78%
iii) 2 gross motor variables Specificity: 58%
iv) 9 observations from oromotor testing Oral stage disorder: dysarthria was
v) 7 observations during trial swallows the best single predictor.
The tool was designed to identify the Sensitivity: 64%
15. Dysphagia pg. 15 of 60
presence or absence of aspiration, oral Specificity:75%
stage disorder, pharyngeal delay, Presence of pharyngeal delay:
pharyngeal stage disorder. being rated as unsafe on at least
8/28 swallowing trials was the best
202 consecutive patients (34% stroke) were predictor.
examined. The results were of the screening Sensitivity: 69%
tool were compared with a VMBS exam. Specificity: 71%
Pharyngeal stage swallow disorder:
reduced laryngeal elevation was
the best single predictor.
Trapl et al. 2007 Preliminary Assessment (vigilance, throat First group of 50 patients: using a
clearing, saliva swallow) cut-off score of 14, the sensitivity
The Gugging Direct swallow ( semisolid, liquid, solid of GUSS to identify subjects at risk
Swallowing Screen swallow trials) of aspiration: 100%
(GUSS) Score: 0 (worst) - 20 (no dysphagia) Specificity: 50%
80 acute stroke patients were included. Second group of 30 patients
Results were compared with fibertopic Sensitivity: 100%
endoscopic evaluation. Specificity: 69%
Martino et al. 2009 311 stroke patients (103 acute, 208 Prevalence of dysphagia identified
rehabilitation) were studied. The tool was using VMBS: 39%
The Toronto Bedside designed to identify the presence/absence
Swallowing Screening of dysphagia. Sensitivity: 91%
Test (TOR-BSST) Specificity: 67%
Items included: voice before, tongue
movement, water swallow and voice after. Reliability (based on observations
The results of the screening tool were from 50 subjects) ICC =0.92 (95%
compared with a subset of subjects who CI: 0.85-0.96)
also received a VMBS exam.
Scoring: pass-4/4 items; fail ≥1/4 items
Edmiaston et al. 300 acute stroke patients screened by Prevalence of Dysphagia identified
2009 nurses within 8 to 32 hours following using MASA: 29%
Sensitivity (Dysphagia): 91%
Acute Stroke Items included: Glasgow Coma Scale score Specificity: 74%
Dysphagia Screen <13, presence of facial, tongue or palatal
asymmetry/weakness. If no to all 3 items, Sensitivity (aspiration risk): 95%
then proceed to 3 oz water swallowing test. Specificity: 68%
If no evidence of swallowing problems on
water swallowing test, then the patient Inter-rater reliability: 94%
passes the screen. Test-restest reliability: 92.5%
Scoring: pass-4/4 items; fail ≥1/4 items
Results were compared with the results of
the Mann Assessment of Swallowing Ability,
performed by a SPL.
Turner-Lawrence et A convenience sample of 84 stroke patients Prevalence of Dysphagia identified
al. 2009 (ischemic/hemorrhagic) was included. by SLPs: 48 (57%)
Examinations were conducted by 45 ER
Emergency Physician MDs. Sensitivity: 96%
15. Dysphagia pg. 16 of 60
The two-tiered bedside tool was developed Specificity: 56%
Tier 1 items included: voice quality, +Likelihood ratio: 2.2
swallowing complaints, facial asymmetry,
and aphasia. Reliability: Kappa=0.90
Tier 2 items included a water swallow test,
with evaluation for swallowing difficulty,
voice quality compromise, and pulse
oximetry desaturation (>or=2%).
Patients failing tier 1 did not move forward
to tier 2.
Patients who passed both tiers were
considered to be low-risk. These results
were compared with those from a formal
assessment by an SLP. Reliability was
assessed using a convenience sample of 32
Antonios et al. 2010 150 consecutive patients with acute Prevalence of Dysphagia identified
ischemic stroke were assessed by 2 by SLP using MASA: 54 (36.2%)
Modified Mann neurologists shortly after admission to
Assessment of hospital. The results were compared with Sensitivity: 87% & 93%
Swallowing Ability the assessments conducted by SLPs using Specificity: 86% & 84%
(MMASA) the full MASA.
+ Predictive Value: 79 & 76%
12 of the 24 MASA items were retained
including: alertness, co-operation, + Likelihood Ratio: 5.5 & 6.8
respiration, expressive dysphasia, auditory
comprehension, dysarthria, saliva, tongue Reliability: Kappa=0.76
movement, tongue strength, gag, volitional
cough and palate movement. Maximum
score is 100.
In addition to multiple component used as both a stand alone screening
tests, stand alone tests can be used to method and also as part of a clinical
screen for dysphagia. We examine two swallowing screening or assessment.
variations of the water swallowing test While the original test required a
in the two tables below. patient to swallow 3 oz (90 mL) of
water, lesser amounts have also been
15.6.2 The Water Swallowing Test used. The results of studies, which
have evaluated this technique, are
The water-swallowing test has also detailed in Table 15.11.
been studied extensively. It has been
Table 15.11 Sensitivity and Specificity of the Water-Swallowing Test
Author/Year Methods Outcome
Garon et al. 100 patients (50% stroke) with confirmed The sensitivity and specificity of the tool to
1995 or suspected dysphagia that required a identify confirmed aspirators were 54% and
USA VMBS study as part of clinical 79%, respectively.
15. Dysphagia pg. 17 of 60
No Score management. All patients were asked to
drink 3 oz. of water from a cup without
interruption. Any coughing or throat
clearing was indicative of an abnormal
water-swallowing test (WST). The results
of the 2 methods were compared.
Lim et al. 50 acute stroke patients received a 50 mL The 50-ml water swallow test had a
2001 water swallowing test (in 10 mL aliquots) sensitivity of 84.6% and specificity of 75.0%.
Singapore and a FEES examination. Patients also The oxygen desaturation test had a sensitivity
No Score received an oxygen desaturation test. of 76.9% and specificity of 83.3%. When the
two tests were combined into one test called
"bedside aspiration," the sensitivity rose to
100% with a specificity of 70.8%. Five (10%)
patients developed pneumonia during their
inpatient stay. The relative risk (RR) of
developing pneumonia, if there was evidence
of aspiration on FEES, was 1.24 (95% CI
Chong et al. 50 patients with suspected dysphagia, 65 The WST had a sensitivity of 79.4% and
2003 years or older, who had suffered either a specificity of 62.5% for the detection of
Singapore recent or remote stroke. Patients received aspiration, with a positive predictive value
No Score a clinical evaluation of swallowing which (PPV) of 81.8% and a negative predictive
included a water swallowing test (WST), value (NPV) of 58.8%. The oxygen
where patients were asked to drink 50 mL desaturation test had a sensitivity of 55.9%
of water in 10mL aliquots, and an oxygen and a specificity of 100% with PPV of 100%
desaturation test (desaturation of ≥ 2% and NPV of 51.6%. When both tests were
was considered clinically significant) and combined, a sensitivity of 94.1% and a
an objective test, fiberoptic endoscopic specificity of 62.5% were attained, with PPV
evaluation of swallowing (FEES), where of 84.2% and NPV of 83.3%. Using the
episodes of aspiration or penetration of clinical assessment test, 3 aspirators were
various food consistencies were noted. detected who would otherwise have been
The consistency or results between the missed if they were assessed with the water
tests were compared. swallow test using thin fluids alone.
Wu et al. 59 stroke outpatients with suspected 55 patients were identified as having some
2004 dysphagia underwent a 100 mL water- form of swallowing dysfunction on VMBS
Taiwan swallowing test. Signs of choking or a examination. An abnormal swallowing speed
No Score wet sounding voice within 1 minute of was detected in 47/55 patients. 2 patients
completing the test were considered with a normal VMBS result demonstrated
evidence of an abnormal swallow. abnormal swallowing speed on the WST. The
Swallowing speed (< 10 mL/s or ≥ 10 sensitivity and specificity of the test was
mL/s) was also recorded. The results 85.5% and 50%, respectively. 33 patients
were compared to a VMBS study. either aspirated or demonstrated penetration
on VMBS study. Of these 11 choked on the
WST, while 3 patients with a normal VMBS
result, choked on the WST. The sensitivity
and specificity of the test was 47.8% and
Nishiwaki et 61 consecutive stroke patients admitted Cough/voice change in the water swallowing
al. 2005 to 4 hospitals were assessed for test was the only variable that was
Japan dysphagia. Symptoms of oromotor significantly associated with aspiration on
No Score functions were evaluated (lip closure, VMBS examination with sensitivity of 72%
tongue movement, palatal elevation, gag and a specificity of 67%.
reflex, voice quality and motor speech
15. Dysphagia pg. 18 of 60
function). The water swallowing test
(using 30 mL of water), saliva swallowing
test and a VMBS examination were also
conducted. Factor analysis was used to
predict dysphagia in patients following
the onset of swallowing, which is
15.6.3 Swallowing Provocation Test identified by visual observation of the
(SPT) characteristic laryngeal movement,
and measured with a stopwatch. The
The SPT is a less frequently responses to the SPT are classified as
encountered two-stage screening test normal or abnormal according to the
that involves the bolus injection of 0.4 induction of the swallowing reflex after
mL and then 2.0 mL of distilled water the water injection. A time of seconds
at the suprapharynx through a small is used as a cut-off point to
nasal catheter (internal diameter 0.5 differentiate a normal from an
mm). This manoeuvre elicits an abnormal swallow.
involuntary swallow. The latent time is
then timed from the water injection to
Table 15.12 The Water Provocation Test
Author/Year Methods Outcome
Teramoto & A retrospective comparative trial of 26 The sensitivity and specificity of first-step SPT
Fukuchi stroke patients with aspiration pneumonia for the detection of aspiration pneumonia
2000 and 26 age-matched controls without were 100% and 83.8%, respectively. Those
Japan pneumonia were selected to assess the of the second-step SPT were 76.4% and
No Score properties of a swallowing provocation 100%, respectively. The sensitivity and
test (SPT) and a water swallowing test specificity of first-step WST using 10mL of
(WST) in detecting aspiration pneumonia water for the detection of aspiration
in elderly patients. The normal response pneumonia were 71.4% and 70.8%,
to SPT was determined by inducing respectively. Those of the second-step WST
swallowing reflex within 3 seconds after using 30mL of water were 72% and 70.3%,
water injection into the suprapharynx. In respectively.
WST, subjects drank quantities of 10 and
30mL of water from a cup within 10
seconds. A test was considered normal if
the subject drank water without
interruption and without evidence of
Warnecke et 100 patients with first-ever stroke were The incidence of endoscopically proven
al. 2008 examined by SPT and fiberoptic aspiration risk was 81%. The 1st-step SPT
Germany endoscopic evaluation of swallowing had a sensitivity of 74% and a specificity of
No Score (FEES) within 72 hours of stroke onset. A 100%. The 2nd-step SPT had 49% sensitivity
two-step approach was used. In the first and 100% specificity.
step 0.4 ml of distilled water was used. In
step 2, 2.0 ml was used.
We have presented a variety of the detection of dysphagia and
techniques and tools available to aid in aspiration. Once a patient fails a
15. Dysphagia pg. 19 of 60
screening test and it has been orophayngeal dysphagia suggest that
determined that a problem exists, there is only sufficient evidence to
typically a more comprehensive support the value of two tests:
assessment follows, from which abnormal pharyngeal sensation and
treatment options are determined. the 50 mL water-swallowing test. Both
of these tests assessed only for the
To be clinically useful, screening tests presence or absence of aspiration.
need to be valid, reliable, easy to use, Their associated likelihood ratios were
non-invasive, quick to administer (15- 5.7 (95% CI 2.5-12.9) and 2.5 (95%
20 min) and pose little risk to the CI 1.7-3.7), respectively. Limited
patient. Although many screening evidence for screening benefit
tools have been developed it is suggested a reduction in pneumonia,
unclear how many of them are used in length of hospital stay, personnel
institutions beyond those where they costs and patients.
were developed. Many institutions use
informal processes, or simply restrict
all food and drink until complete 15.6.4 The Bedside Clinical
assessment by an SLP. A wide range Examination for Assessment of
of sensitivities were reported among Dysphagia
the tools we reviewed (0% to 100%).
Usually, as sensitivity increased, Several forms of clinical or bedside
specificity decreased, such that the swallowing evaluations have been
number of patients who were described for the purposes of
incorrectly identified as dysphagic screening and/or assessment. Some of
increased. Generally screening tools these methods target specific
with sensitivity > 80%, with a functions or tasks, while others
specificity that approaches this figure evaluate swallowing ability using a
are considered to be both valid and more comprehensive approach. These
clinically useful. The majority of the methods may or may not include a
tools presented above do meet these water-swallowing test. Many of these
criteria. methods have been described
previously in the section on screening
The results of a systematic review by and share common features. (Table
Martino et al. (2000), evaluating the 15.13).
screening accuracy of 49 individual
clinical screening tests for
Table 15.13 Components of Various Bedside Techniques to Screen for or Assess
Author/Name of Components of test
test Details of validation study
Smithard et al. 121 stroke patients consecutively 50% of the patients were
1997 admitted to an urban hospital. considered to have an unsafe
Patients were given an assessment of swallow based on bedside
Bedside Swallowing conscious level, head and trunk evaluation alone.
Assessment control, breathing pattern, lip closure, Of these, 20 (16.5%)
palate movement, laryngeal function, patients aspirated on VMBS.
gag and voluntary cough (includes Sensitivity of bedside exam
water-swallow test). Patients received to detect aspiration on
both bedside and VMBS (n=94) VMBS: 47% (SLP); 68%
15. Dysphagia pg. 20 of 60
evaluations within 3 days of stroke. (MD).
Both an MD and a SLP each conducted Specificity: 86% (SLP); 67%
the bedside exam. (MD)
Mann et al. 2002 128 acute first-ever stroke patients 65 (51%) subjects
received both a bedside and VMBS demonstrated evidence of
Mann Assessment exam. General examination: dysphagia on bedside exam
of Swallowing Consciousness, cooperation, language and 28 (21.9%)
Ability function, verbal/oral praxis, demonstrated evidence of
articulation aspiration on VMBS exam.
24 items including- Using a cut-off score of <180
Oral preparation: Control of saliva, lip the sensitivity and specificity
seal, tongue movement/strength, oral of bedside assessment to
preparation, assessment of respiration detect dysphagia were 71%
Oral phase: Gag reflex, palatal and 72%.
movement, oral transit time, bolus
clearance The sensitivity and specificity
Pharyngeal phase: Pharyngeal of bedside assessment to
control/pooling, laryngeal elevation, detect aspiration were 93%
reflex/voluntary cough, voice quality and 53%.
Includes water swallowing test
Scoring for dysphagia:
No abnormality ≤178-200
Mild ≤ 168-177
Moderate ≤ 139-167
Severe ≤ 138
15.6.5 Other Methods of whom had suffered a stroke) using
VFS as the diagnostic gold standard.
In addition to conventional assessment Of five voice parameters tested
methods tracheal pH monitoring has (average fundamental frequency,
also been used experimentally to relative average perturbation, shimmer
detect drops in pH, which may indicate percentage, noise-to-harmonic ratio,
aspiration. Clayton et al. (2006) and voice turbulence index), relative
reported that in 9 of 32 patients average perturbation most accurately
examined, there was a drop in tracheal predicted aspiration.
pH following ingestion of acidic foods.
Tracheal pH was monitored by the use Cervical auscultation of the mechanical
of a sensor, which was inserted into and/or respiratory components of
the trachea by the crichothyroid swallowing, lateral cervical soft tissue
membrane. All patients were studied radiographs and pharyngeal or
following the ingestion of foods which esophageal manometry have also been
had been considered to be safe on the used to detect dysphagia (as reviewed
basis of a VMBS examination. by Ramsey et al. 2003).
Other forms of clinical assessment While bedside assessment and other
have been used to detect the presence non-invasive methods are easy to
of aspiration. Ryu et al. (2004) perform, these methods have been
recently evaluated voice analysis as a shown to predict poorly the presence
means to clinically predict laryngeal of silent aspiration. Smith et al. (2000)
penetration among 93 patients (46% reported that aspiration cannot be
15. Dysphagia pg. 21 of 60
distinguished from laryngeal pudding, bread, and cookies are
penetration using a bedside evaluation, routinely used. Various aspects of
resulting in the over diagnosis of oral, laryngeal, and pharyngeal
aspiration and, in some cases, involvement are noted during the
needless dietary restrictions. radiographic examination (Table
Therefore, instrumental methods are 15.14). The VMBS study is then
frequently used to directly observe the followed by a chest x-ray to document
swallowing mechanism. any barium, which may have been
aspirated into the tracheobronchial
Conclusions Regarding Dysphagia tree.
Screening and Non-instrumental
Assessment Techniques The VMBS assessment not only
establishes the presence and extent of
Although a wide variety of screening aspiration but may also reveal the
and assessment tests are available for mechanism of the swallowing disorder.
use, none have acceptable sensitivity Aspiration most often results from a
and specificity to ensure accurate
functional disturbance in the
detection of dysphagia.
pharyngeal phase of swallowing related
to reduced laryngeal closure or
15.7 Instrumental Methods Used in pharyngeal paresis. A VMBS study is
the Detection of recommended in those cases where
Dysphagia/Aspiration the patient is experiencing obvious
problems maintaining adequate
hydration/nutrition, where concern is
15.7.1 VMBS Examination expressed regarding frequent choking
while eating, or in the case of
When aspiration is suspected, the recurrent respiratory infections. Other
videofluoroscopic modified barium factors such as cognition, recurrent
swallow (VMBS) study is often stroke, depression,
considered the "gold standard" in immunocompromization, and
confirming the diagnosis (Splaingard et underlying lung disease must also be
al. 1988). A VMBS study examines the considered. A definitive criterion to
oral and pharyngeal phases of determine if a VMBS study is required
swallowing. The patient must have has yet to be determined in a
sufficient cognitive and physical skills systematic and scientific manner.
to undergo testing (Bach et al. 1989). Repeat VMBS studies are usually
The subject is placed in the sitting conducted at the discretion of the
position in a chair designed to simulate SLP/MD based on the progress and
the typical mealtime posture. Radio- prognosis of the individual patient. No
opaque materials of various standard schedule for re-assessment
consistencies are tested: barium exists.
impregnated thin and thick liquids,
15. Dysphagia pg. 22 of 60
Table 15.14 Radiological Evaluation During VMBS (from Bach et al. 1989)
Tongue: Anterior and posterior motion with consonants; motion and coordination during
transport, and manipulation of bolus
Soft palate: Evaluation and retraction with consonants
Swallow: Delay, absence
Peristalsis: Residue in valleculae, pyriform sinuses nasopharyngeal regurgitation
Elevation of larynx
Penetration into laryngeal vestibule
Cough: Presence, delay, effectiveness
Vocal cord function
Post Exam Chest X-Ray
Presence of barium in valleculae, pyriform sinuses, tracheoboncheal tree, lungs
While VMBS studies can be useful in Although VMBS studies are considered
analyzing the anatomic structures the gold standard for detection of
during swallowing and detecting silent aspiration, other clinical assessment
aspiration, there are some techniques, designed to be less
disadvantages: i) The procedure is invasive, cheaper and easier to
relatively complex, time consuming administer are in current use. Flexible
and resource intensive; ii) there is endoscopic examination of swallowing
some exposure to small amounts of (FEES), also referred to as fibertopic
radiation; iii) the test is not endoscopic evaluation of swallowing,
appropriate for some patients who is also recognized as an objective tool
may for the assessment of swallowing
have difficulty in sitting upright in a function and aspiration. The method
chair. The results of the test can also has been demonstrated to be safe and
be difficult to interpret and there can well-tolerated (Warneke et al. 2009).
be significant variation among FEES is a procedure that allows for the
individual raters (Ramsay et al. 2003). direct viewing of swallowing function.
The procedure involves passing a very
15.7.2 Flexible Endoscopic Evaluation thin flexible fiberoptic tube through
of Swallowing (FEES) the nose to obtain a view directly
down the throat during swallowing.
FEES allows for the full evaluation of
15. Dysphagia pg. 23 of 60
the swallow function as food passes the stroke patients, the incidence of
from the mouth into the throat. It is pneumonia managed by FEESST was
able to identify functional significantly lower. The authors
abnormalities that may occur and is speculated that one of the reasons for
used in 'practice swallows' to help the lower incidence might be due to
determine the safest position and food the sensory testing component of the
texture to maximize nutritional status FEES examination, absent from VMBS
and eliminate the risk of aspiration evaluation, information which was
and unsafe swallowing. In addition to used to more effectively guide
assessing the motor components of management.
swallowing, FEES can also include a
sensory testing assessment when an Rather than attempt to compare the
air pulse is delivered to the mucosa accuracy of swallowing abnormalities
innervated by the superior laryngeal assessed between VMBS and FEES
nerve. This form of assessment is evaluations Leder & Espinosa (2002)
known as flexible endoscopic compared the ability of six clinical
examination of swallowing with identifiers of aspiration (dysphonia,
sensory testing (FEESST). FEESST was dysarthria, abnormal gag reflex,
shown to be a safe technique when abnormal volitional cough, cough after
used to assess the swallowing function swallow, and voice change after
of 500 consecutive subjects. There swallow), with FEES to determine the
were only three occurrences of a ccuracy of predicting aspiration risk
nosebleeds and no instances of a following stroke. Their results suggest
compromised airway. The procedure that the ability of the test to correctly
was generally found to be, at worst, identify patients not at risk of
mildly uncomfortable (Aviv et al. aspiration, was poor using clinical
2000). criteria. Two studies used FEES as the
gold standard to assess the accuracy
Aviv et al. (2000) compared the of either the water-swallowing test
incidence of pneumonia over a one- and/or pulse oximetry to detect
year period between patients aspiration (Lim et al. 2001, Chong et
managed by VMBS or FEES. Among al. 2003).
Table 15.15 Studies Evaluating FEES
Author/Year Methods Outcome
Aviv 2000 78 outpatients referred for dysphagia There was no difference in the incidence of
USA evaluation were assigned to a VMBS pneumonia between the groups. At the end of
No Score group to guide swallowing management, one-year 14 (18.4%) patients whose
while 61 patients received FEES with management had been guided by MBS
sensory testing. The incidence of developed pneumonia, compared with 6
pneumonia over a one-year period (12%) patients in the FEES group (p< 0.20).
between groups was compared. Patients However, among 45 stroke patients the
received feeding tubes, therapy from a incidence of pneumonia was lower among
speech-language pathologist based on the FEES group patients (1/21 vs. 7/24, p<0.05).
results obtained from the VMBS/FEES test
Leder & 53 consecutive stroke patients referred The clinical exam correctly identified 19/22
Espinosa for swallowing assessment were patients considered at risk for aspiration. The
15. Dysphagia pg. 24 of 60
(2002) evaluated for the presence of aspiration clinical exam incorrectly identified 8/27
No Score using a bedside evaluation which was patients to be at risk of aspiration. The
immediately followed by a FEES sensitivity and specificity of the clinical
examination. FEES was used as the assessment were 86% and 30%, respectively.
diagnostic standard. The corresponding positive and negative
predictive values were 50% and 73%.
15.7.3 Pulse Oximetry
Pulse oximetry has also been simultaneously by VFS, among 60
suggested as an alternative to patients with dysphagia due to stroke
detecting aspiration, based on the and nasopharygeal cancer, while
principle that aspiration of food into Collins and Bakheit (1997) reported
the airway leads to bronchospam or that pulse oximetry could be used to
airway obstruction, which leads to a detect a high proportion of stroke
reduction in oxygen saturation. This patients who aspirated on VMBS.
technique is non-invasive, requires
little patient cooperation and is easy Age may also be a factor in predicting
to obtain. However, the accuracy of oxygen saturation. Rowat et al.
pulse oximetry in detecting aspiration (2000) reported that the baseline
is unproven and it remains uncertain oxygen saturation among a group of
whether oxygen desaturation can stroke patients deemed safe to feed
predict aspiration. Wang et al. (2005) orally was significantly lower
reported no significant association compared to both hospitalized elderly
between the reduction in oxygen patients and young healthy subjects
saturation and aspiration, identified (95.7 vs. 96.7 vs. 97.9%, p<0.001).
Table 15.16 Studies Evaluating Pulse Oximetry
Author/Year Methods Outcome
Collins & 54 consecutive stroke patients with 22 patients demonstrated aspiration on VMBS
Bakheit swallowing difficulties were studied. evaluation. Correlation of the pulse oximetry
1997 Patients received a VMBS study and results with VMBS findings showed that 12
UK simultaneously had their arterial oxygen (55%) of the patients who aspirated had a
No Score saturation measured. The barium meal significant degree of oxygen desaturation at
consisted of 150 mL liquid, 3 oz. mousse the point of swallow/aspiration, but none of
and biscuit. A drop of 2% in the arterial the nonaspirators desaturated by 2%. When
oxygen saturation was considered the results of oximetry at swallow/aspiration
clinically significant. Oxygen saturation and at 2 minutes after swallowing were
was measured during swallowing, 2 combined, 16 (73%) of the aspirators could
minutes after the test meal and 10 be identified by this method, and 4 (13%) of
minutes after the VMBS study was the nonaspirators also had a significant
completed. oxygen desaturation. In total, 44 patients
(81.5%) were accurately predicted as
aspirators or nonaspirators ( =0.61, P<.001).
Prediction was better for males compared to
females. The sensitivity and specificity of
pulse oximetry were 73% and 87%,
15. Dysphagia pg. 25 of 60
Sellars et al. Six patients (4 with stroke) with 4 patients demonstrated aspiration of VMBS.
1998 established dysphagia underwent both Of these, 2 exhibited significant 02
UK VMBS evaluation with simultaneous desaturation.
No Score oxygen saturation monitoring. Decline in
02 saturation of 4% from baseline was
considered clinically significant.
Sherman et 46 (16 with stroke) with swallowing 12/46 patients (6 with stroke) aspirated on
al. 1999 difficulties underwent VMBS evaluation VMBS. Patients who aspirated had a
USA with simultaneous oxygen saturation significantly greater decline in oxygen
No Score monitoring (with a 5-6 second sampling saturation compared to those who did not
interval). aspirate. The lowest O2 saturation value
among patients who aspirated was 81%
compared with 92% among patients who did
Smith et al. 53 consecutive patients with acute stroke 15/53 patients aspirated on VMBS
2000 received a bedside evaluation, pulse examination. The SN, SP, PPV and NPV for
UK oximetry and a VMBS evaluation of pulse oximetry to identify aspiration were
No Score swallowing. The sensitivity (SN), 87%, 39%, 36% and 88%, respectively.
specificity (SP), positive predictive value
(PPV) and negative predictive value (NPV)
were calculated for both the bedside
evaluation and pulse oximetry.
Wang et al. 60 patients (27 with stroke) received both 23/60 patients demonstrated aspiration on
2005 oxygen saturation and VMBS evaluation. VMBS examination. Of these patients 9
Taiwan Oxygen saturation was monitored for 5 displayed significant oxygen desaturation (a
No Score minutes before and for 5 minutes after drop of > 3% was considered significant. Of
the VMBS evaluation. the 37 patients who did not demonstrate
aspiration on VMBS, 15 had an episode of
oxygen desaturation. The sensitivity and
specificity were 39.1% and 59.4%,
respectively. The positive and negative
predictive values were 37.5% and 61.1%,
respectively. The positive likelihood ratio was
Ramsey et al. 189 stroke patients received a bedside 15 (28%) demonstrated aspiration on VMBS.
2006 swallowing assessment (BSA), pulse Of these, 2% destauration was seen in 5
UK oximetry and VMBS (n=54) studies. Two (33.3%) of these patients and in 2 (13.3%)
No Score cut-points were selected to determine the when >5% threshold was used. 7/15
presence/absence of oxygen destauration patients (47%) with demonstrated aspiration,
(>2% and >5%). failed the BSA. The sensitivity and specificity
associated with >2% destauration were 33%
and 62% and were 13% and 95% for an
oxygen desaturation threshold of >5%.
Although pulse oximetry is a quick and above studies will attest to.
non-invasive method to detect
aspiration following stroke, its 15.8 Management of Aspiration
association with oxygen desaturation
have been inconclusive. Generally, its
performance when measured against
VMBS studies has been poor as the As mentioned previously, the VMBS
low sensitivities/specificities from the study is still considered the "gold
standard" in the diagnosis of
15. Dysphagia pg. 26 of 60
aspiration. Those patients who have Conclusions Regarding Instrumental
difficulty with high volumes of thin Methods to Detect Dysphagia Post
liquids are considered to be at mild to Stroke
moderate risk of aspiration. In these
cases oral feedings are regarded as The VMBS study is considered the gold
appropriate. Before deciding if a standard to detect silent aspiration.
patient is a candidate for oral feeding, Other methods such as FEES and pulse
oximetry are also in use.
factors such as the patient's
respiratory status, the effectiveness of
15.8.1 Management Strategies for
airway clearance along with the type
and amount of aspirate must first be
considered (Bach et al. 1989).
The Heart and Stroke Foundation
Aspirating more than 10% of the test
Dysphagia Guidelines noted that, “a
bolus is generally considered an
well coordinated care plan can
indication for non-oral (ie. nasogastric,
minimize the development of
gastrostomy, jejunostomy tube)
dysphagic complications, reduce
feedings; however, the actual risks
length of hospital stay in acute-care
present with oral feedings for this
facilities and expedite access to
group of patients have not been fully
specialized rehabilitation centers.
established. Determining whether the
Dysphagia management has the
patient actually aspirates more or less
than 10% of the test bolus is, as
• Meeting the nutrition and hydration
mentioned previously, an inexact
requirements of the stroke survivor.
• Preventing aspiration-related A speech-language pathologist should
complications. regularly monitor the status of
• Maintaining and promoting individuals with dysphagia to ensure
swallowing function as much as that the management strategies
possible. employed remain appropriate,” (Heart
and Stroke Foundation of Ontario
Dysphagia management strategies 2002).
include the following:
• Modifying food and fluid textures to 15.8.2 Best Practice Guidelines for
increase safety of oral intake. Managing Dysphagia
• Using low-risk feeding practices and
compensatory strategies to prevent Best practice guidelines for managing
complications such as aspiration and dysphagia were developed by a
choking. consensus committee sponsored by
• Monitoring oral intake to prevent the Heart and Stroke Foundation of
dehydration. Ontario (2002). These are
• Supplementing the diet to maintain summarized in Table 15.17.
• Using enteral feeding for individuals
who are unable to swallow.
• Implementing swallow therapy to
rehabilitate specific physiological
15. Dysphagia pg. 27 of 60
Table 15.17 Best Practice Guidelines for Managing Dysphagia Post-Stroke (HSFO
• Maintain NPO until swallowing status is determined
• Regular oral care, with minimum of water to limit build-up of bacteria
• Screen for swallowing status by trained team member once awake and alert
• Screen for risk factors of poor nutrition early by trained team member
• Swallowing assessment necessary for all those who fail swallowing screen
• Swallowing assessment by speech-language pathologist to:
- assess ability to swallow
- determine swallowing complications
- identify associated factors which may be compromising swallowing and nutrition
- recommend appropriate individualized management program, including appropriate
- monitor hydration status
• Where appropriate feeding assistance or mealtime supervision by individuals trained in low-
risk feeding strategies
• Assess nutrition and hydration status and needs of those who fail screening; reassess regularly
• Education of patient and family into follow-up upon discharge
• Consider the wishes and values of the patient and family concerning oral and non-oral
nutrition; provide information to allow informed choices.
Conclusions Based on Best Practice
Guidelines for Managing Dysphagia There is consensus (Level 3) opinion
that a dietician should assess the
There is consensus (Level 3) opinion nutrition and hydration status of all
that acute stroke survivors should be stroke patients who fail swallowing
NPO until swallowing ability has been screening.
All stroke survivors should remain
There is consensus (Level 3) opinion NPO until a trained assessor has
that a trained assessor should screen assessed swallowing ability.
all acute stroke survivors for
swallowing difficulties as soon as they
are able. Feeding assistance should be
provided by an individual trained in
There is consensus (Level 3) opinion low-risk feeding strategies where
that a speech and language pathologist appropriate,
should assess all stroke survivors who
fail swallowing screening and identify
Following a failed screening
the appropriate course of treatment.
assessment, all patients should be
assessed by a Speech-Language
There is consensus (Level 3) opinion
Pathologist and an appropriate
that an individual trained in low-risk
management plan be initiated.
feeding strategies should provide
feeding assistance or supervision to
stroke survivors where appropriate.
15. Dysphagia pg. 28 of 60
15.8.3 Dysphagia Screening Protocols
Two studies have evaluated whether pneumonia. One study used a
the implementation of dysphagia historical control while the other used
screening protocols resulted in a a concurrent control group (Table
reduction in the incidence of 15.18).
Table 15.18 Dysphagia Screening Protocols
Author/Year Methods Outcome
Odderson et The incidence of pneumonia was assessed The percentages of patients who developed
al. 1995 in a single institution before the pneumonia before the pathway was
USA implementation of a dysphagia screening developed, during the first year of the
No Score protocol, during the first year after its pathway and during the second year of the
implementation and during the second pathway were 6.7%, 4.1% and 0%,
Hinchey et al. 15 acute care hospital sites were 6 sites had a formal dysphagia screen. Their
2005 surveyed to determine whether they had adherence rate was 78% compared with 57%
USA an established dysphagia screening at sites with no formal screen. The
No Score protocol in place and to establish the pneumonia rate at sites with a formal
adherence level. The incidence of dysphagia screen was 2.4% versus 5.4%
pneumonia between institutions which (p=0.0016) at sites with no formal screen.
had/ did not have formal screening in There was no difference in median stroke
place was compared. severity (5 versus 4; P=0.84) between the
sites with and without a formal screen.
There is evidence from two studies dysphagia who are fed are
that the initiation of a dysphagia approximately 20 times more likely to
screening program can help to develop pneumonia than those who
reduce the incidences of pneumonia, feed themselves (Langmore et al.
presumably through earlier detection 1998). Therefore, if dysphagic
and subsequent management of individuals cannot feed themselves
swallowing difficulties. independently, hand- over-hand
support should be provided from an
Conclusions Regarding the Benefits of eye level position. If full feeding
Dysphagia Screening Protocols assistance is necessary, it should be
provided using low risk feeding
There is limited (Level 2) evidence that strategies.
dysphagia screening protocols can
reduce the incidence of pneumonia. Routine use of low-risk feeding
strategies can prevent serious health
15.8.4 Low-Risk Feeding Strategies
problems and improve the quality of
the experience for the person being
fed. All health care professionals
The Heart and Stroke Foundation involved in feeding dysphagic
Dysphagia Guidelines noted that, individuals should also be able to deal
“Stroke survivors should be with emergencies, such as choking,
encouraged and assisted to feed which may occur during feeding.”
themselves. Individuals with
15. Dysphagia pg. 29 of 60
Guidelines for low-risk feeding
practices are summarized in Table
Table 15.19 Heart and Stroke Foundation of Ontario Guidelines for low-risk feeding
•Check the food tray to ensure the correct diet type has been provided.
•Ensure the environment is calm during meals and minimize distractions.
•Position the stroke survivor with the torso at 900 angle to the seating plane, aligned in mid-position with
the neck slightly flexed.
•Support the stroke survivors with pillows if necessary.
•Perform mouth care before each meal to remove bacteria that have accumulated on the oral mucosa.
•Feed from a seated position, so that you are at eye level with the stroke survivor.
•Do not use tablespoons. Use metal teaspoons, never plastic for feeding individuals with bite reflexes.
•Use a slow rate of feeding and offer a level teaspoon each time.
•Encourage safe swallowing of liquids by providing them with wide-mouth cup or glass or in a cut-down
nosey cup, which helps prevent the head from flexing backward and reduces the risk of aspiration. Some
individuals may benefit from drinking through a straw.
•Ensure that swallowing has taken place before offering any additional food or liquid.
•Observe the stroke survivor for any signs or symptoms of swallowing problems during and for 30
minutes after the meal.
•Perform mouth care after each meal to ensure that all food debris is cleared from the mouth.
•Position the patient comfortably upright for at least 30 minutes after each meal to promote esophageal
clearance and gastric emptying and to reduce reflux.
•Monitor the oral intake of the stroke survivor with dysphagia: note any food items that are not
consumed and ensure that intake is adequate, especially important in individuals receiving a thickened-
•Document the patient’s intake, any changes in swallowing status and any self-feeding problems.
Conclusions Regarding Feeding
Strategies in Dysphagia
There is limited (Level 2) evidence that
individuals with dysphagia should feed
themselves to reduce the risk of
For patients who require assistance to
feed, there is a consensus (Level 3)
opinion that low-risk feeding strategies
by trained personnel should be
Individuals with dysphagia should
feed themselves whenever possible.
When not possible, low-risk feeding
strategies are needed.
15. Dysphagia pg. 30 of 60
dysphagia following stroke. The review
15.9 Specific Interventions to included 6 studies, including an
Manage Dysphagia abstract and unpublished data,
assessing how and when to feed, oral
supplementation and how and when to
Previous Reviews treat. Although few studies were
A Cochrane systematic review (Bath et available, the following conclusions
al. 1999) evaluated the benefit of were reached.
different management strategies for
Table 15.20 Results From Cochrane Review Evaluating Treatments for Dysphagia
Enteral feeding: Based on the results from 2 studies percutaneous endoscopic gastrostomy (PEG) was
associate with lower case fatality rates, treatment failures and improved nutritional parameters,
compared with nasogastric (NG) tube feeding.
Timing of feeding: No studies
Nutritional supplementation: Based on the results from a single study this intervention was associated
with improved energy and protein intake.
Fluid supplementation: Based on the results of a single trial there was no evidence of a benefit in
reducing the time to resolution of dysphagia.
Swallowing therapy: Based on the results from two studies there no evidence of a reduction in end-of-
Drug therapy: Based on the result of a single trial, there was no evidence of a decrease in mortality or
frequency of dysphagia associated with nifedipine treatment.
A recent systematic review (Foley et
al. 2008) also evaluated the efficacy of 15.9.1 Dietary Modifications
a broader range of dysphagia
treatments including: texture-modified Dysphagia diets have three purposes:
diets, general dysphagia therapy 1) to decrease the risk of aspiration, 2)
programmes, non-oral (enteral) to provide adequate nutrients and
feeding, medications, and physical and fluids, and 3) to provide a progressive
olfactory stimulation. In this review, 15 approach to feeding based on
RCTs were identified. In contrast with improvement or deterioration of
the findings of the Cochrane review, swallowing function (Bach et al. 1989).
there was evidence that nasogastric No single dysphagia diet exists. Diets
tube feeding was not associated with a include modified food and liquid
higher risk of death compared to textures (HSFO, 2002). Special diets
percutaneous feeding tubes. General are based upon four distinct
dysphagia therapy programmes were consistencies: thick fluids, pureed,
associated with a reduced risk of minced and soft chopped. A dysphagia
pneumonia in the acute stage of soft diet excludes all hard, small and
stroke. stringy food particles (Bach et al.
1989). There are three consistencies
of meat in the soft diet; soft chopped,
15. Dysphagia pg. 31 of 60
minced and ground. A pureed diet has frequent cueing may be necessary in
the consistency of pudding and is these cases (Milazzo et al. 1989).
generally easier to swallow than a
more regular diet (Veis and Logemann The restrictions associated with a diet
1985). However, the risk of aspiration of thick fluids can eliminate all thin
of pureed food was recently reported liquids. Alternatives to thin liquids
by Perlman et al. (2004). 204 stroke such as jelled water or liquids may be
patients were divided into six groups required. There is some evidence that
based on the results of dietary modifications may reduce the
laryngopharyngeal sensory testing, incidence of aspiration pneumonia
assess by flexible endoscopic (Groher 1987) although it has not
evaluation. No patients with both been definitively established as to what
normal sensation and pharyngeal effect the mode of feeding has on the
squeeze aspirated pureed consistency rate of respiratory infection.
foods. The percentage of aspirators
increased to 67% in patients with The Heart and Stroke Dysphagia
moderately decreased sensation and Guidelines noted “Diet texture
absent motor function. The results of modification, however, can reduce an
this study suggest that motor strength individual’s enjoyment of food,
may be more important than sensory resulting in decreased oral intake. This
impairment in the prediction of can rapidly lead to dehydration and
aspiration. eventually to malnutrition. Also, the
use of starch-based food thickeners
Over time, particularly in the earlier increases carbohydrate intake, which
stages following stroke, changes to the may produce a nutritional imbalance if
diet can be made as the patient's the diet is not carefully monitored.
dysphagia improves and the risk of Controlling dietary carbohydrates is
aspiration lessens. Progression can be especially important in individuals with
determined by clinical swallowing diabetes. It is therefore critical to
assessments unless the patient is a consult a dietitian to ensure that the
"silent aspirator", detectable only on modified diet is nutritionally adequate
VMBS study, in which case the clinical and appropriate, and to consult the
examination must be considered stroke survivor or substitute decision-
unreliable. A repeat VMBS study may maker to ensure that the modified diet
be needed in these cases in order to is as appealing as possible” (Heart and
guide management. Special Stroke Foundation of Ontario 2002).
techniques such as compensatory head
and neck postures (Logemann 1983), Avoidance or careful regulation of thin
double swallowing or coughing after liquids is a common dietary
swallowing (Horner et al. 1988b) may modification, as this food consistency
be employed. Many stroke patients, is the most likely to be aspirated. Thin
especially those with right hemispheric fluids are poorly manipulated in transit
lesions, are very impulsive and may through the oral-pharynx. Severely
attempt to eat and swallow at too fast dysphagic patients are often managed
a rate. Finestone et al. (1998) initially by enteral tube feedings and
documented a case in which a man, progress to the re-introduction of oral
post stroke died following airway feeding, typically beginning with a
obstruction caused by a food bolus. pureed diet. Eventually patients are
Therefore close supervision with allowed thin liquids when it has been
15. Dysphagia pg. 32 of 60
established that the patient can CI 3.6-14.3), Diuretic usage
successfully swallow without augmented the risk; an aspirating
aspirating. Currently no randomized patient concurrently taking a diuretic
controlled studies have demonstrated for hypertension or management of
whether these modified diets influence congestive heart failure was 20 times
outcome although a large multi- more likely to experience dehydration
centered trial has been completed and (OR 19.8, 95% CI 3.0-211).
the results are pending publication
(Dennis 1997). In a recent study, Diniz et al. (2009)
examined 61 acute stroke patients for
Although thickened fluids may help to signs of aspiration after receiving both
reduce the risk of aspiration and thin liquids and pudding-like feeds
associated morbidity, Finestone et al using nasoendoscopy. Aspiration
(2001) reported that patients occurred in only 3 patients with the
restricted to thickened fluids not drink spoon-thick consistency vs. 21 with
sufficient quantities to meet their fluid the liquid consistency (relative
needs and are at risk for dehydration. risk=0.13; 95% confidence
Patients receiving dysphagia diets interval=0.04-0.39; P<.001). There
along with texture-modified solids were no episodes of laryngeal
received only 43% of their estimated penetration with pudding-like fluids
fluid requirement over the first 21 days and 8 incidences with thin liquid.
post stroke, while in hospital. Although Patients in this study all had feeding
dietary modifications were not tubes in situ. However, Leder & Suiter
specifically addressed, Churchill et al. (2009) reported than the placement of
(2004) found that dysphagic patients NG feeding tubes did not increase the
had a higher risk of becoming risk of aspiration for liquid or pureed
dehydrated, defined as a peak blood food consistencies. This study included
urea nitrogen (BUN) ≥ 45. The odds dysphagic patients with a broad range
ratio (OR) associated with dehydration of etiologies, including stroke. The
was 4.2 (95% CI 2.1–8.3) among sample size was large (n=1,260).
patients admitted for inpatient stroke
rehabilitation, and was even higher for Dietary management is often directed
patients with aspiration, detected by the results of the VMBS studies.
through videofluoroscopic Studies examining the efficacy of fluid
examinations and presumed to be on a modifications are presented in Table
texture-modified diet (OR: 7.2; 95% 15.21.
Table 15.21 Studies of Dietary Modifications in Dysphagia
Author/Year Methods Outcome
Groher et al. 56 stroke patients with chronic Study group had fewer occurrences of
1987 dysphagia, on a pureed diet prior to aspiration pneumonia (5 vs. 28, p<0.05). (If
USA study and at least 1 month post persons who developed pneumonia on more
3 (RCT) resolution of aspiration pneumonia were than one occasion are ignored the incidence
randomized to receive: i) a soft of pneumonia was still lower in the study
mechanical diet and thickened liquids or group: 4 vs. 18).
ii) pureed foods and thin liquids.
The recurrence of aspiration pneumonia
over a 6-month period was assessed.
Garon et al. 20 dysphagic stroke patients were No patient in either group developed
15. Dysphagia pg. 33 of 60
1997 randomized to receive either a regular dehydration or pneumonia within the 30- day
USA dysphagia diet including thickened fluids trial period, or required intravenous fluids.
5 (RCT) (control group) or to a dysphagia diet There were no significant differences in total
which allowed the inclusion of unlimited fluid intake between the groups. However,
amounts of water (study group) between patients in the study group drank significantly
meals. less thickened fluid compared to patients in
the control group.
Goulding & 46 dysphagic inpatients were Higher viscosity of fluid prepared using
Bakheit 2000 randomized to receive thickened fluids subjective assessment. There were no
UK prepared using conventional subjective significant differences in the incidence of
6 (RCT) assessment of viscosity or fluids aspiration between the groups. Strong
thickened with the aid of viscometer for correlation between increased viscosity and
7 days. portion of thickened fluid that was not
Perlman et al. 204 dysphagic patients underwent Sensation Motor Function Aspiration (%)
2004 assessment of swallowing function and Normal Normal 0
USA sensory evaluation with flexible Normal Absent 14
No Score endoscope. Patients were then divided Mod decrease Normal 0
into 3 groups, with normal, moderate Mod decrease Absent 67
and severe sensory deficits. Each group Severe/absent Normal 6
was divided into those with Severe/absent Absent 40
impaired/normal pharyngeal squeeze.
Patients were then tested for aspiration
following a pureed food bolus.
Diniz et al. 61 patients, 19 with acute stroke Aspiration occurred in 24 patients. A higher
2009 received a trial of either liquid or spoon- proportion of patients aspirated with liquid
Brazil thick liquids in random order and were samples (3 vs. 21, p<0.001). There was no
6 (RCT) assessed for evidence of dysphagia evidence of penetration among patients given
(penetration, aspiration or residue) using spoon-thick liquids compared with 8 instances
nasoendoscopy. Patients also underwent following liquid challenges (p<0.006).
a clinical examination and bedside
Conclusions Regarding Dietary There is moderate (Level 1b) evidence
Modifications that thickened fluids result in fewer
episodes of aspiration and penetration
There is consensus (Level 3) opinion compared with thin fluids among
that dysphagic stroke patients, who are dysphagic individuals following stroke.
considered safe with oral intake require
diets with modified food and liquid Dysphagic stroke patients should be
textures. Although dietary provided with an appropriate modified
modifications have been used to help diet, after consultation with a dietitian.
reduce the risk of aspiration and their
consequences following stroke, the 15.9.2 Swallowing Treatment
evidence in support of their use is
lacking. Further research is needed in
this area. Four studies have examined the effect
of formal dysphagia therapy on a
There is limited (Level 2) evidence that variety of outcomes. Dysphagia
dysphagia diets reduce the incidence therapy usually involves a combination
of aspiration pneumonia. of approaches, including exercises
aimed at strengthening muscles, and
improving movement and
15. Dysphagia pg. 34 of 60
coordination. Possible exercises may found a trend towards statistical
include the Mendelsohn maneuver significance when examining the
(the patient hold the larynx up, either impact of two levels of dysphagia
using the muscles of the neck or with treatment programs (low and high
the hand, during the swallow for an intensity) on decreasing the need for a
extended period of time), the Masako modified diet. Compared to usual
maneuver (patient protrudes tongue care, patients who received instruction
and then swallows), Shaker exercise on compensatory swallowing
(http://www.mcw.edu/display/docid26 strategies, swallowing exercises and
360.htm), and gargling, among regular re-evaluation of dietary
others. Other strategies include modifications were more likely to have
postural changes (head turn and chin returned to an unmodified diet at six
tuck postures) and multiple swallows. months. Odderson et al. (1995) in an
These therapies are usually provided unrated retrospective study found the
in addition to dietary modifications. introduction of a stroke program with
dysphagia therapy improved
DePippo et al. (1994) conducted the dysphagia-related outcomes. Lin et al.
only RCT, which demonstrated no (2003) also reported improvements in
benefit of formal dysphagia therapy. various nutrition parameters and
However, the two-week treatment choking frequency among patients
period may have been too short to who participated in a swallowing
actually demonstrate a significant training program.
difference. Carnaby et al. (2005)
Table 15.22 Studies of Dysphagia Therapy Post Stroke
Author/Year Methods Outcome
De Pippo et al. 115 patients randomized to receive either Up to 1 year follow-up revealed no
1994 one formal dysphagia treatment session significant differences between the 3 groups
USA and choice of modified-texture diet, one in the incidence of pneumonia, dehydration
5 (RCT) dysphagia session with prescribed No deaths were reported. Only one instance
texture-modified diet or daily intervention of recurrent upper airway obstruction.
by SLP and prescribed diet.
Odderson et 124 patients with non-hemorrhagic stroke 48 (39%) patients were diagnosed with
al. 1995 admitted to an urban community hospital. dysphagia on admission. No incidences of
USA Within 24 hours of admission, patients aspiration pneumonia were reported. The
No Score received a clinical swallowing evaluation year prior to the introduction of the
and received appropriate dysphagia pathway, 6.7% of patients developed
interventions if required, as per the aspiration pneumonia. The first year the
protocol of a recently implemented clinical pathway was introduced, 4.1% of patients
pathway. The incidences of aspiration developed aspiration pneumonia. Patients
pneumonia, LOS and outcome disposition without dysphagia had a shorter LOS and
were recorded (criteria for defining were more likely to be discharged to the
pneumonia was not reported). Functional community. Patients who passed the initial
outcome was assessed using FIM. swallowing screen had higher FIM scores
compared to those who failed.
Lin et al. A quasi-experimental parallel, cluster The results of between group comparisons
2003 design study that recruited 61 patients on change scores (pre-test, post test)
Taiwan (2:1) from 7 long-term care facilities to showed statistically significant
No Score receive either swallowing training or no improvements favouring the treatment
therapy (Patients received therapy group for: swallowing function (incidence of
15. Dysphagia pg. 35 of 60
following data collection). Swallowing coughing/choking, volume/second
training consisted of direct therapies swallowed, volume per swallow),
(compensatory strategies, diet neurological examination and nutrition
modification, environmental arrangement, parameters (mid-arm circumference and
the Mendelssohn manoeuvre, supraglottic weight)
swallowing and effortful swallowing) and
indirect therapies (thermal stimulation,
oral motor and lingual exercises and were
provided 30 min/days 6 days/week x 8
Carnaby et al. 306 patients with clinical dysphagia Of patients randomly allocated usual care,
2006 admitted to hospital with acute stroke 56% (57/102) survived at 6 months free of
USA were randomly assigned to receive usual a modified diet compared with 64%
8 (RCT) care (n=102), standard low-intensity (65/102) allocated to standard (low-
intervention (n=102), or standard high- intensity) swallowing therapy and 70%
intensity intervention and dietary (71/102) patients who received high-
prescription (n=102). Treatment intensity swallowing therapy. Compared
continued for up to a month. The primary with usual care and low-intensity therapy,
outcome measure was survival free of an high-intensity therapy was associated with
abnormal diet at 6 months an increased proportion of patients who
returned to a normal diet (p=0.04) and
recovered swallowing (p=0.02) by 6
months. Results also presented in Figure
Figure 15.3 Percentage of Patients Achieving Normal
Diets at 6 M onths
sit y si ty sit y
sten nt en Inte n
U sual In L ow I High
Conclusions Regarding Dysphagia There is moderate (Level 1b) evidence
Therapy that while a one-month dysphagia
intervention program does not improve
There is moderate (Level 1b) evidence the likelihood of returning to a normal
that a short course of formal dysphagia diet by six months, it may reduce the
therapy does not alter clinical likelihood of chest infections and death
outcomes. or institutionalization.
15. Dysphagia pg. 36 of 60
weeks, a gastrostomy or jejunostomy
A short course of formal dysphagia feeding tube may be indicated,” (Heart
therapy may not alter clinical and Stroke Foundation of Ontario
outcomes. 2002). Although enteral feeding tubes
have been shown to deliver adequate
15.9.3 Non-Oral Feedings nutrition and hydration to stroke
survivors, and can improve indicators
Non-oral or tube feeding in neurogenic of nutritional status, their use has
aspiration has become a well- been associated with some medical
established rehabilitation practice. The complications, most notably, aspiration
Heart and Stroke Dysphagia Guidelines pneumonia (Finestone et al. 1995,
state, “Enteral feeding is 2001, James 1998). However, the
recommended if a swallowing association between enteral feeding
assessment indicates high-risk and the subsequent development of
dysphagia or inability to meet pneumonia remains unclear, tube
nutritional needs orally. Enteral feeding has been identified as both
feeding should be considered after a protective and a risk factor for
stroke survivor has been NPO for 48 pneumonia. Table 15.23 presents two
hours and implemented within 3-4 studies, which have investigated this
days. If dysphagia is severe and relationship.
expected to last for more than 6
Table 15.23 Studies which Examine the Risk of Aspiration Pneumonia Associated
with Enteral Feeding
Author/Year/ Methods Outcome
Nakajoh et al. The incidence of pneumonia was The incidence of pneumonia was significantly
2000 prospectively analyzed for 1 year in higher in patients with oral feeding than in
Japan three groups of post-stroke patients on those with tube feeding (54.3% vs. 13.2%, P
No Score the basis of the following clinical < 0.001). In bedridden patients with tube
conditions: oral feeding without feeding, the latency of response was longer
dysphagia (n = 43); oral feeding with than 20 sec and no patient coughed at the
dysphagia (n = 48); and nasogastric highest concentration of citric acid. The
tube feeding with dysphagia (n = 52). incidence of pneumonia was 64.3% in such
The incidence of pneumonia in patients. The state of protective reflexes had a
bedridden patients with nasogastric significant relation to the incidence of
tube feeding (n = 14) was also pneumonia. Feeding tube placement may have
studied. Pre-study, the swallowing and a beneficial role in preventing aspiration
cough reflexes of each patient were pneumonia in mildly or moderately disabled
measured. The swallowing reflex was post-stroke patients with attenuated protective
evaluated according to latency of reflexes.
response, which was timed from the
injection of 1 mL of distilled water into
the pharynx through a nasal catheter
to the onset of swallowing.
Dziewas et al. Over an 18-month period, 100 Pneumonia was diagnosed in 44% of the tube
2004 consecutive acute stroke patients who fed patients. All pneumonias occurred while
Germany were fed by a naso-gastric feeding the tube was in situ. Most patients acquired
No Score tube because of dysphagia were pneumonia on the second or third day after
prospectively evaluated. stroke onset. Patients with pneumonia more
15. Dysphagia pg. 37 of 60
often required endotracheal intubation and
mechanical ventilation than those without
pneumonia. Independent predictors for the
occurrence of pneumonia were a decreased
level of consciousness and severe facial palsy.
Marum & Lim 122 patients admitted to a geriatric 90 patients were recommended for non-oral
2005 ward (75% with stroke) were assessed feeding. Of these, 64 agreed and 26 refused
Singapore by a SLP. Following assessment and were fed orally. 32 patients were deemed
patients were recommended to have safe with an oral, modified diet. There were 14
either oral feeding with modified diet cases of aspiration pneumonia confirmed using
or nasogastric tube feeding. The pre-defined criteria during the 2-month follow-
incidence of aspiration pneumonia up, resulting in death in 5 cases. 12 of these
among patients on oral feeding, cases were reported among patients fed by an
nasogastric (NG) tube feeding and NG tube, 2 in patients who refused NG tubes
patients who refused nasogastric tube and no cases were reported among patients
feeding were compared. deemed safe on an oral diet. Four of the 5
deaths occurred in the NG group. The
difference was statistically significant
Leder et al. 1260 consecutively enrolled inpatients, There were no significant differences in
2008 630 with an NG tube in place and 630 aspiration of either liquid or puree food
USA without at the time of assessment for consistencies dependent on presence of an NG
No Score dysphagia. The aspiration status of all tube. The analysis was adjusted for sex, age,
subjects was established using FEES. or diagnostic category.
3 trials each of both pudding and thin
fluid consistencies were trialed.
Langdon et al. A cohort of 330 ischemic stroke Over the study period the number of
2009 survivors were followed for 30 days to respiratory infections in tube fed and orally fed
Australia determine whether the risk of patients were 30/51 (59%) and 21/64 (33%),
No Score pneumonia was higher in tube fed respectively. The risk of pneumonia was
patients compared with orally fed. increased in tube fed patients (RR=4.94, 95%
CI 3.02-8.10, p<0.001).
Dziewas et al. (2004) reported an of aspiration, at least not in subjects
extremely high rate of pneumonia with mild or moderately-disabling
among 100 acute stroke patients who stroke. Therefore, while it remains
were fed via a nasogastric tube due to uncertain whether NG tubes pose a
dysphagia. Most patients developed higher risk for the development of
pneumonia on the second or third day pneumonia following, a physiological
following stroke (median of 2 days, basis for a putative mechanism
range 0-9 days) and in some cases, remains unknown. Most likely, other
while the feeding tube was being used factors such as being bed bound,
only for gastric decompression, increased age and medical comorbidity
highlighting the fact that feeding tubes confound the relationship.
are not protective from colonized oral
secretions. Factors most predictive of Although there was no comparison
the development of pneumonia were group, the high incidence of
initial decreased level of consciousness pneumonia raises troubling concerns
and facial palsy. More recently, the about the effectiveness of feeding
same authors (Dziewas et al. 2008) tubes in preventing pneumonia in
suggested that correctly-placed NG high-risk populations. Marum & Lim
tubes do not interfere with swallowing (2005) also reported a higher
physiology and do not increase the risk incidence of aspiration pneumonia and
15. Dysphagia pg. 38 of 60
death among geriatric patients meet their nutritional needs orally.
assigned to NG feeding. The results Enteral feeding should be considered
are confounded by the fact that NG fed after a stroke survivor has been NPO for
patients were more cognitively- and 48 hours.
functionally-impaired compared to
those on oral feeding. However, in sub Although enteral feeding for dysphagic
group analysis the rate of pneumonia stroke patients is a well-established
practice, there is conflicting (Level 4)
was still higher among patients who
evidence that nasogastric tubes reduce
accepted NG feeding compared with
the risk of pneumonia.
those who refused the treatment.
In contrast to findings from these 2
studies, Nakajoh et al. (2004) reported Enteral tube feeding should be
considered for stroke patients at risk
that the incidence of pneumonia was
4.1 times greater among 73 dysphagic
stroke patients who were orally fed
15.9.4 Selection of Feeding Tubes
(n=35), compared to those who
received non-oral feedings suggesting
that nasogastric tubes are protective Enteral feeding may be required for
for pneumonia. The authors also either brief or prolonged periods of
suggested that this protective effect time and is used most commonly in
might be limited to patients who are the treatment of dysphagia. As a
not bedridden. result, the choice of feeding tube is
dictated, in large part, by the
In contrast to these findings Landon et anticipated length of swallowing
al. (2009) reported an increased risk in impairment. Broadley et al. (2003)
the incidence of pneumonia associated have identified several predictors of
with tube feeding. There was also a prolonged dysphagia, which include
significant time-to-event effect with initial stroke severity, dysphasia and
73% (22/30) respiratory infections in the involvement of frontal or insular
tube-fed survivors diagnosed on days cortex on brain imaging. However,
2-4 after stroke, and 76% (39/51) of clinically, it can be challenging to
infections in all tube-fed survivors accurately predict the length of time
occurring by day 7 after stroke. The that enteral feeding will be required.
authors suggested that there may be a Feeding tubes fall into two broad
period of increased susceptibility to categories, nasogastric (NG) tubes,
infections in the acute post stroke usually intended for short-term use
period. The phenomenon, “stroke- and which are positioned directly into
induced immunodeficiency” has been the stomach (with extensions into the
coined to describe the condition in small bowel) or small intestine either
which there is an inhibition of cell- percutaneously or surgically.
mediated immunity, which has been Generally, gastro-enteric tubes are
demonstrated in animal models. used for long-term feeding. There are
advantages and disadvantages to both
Conclusions Regarding the Use of Non- tube types. Nasogastric tubes have
Oral Feeding been shown to be less effective with
greater side effects compared to
There is consensus (Level 3) opinion gastrostomy tubes for patients that
that enteral tube feeding be used in require a longer duration of non-oral
stroke patients who are dysphagic and feeding (Hull et al. 1993, Park et al.
at high risk for aspiration or who cannot 1992), although significant mortality
15. Dysphagia pg. 39 of 60
and morbidity has been associated nasal loop technique to anchor tubes
with more invasive enteric tubes, such securely in place, preventing
as the percutaneous endoscopic dislodgement and subsequent
gastrostomy (PEG) (Anderson et al. reinsertion. Table 15.24 presents the
2004). Anderson et al. (2004) results of several studies evaluating
describes the successful placement of the nasogastric and percutaneously
NG tubes in stroke patients using the placed feeding tubes.
Table 15.24 The Efficacy of Non-Oral Feeding Post Stroke: Gastric/gastro-jejunal
vs. NG Feeding Tubes
Author/Year/ Methods Outcome
Park et al. 28 days of enteral feeding using either Treatment failure occurred in 18/19 patients in
1992 a percutaneous endoscopic NG group compared to 0/19 in PEG group
Scotland gastrostomy (PEG) tube or naso- Patients in NG group received less volume of
6 (RCT) gastric (NG) tube was evaluated in 40 feed compared to PEG group (55% vs. 93%).
patients (18 with stroke) with long-
standing (>4 weeks) dysphagia.
Norton et al. 30 dysphagic stroke patients At 6 weeks post stroke, a significantly greater
1996 randomized to receive either a proportion of patients died in the NG group
UK gastrostomy feeding tube (GT) or a compared to the GT group (8 vs. 2). Patients
6 (RCT) nasogastric tube (NG). in the GT group had better nutritional indices
including weight, serum albumin, mid-arm
circumference. There were no omitted feeds
among patients in the GT group compared to
at least one missed feed in 10 patients in the
Lien et al. 8 stroke patients with a modified 24 hr esophageal acid exposure (% of time
2000 feeding tube in place allowing for both that pH readings was <4) were significantly
Taiwan gastric (PEG) and jejunal (PEJ) feeding lower on PEJ feeding days compared to PEG
No Score were tested for gastroesophageal feeding days (10.1% vs. 20.6%). During meal
reflux using 24 hr esophageal pH infusion, 7/8 patients had less esophageal acid
monitoring. exposure during PEJ feeding compared to PEG
FOOD Trial 321 acute stroke patients, from 47 Feeding with a PEG tube was associated with
2005 hospitals in 11 countries, were an increase in the absolute risk of death or
UK randomized to receive either a PEG poor outcome of 7.8% (p=0.05). There was no
7 (RCT) (n=162) or NG feeding tube (n=159) difference in the incidence of pneumonia
within 3 days of enrolment into the between the groups. There were more
study. Death and poor outcome gastrointestinal bleeds among patients in the
(defined as a Modified Rankin Score of NG group (18 vs. 5, p=0.005), but more
4-5) was assessed at 6 months. pressure sores among patients in the PEG
group (12 vs. 4, p=0.04). Only 48% of
patients allocated to treatment in the PEG
group actually received the treatment within 3
Kostadima et 41 acutely ill, ventilator dependent At the end of weeks 2 and 3 the cumulative
al. patients with a diagnosis of either incidence of pneumonia was significantly
2005 stroke (n=25) or head injury (n=16) higher in the NG compared to the gastrostomy
Greece were randomized to receive a group (p<0.05). At the end of the first week
6 (RCT) gastrostomy or to NG tube for enteral the incidence of pneumonia was higher in the
15. Dysphagia pg. 40 of 60
feeding. Tubes were inserted within 24 gastrostomy group although the result was not
hours of intubation. Patients were statistically significant.
followed for 3 weeks and the incidence
of pneumonia was noted and Gastostomy NG
compared between groups. A diagnosis Week 1 2/20 1/20
of pneumonia was established using Week 2 2/18 8/19
previously validated criteria. Week 3 2/16 8/18
Beavan et al. 104 patients requiring non-oral feeding Subjects in the nasal loop group received a
2010 following acute stroke received an NG significantly greater volume of prescribed feeds
UK tube which was secured using either and fluids over 2 weeks (75% vs. 57%,
7 (RCT) conventional means (adhesive tape) p=0.02) and required fewer NG tubes (median
(n=53) or a nasal loop (n = 51). The 1 vs.4). There were no differences in outcomes
main outcome measure was the at 3 months (death, BI scores. Death or
proportion of prescribed feed and dependency, length of hospital stay.
fluids delivered via NGT in 2 weeks.
Secondary outcomes were frequency
of NGT insertions, treatment failure,
tolerability, mortality; length of
hospital stay; residential status; and
Barthel Index at 3 months.
studies. The results are summarized in
1. Death or Poor Outcome Table 15.25. While two studies
reported an increased risk of death
Three trials evaluated the risk of death associated with NG feeding, neither
associated with type of feeding tube the results from the individual studies,
(Norton et al. 1996, FOOD 2005, nor the pooled estimate was
Kostadima et al. 2005). The FOOD statistically significant. This finding
trial (2005) also assessed the risk of suggests that the type of feeding tube
the combined outcome of death or used does not increase the risk of
poor outcome (defined as a modified death. The results from the largest
Rankin scale score of 4-5). The and most important of the trials
results are difficult to pool and to (FOOD 2005) are presented in Figure
interpret as the patient population and 15.4.
the length of follow-up varied between
Table 15.25 The Relative Risk of Death Associated with NG vs. Gastrostomy
Feeding Among RCTs.
Study Patients (n) Length of follow-up Relative Risk (95% CI) for Death
( using NG as reference condition)
Norton et al. Acute stroke 6 weeks 5.47 (1.16, 18.05)
FOOD 2005 Acute stroke 6 months 0.98 (0.78, 1.23)
Kostadima et al. ICU (n=41) 3 weeks 1.43 (0.47, 4.32)
Pooled estimate 1.07 (0.86, 1.33)
15. Dysphagia pg. 41 of 60
Figure 15.4 NG vs. PEG Tube Feeding on Stroke Outcome (FOOD 2005)
60.0% 48.0% 49.0%
Death Death/Poor Outcome
2.Pneumonia all were ventilator-dependent. Both
groups of patients were similar in
While two RCTs assess ed the terms of baseline characteristics and
incidence of pneumonia associated medical management. The authors
with feeding tube type (FOOD 2005, speculate that the reasons for the
Kostadima et al. 2005), unfortunately, increase among patients with NG
the data from the FOOD trial were not tubes may be due to: “disturbance of
reported, although the authors noted the pharyngoglottal refluxes that
that there was no difference in the prevent aspiration, dysfunction of the
proportion of patients who developed upper and lower oesophageal
pneumonia between groups sphincters and associated gastro-
(gastrostomy vs. NG). However, esoghageal reflux secondary to the
Kostadima et al. (2005) reported that presence of the tube and colonization
a significantly greater proportion of of the stomach by bacteria that may
patients fed by a NG tube developed subsequently migrate into the
pneumonia within 3 weeks, compared oropharynx and into the lower
to patients who had a gastrostomy respiratory tract.” It is uncertain
tube placed immediately following whether these results can be
admission to an ICU. The majority, extrapolated to a non-ventilated
but not all patients recruited for this population.
study had suffered from a stroke and
Conclusions Regarding Choice of mechanical failures compared to
Feeding Tube nasogastric feeding tubes.
There is consensus (Level 3) opinion Based on the results from one large,
that if dysphagia is severe and international trial, there is moderate
expected to last more than 6 weeks, a (Level 1b) evidence that the type of
gastrostomy or jejunostomy feeding feeding tube (nasogastric or gastro-
tube may be indicated. enteric) does not affect the odds of
death or the combined outcome of
Based on the results from two “good” death or poor functional outcome.
quality RCTs, there is strong (Level 1a)
evidence that intragastric feeding There is moderate (Level1b) evidence
devices are associated with fewer that the risk of developing pneumonia
15. Dysphagia pg. 42 of 60
is higher among ventilated patients fed
by a naso-gastric tube compared with a Enteral tube feeding may be necessary
gastrostomy tube. when stroke patients fail to meet their
nutritional needs orally. Gastric or
There is moderate (Level 1b) evidence jejunostomy feeding tubes are preferred
that securing naso-gastric tubes with a over nasogastric tubes for providing
tether-like device reduces the number nutrition and hydration to dysphagic
of dislodged tubes and increases the patients who require non-oral support
amount of required feed and fluids that for more than 28 days.
15.9.5 Alternative Interventions thermal and electrical stimulation,
In addition to texture-modified diets acupuncture, antihypertensive agents
and non-oral feeding, a variety of and decontamination of the digestive
mostly small studies have evaluated tract. An evaluation of a variety of
the efficacy of a variety of dysphagia treatment modalities is
miscellaneous treatments including presented in Table 15.26.
Table 15.26 Effect of Alternative Interventions in Dysphagic Stroke Patients
Author/Year Methods Outcome
Logemann et al. The effect of head rotation on Head rotation did not alter the swallowing
1989 swallowing function was evaluated efficiency of healthy subjects. In stroke
USA on 5 lateral medullary stroke patients head rotation improved swallowing
No Score patients and 14 healthy adults. “efficiency” from 21 to 50% and increased the
diameter of the upper esophageal sphincter
from 7.7 to 11.6 mm.
Rosenbek et al. In a crossover ABAB study, 7 No evidence that treatment with thermal
1991 patients received a week-long period application improved incidence of aspiration,
USA of thermal application (chilled penetration or residuae.
6 (RCT) laryngeal mirror used to stroke the
anterior faucial pillar on both sides),
followed by 3 cc of water or ice
chips, followed by no treatment for
Park et al. 1997 Case reports of 4 dysphagic stroke Improvement in swallowing function in 2/4
UK patients receiving electrical patients including a reduction in transit time
No Score stimulation of the palatal area to and absence of pooling/penetration/aspiration.
improve swallowing function.
Perez et al. 17 patients were randomized to Patients in the treatment group demonstrated
1998 receive 30 mg slow release significant improvement in mean pharyngeal
UK nifedipine orally or placebo for 28 transit time and swallowing delay compared to
7 (RCT) days. All patients also received patients in the control group.
treatment by a speech therapist.
Arai et al. 1998 16 hypertensive stroke patients with Symptomless dysphagia improved in 10/16
Japan symptomless dysphagia and 10 patients, as assessed by changes in serum
No Score hypertensive patients without substance P concentrations. No details of
dysphagia and 7 control patients dosages of ACE inhibitor or length of treatment
were studied. To observe the time were reported.
occurrence of symptomless
dysphagia 1 mL of Technetium Tin
15. Dysphagia pg. 43 of 60
Colloid was given during sleep by
nasal catheter. Hypertensive patients
received an ACE inhibitor.
Rosenbek et al. 45 patients were randomized to Combing all levels of intensity, mean DST was
1998 receive treatment that included reduced with 3 mL fluid intake at week 2 (1.17
USA rubbing both anterior faucial pillars sec, p=0.06). There were no significant
5 (RCT) briskly, 3 or more times with an ice improvements in DST using 10 mL fluid. With
stick. Study Group A:150 trials of both 3 and 10 mL boluses, no intensity of
tactile-thermal stimulation per week; treatment was associated with a clinically
Study Group B:300 trials per week; significant improvement in P/A. score. A
Study Group C:450 trials per week; statistically significant improvement in mean
Study Group D:600 trials per week P/A scores was associated with 150 trials per
2 outcomes were assessed at 1 and week at weeks 1 and 2 (3 mL bolus only).
2 weeks: Duration of Stage Combining all levels of intensities, mean P/A
Transition-DST (sec) with intakes of scores were reduced with 3 mL fluid intake at
3 mL and 10 mL liquid; weeks 1 (0.55, p=0.04 and 2 (0.59, p=0.03).
intakes of 3 mL and 10 mL liquid.
Freed et al. Controlled trial whereby 99 Mean swallowing scores between the groups
2001 dysphagic stroke patients were were similar at baseline. At the time of final
USA assigned to receive either thermal- assessment the mean swallowing scores were
No score tactile stimulation (TS) or electrical significantly higher among patients in the ES
stimulation (ES). TS was given in 3- groups compared to the TS group (4.52 vs.
20 minutes daily sessions. A small 1.13). 98% of ES patients showed some
mirror was chilled in ice and then improvement, whereas 27% of TS patients
applied to the anterior faucial arch. remained at initial swallow score and 11% got
In ES treatment, the electrodes of a worse. These results are based on similar
hand-held stimulator were placed on numbers of treatments (average of 5.5 for ES
the neck in one of two positions until and 6.0 for TS).
muscle fasciculations occurred.
Frequency and pulse width were
fixed at 80Hz and 300 ms.
Swallowing function was assessed
before and after treatment using a 0
(worst) to 6 (best) aspiration scale.
Treatment continued until patient
achieved a score of 5 or was
discharged from hospital.
Arai et al. 51 stroke patients, all with proven Silent aspiration disappeared in 10/13 patients
2003 silent aspiration (assessed by 1 mL given cabergoline, 10/14 patients given
Japan of Technetium Tin Colloid was given amantadine and 9/12 patients given imidapril
RCT (insufficient during sleep by nasal catheter) were and in 1/12 of the control patients. Significant
data provided to studied. 39 normotensive patients differences were noted between the collective
score-letter to were randomized to receive treatment group and no treatment group.
the editor) cabergoline (0.25 mg/day) n=13,
amantadine (50 mg/day) n=14, or
no active treatment (n=12). The
remaining 12 patients were
hypertensive and received imidapril
(5 mg/day). Treatment lasted for 12
Crary et al. 25 patients with dysphagia 92% of the stroke patients increased functional
2004 underwent a systematic therapy oral intake by at least one scale score following
15. Dysphagia pg. 44 of 60
Florida program. Stroke patients outcomes therapy. 48% of the stroke patients improved
No Score were compared to 20 head/neck 1 or 2 levels, 20% improved 3 to 5 levels, and
cancer patients. Sessions were 50 24% improved 6 levels. Of the stroke patents
min per day (no weekends) with reliant on nonoral feeding pre-therapy, 55%
surface electromyographic (sEMG) progressed to total oral feeding.
biofeedback. Outcome measures
included change in functional oral
intake, the number of therapy
session to discharge, and estimated
cost per unit of functional charge.
Seki et al. 2005 32 stroke patients with severe In the intervention group, the swallowing time
Japan dysphagia were randomized to of water and fluid food were shortened
RCT receive acupuncture 3 x per week x significantly. The incidence of aspiration on 3
(insufficient 4 weeks + usual care or to usual food consistencies (water, fluid food and solid
data provided to care. Swallowing function was food) was reduced significantly in the
score-letter to assessed by VMBS at baseline and at intervention group, with no corresponding
the editor) the end of treatment. declines in the control group.
Gosney et al. 203 stroke patients were randomized 58/203 (29%) patients had dysphagia on
2006 to receive either selective admission. AGNB was acquired on 2 or more
UK decontamination of the digestive consecutive samples in 6 patients in the
6 RCT tract (SDD) gel or placebo 4 x daily treatment group and 11 in the control group.
for 2 weeks (patients with safe The difference between groups was not
swallow) or 3 weeks (unsafe statistically significant. Four patients in the
swallow). Outcomes included the treatment group acquired either pneumonia or
incidence of colonization of aerobic septicemia during the study period compared
gram negative bacilli (AGNB) and to 10 in the placebo group (p=0.029).
septicemia or respiratory tract Mortality between groups was similar (9 in
infections during hospital stay. treatment group vs. 11 in control group).
Ebihara et al. 105 chronic stroke patients residing Nasal inhalation of BPO shortened LTSR,
2006 in nursing homes were randomized compared with that of lavender oil and distilled
Japan to either a study group, black pepper water (P < .030. The number of swallowing
5 (RCT) oil (BPO)(n=35), or one of 2 control movements for 1 minute during the nasal
groups, lavender oil (LO) (n=35), or inhalation of BPO increased (P < .001).
distilled water (n=35). Nasal
inhalation of 100цL of one of the 3
substances was administered to the
nostrils with a paper stick. Subjects
received the treatment 1 minute
before each meal during the 30-day
study period. Latency of the
swallowing reflex (LTSR) and the
number of swallowing movements
Power et al. 16 dysphagic stroke subjects were Compared with baseline, no change was
2006 randomized to receive treatment observed in the speed of laryngeal elevation,
UK consisting of stimulation of the pharyngeal transit time, or aspiration severity
4 (RCT) anterior faucial pillar with either no within subjects or between groups for either
(sham) stimulation or stimulation at active or sham stimulation.
a frequency of 0.2 Hz for 10 minutes
(5 on each side). Swallowing was
assessed before and 60 min after
electrical or sham stimulation.
Swallowing measures included
15. Dysphagia pg. 45 of 60
laryngeal closure (initiation and
duration) and pharyngeal transit
time, taken from VMBS study.
Aspiration severity was assessed
using an 8-point scale.
Robbins et al. 10 stroke patients (6 acute and 4 There was a significant increase in maximum
2007 chronic) performed an 8-week isometric pressure (anterior and posterior
USA isometric lingual exercise program tongue) over the study period. There was
No Score by compressing an air-filled bulb significant reduction in overall residue for 3
between the tongue and the hard bolus conditions (3 mL effortful swallow, 10 mL
palate. This exercise was repeated liquid and 3 mL liquid). There were significant
10 x, 3 times a day, 3 days a week. improvements 3/11 subscales of the QoL
Isometric and swallowing lingual questionnaire.
pressures, bolus flow parameters,
diet, and a dysphagia-specific quality
of life questionnaire (QoL)were
assessed at baseline, week 4, and
Shimizu et al. The pharyngeal transit time (PTT) of The PTT of control subjects was unchanged
2008 10 elderly subjects with stroke was from first to second assessment. (2.4 vs. 2.6
Japan assessed using VMBS before and sec). The PTT of subjects receiving the ACE
No Score after 6 weeks of therapy with 5 mg inhibitor significantly decreased from baseline
imidapril. The results were compared to 5 weeks (2.5 vs. 1.6 sec, p<0.01).
with 10 age-matched healthy Abnormalities in the oral and esophageal
subjects. phases were not altered by treatment.
Bϋlow et al. 25 stroke patients from 3 European While subjects in both groups improved over
2008 swallowing centers were randomized the treatment period there were no statistically
Sweden to receive a 3-week trial (15 significant differences on any of the outcomes.
3 (RCT) sessions) of either neuromuscular
electrical stimulation (NMES) or
traditional swallowing therapy (TT).
evaluation, nutritional status, oral
motor function test, and a visual
analog scale (VAS) for self-
evaluation of complaints, were
assessed before and after treatment.
Khedr et al. 26 patients with post-stroke At baseline the mean dysphgaia score for the
2009 dysphagia due to single hemispheric control group was 3.7 vs. 3.4 for the real rTMS
Egypt stroke were randomly allocated to group. By 2 months the real rTMS groups’
6 (RCT) receive real (n = 14) or sham (n = mean score was approximately 1.0 vs. 3.0 for
12) rTMS of the affected motor the control group. There was a significant time
cortex. Each patient received a total x group interaction.
of 300 rTMS pulses at an intensity of
120% hand motor threshold for five
consecutive days. Clinical ratings of
dysphagia were assessed using the
Dysphagic Outcome and Severity
Scale before and after the last
session and then again after 1 and 2
months. Scores ranged from 1 (no
dysphagia) to IV (obvious dysphagia
15. Dysphagia pg. 46 of 60
precluding oral feeding). All subjects
received standard medical and
Permsirivanich 23 stroke patients with dysphagia Before therapy, 73% of the RST group and
et al. 2009 persisting for > 2 weeks were 83% of the NMES group required non-oral
Thailand randomized to receive either feeding (FOIS levels 1-3). At the end of the
6 (RCT) rehabilitation swallowing therapy study period, 75% of the RST group and 90%
(RST) or neuromuscular electrical of the NMES group could manage oral intake
stimulation therapy (NMES). The (FOIS groups 4-7). The differences in
subjects received 60 minutes of proportions were not statistically significant.
either RST or NMES treatment for 18% of RST and 17% of the NMES subjects
five consecutive days, had two days had attained a FOIS score of 7. There was a
off and then five more consecutive significant difference in the change scores,
days of treatment for a four-week favouring the NMES group (+3.17 vs. 2.46,
period or until they reached p<0.001)
functional oral intake scale (FOIS)
level 7. FOIS, the primary outcome
measure, was assessed before /after
treatment. FOIS score 1=NPO, FOIS
score 7= oral diet, no restrictions
Lim et al. 2009 36 received thermal-tactile 28 persons completed the study. Median
Korea stimulation (TTS) treatment only swallowing scores for the control group, on
No Score (control group) or TTS + semi-solids consistency, before and after
neuromuscular electrical stimulation, treatment were 3 and 4, and 2 and 4 for the
applied simultaneously. Swallowing experimental group. Median PAS scores for the
function was assessed before and 4 control group before and after treatment were
weeks after treatment using the 3.5 and 4 (indicating a worsening) and 5.5 and
swallow function scoring system 2.5 for the experimental group. The differences
(scoring: 0-6 with lower scores in both scores between the two groups were
indicating greater severity), the significant. There was significantly greater
penetration-aspiration scale (PAS) improvement in pharyngeal transit time in the
(scoring: 1-8 with higher scores experimental group.
pharyngeal transit time. Semi-solid
and liquid consistencies were
Khedr & Abo- 22 patients with acute ischemic Among patients with lateral medullary there
Elfetoh 2010 stroke with lateral medullary were significant improvements in dysphagia
Egypt syndrome or brainstem infarction scores and BI scores in the active rTMS group
6 (RCT) severe bulbar manifestation were compared with the sham group that were
randomly allocated to receive active maintained over the study period. Among
(n=11) or sham (n=11) repetitive patients with other types of brainstem infarcts
transcranial magnetic stimulation who received rTMS, there was significant
(rTMS) of the oesophageal motor improvement in dysphagia scale scores
cortex. Each patient received 300 compared with sham treatment.
rTMS pulses at 3 Hz and an intensity
of 130% resting motor threshold to
each hemisphere for five consecutive
days. Outcomes were assessed
before and immediately after the last
session, and then again after 1 and 2
months using a 4-point dysphagia
grading scale, NIHSS, BI and the
15. Dysphagia pg. 47 of 60
Hemiplegic Stroke Scale.
Jayasekeran et 50 acute dysphagic stroke patients Patients who received the active form of PES
al. 2010 were assigned randomly to receive experienced significantly fewer episodes of
UK either active or sham pharyngeal aspiration, greater improvement in DSR and
8 (RCT) electrical stimulation (PES) once remained in hospital for a shorter period of
daily for 3 days. (n = 28). The time compared with patients who received
primary end point was the reduction sham treatment.
of airway aspiration at 2 weeks
postintervention assessed using VFS.
Additional outcomes included scores
on a Dysphagia Severity Rating
(DSR) rating scale
Discussion ACE inhibitor, imidapril on a small
group of elderly stroke subjects. The
The use of medications to improve use of an ACE inhibitor was associated
swallowing function was assessed in with a reduction in pharyngeal transit
three small RCTs (Perez et al. 1998, times. ACE inhibitors are believed to
Kobayashi et al. 1996, Arai et al. confer benefit through an increase in
2003). Perez et al. reported that serum substance P concentration. All
Nifidipine, a calcium channel blocker of the studies evaluating the use of
improved pharyngeal transit time and drugs to improve parameters of
swallow delay. The mechanism swallowing function were small.
through which the benefits were
achieved is uncertain although the Two studies authored by Rosenbeck et
authors speculated that it might be al. (1991, 1998) evaluated the
mediated by the reduction of effectiveness of cold stimulus to
esophageal spasm, through the action improve specific aspects of the
of dihydropyridines on the calcium swallowing mechanism. The earlier
channels, of nonvascular smooth study evaluating 7 patients using a
muscle. Kobayashi et al. (1996) crossover design, failed to
reported improved latency of response demonstrate a significant benefit of
in a small crossover designed study the treatment. A second, slightly
evaluating levadopa. Arai et al. (2003) larger study, evaluated the effect of
evaluated the effectiveness of the four increasing intensities of tactile
dopamine agonists, cabergoline, thermal application. The study design
reported to have fewer side effects did not include a control group. The
than levadopa, and the drug results did not favour a single level of
Amantadine, an antidyskinetic and intensity of treatment. In the absence
reported a significant reduction in the of a control group, conclusions
incidence of silent aspiration among regarding the effectiveness of these
normotensive patients with stroke, treatments could not be drawn.
compared to a no drug control
condition. Among patients with known The use of antimicrobial agents to
hypertension, the angiotensin- reduce the bacterial load in the
converting enzyme (ACE) imidaril digestive tract of stroke patients, in an
hypochloride also reduced the effort to reduce the incidence of
incidence of silent aspiration aspiration pneumonia was assessed in
compared to control. Shimizu et al. a single RCT (Gosney et al. 2006).
(2008) also evaluated the effect of the Treatment with the antimicrobial gel
15. Dysphagia pg. 48 of 60
removed the presence of a variety of established when compared to
aerobic gram-negative bacilli, which traditional swallowing therapy.
resulted in a decreased incidence of
septicemia and pneumonia. Ebihara et al. (2007) provided
preliminary evidence that inhalation of
Although electrical stimulation is black pepper oil can help to prevent
widely used clinically in the United the development of aspiration
States, there is a lack of evidence pneumonia. The authors speculated
supporting its use. A recent meta- that the insular cortex plays a role in
analysis (Carnaby –Mann & Crary both dysphagia and appetite
2007), which included the results from stimulation, and since black pepper oil
7 trials reported a large effect size is an appetite stimulant and increases
associated with the treatment. The blood flow to this area, it might be an
participants in the individual trials effective approach to the treatment of
were dysphagic due to a variety of dysphagia.
conditions, including stroke. The
results from the 3 trials included in The results of studies using an RCT to
the present review suggested that the evaluate an alternative intervention
effectiveness of the electrical are presented in table 15.27.
stimulation has not yet been
Table 15.27 Summary of RCTs Evaluating an Alternative Interventions
Intervention Author/Year/(PEDro) n Result
Electrical stimulation Power et al. 2006 (4) 16 -
Bϋlow et al. 2008 (3) 25 -
Permsirivanich et al. 2009 23 -/+
Jayasekeran et al. 2010 (8) 31 +
Thermal stimulation Rosenbek et al. 1991(6) 7 -
Rosenbek et al. 1998 (5) 45 -
Nifedipine Perez et al. 1998 (7) 17 +
SDD (selective Gosney et al. 2006 (6) 203 +
decontamination of the
Black pepper oil Ebihara et al. 2006 (5) 105 +
Transcranial magnetic Khedr et al 2009 (6) 26 +
stimulation Khedr & Abo-Elfetoh 22 +
+ evidence of benefit when compared to control condition
- no evidence of benefit when compared to control condition
be used to improve specific aspects of
Conclusions Regarding Alternative swallowing following stroke.
Interventions in Dysphagia
There is moderate (Level 1b) evidence
There is strong (Level 1a) evidence that that selective decontamination of the
transcranial magnetic stimulation digestive tract can help to reduce the
improves swallowing function post incidence of pneumonia.
There is strong (Level 1a) evidence that
There is moderate (Level 1b) evidence thermal stimulation does not improve
that Nifedipine and black pepper oil can swallowing function post stroke.
15. Dysphagia pg. 49 of 60
EMG treatment can be used to improve
There is conflicting (Level 4) evidence swallowing function post stroke.
that electrical stimulation can improve
swallowing function post stroke. A variety of alternative treatments can
be used to improve swallowing
There is limited (Level 2) evidence that function post stroke.
head rotation, lingual exercises and
15. Dysphagia pg. 50 of 60
1. The incidence of dysphagia appears feeding assistance or supervision to
to be quite high following acute all stroke survivors.
stroke, with between one-third to two-
thirds of all stroke patients affected. 10. There is consensus (Level 3)
opinion that a dietician should assess
2. VMBS studies are the “gold the nutrition and hydration status of
standard” for diagnosing dysphagia all stroke patients who fail a
and aspiration. swallowing screening.
3. The incidence of aspiration in the 11. There is consensus (Level 3)
acute phase of stroke varies from 21- opinion that dysphagic stroke
42% and decreases to less than 12% patients typically require diets with
by 3 months post stroke. Between modified food and liquid textures.
one-third and one-half of patients
who aspirate following stroke are 12. For patients who require assistance
silent aspirators. to feed, there is a consensus (Level 3)
opinion that low-risk feeding
4. Aspiration appears to be associated strategies by trained personnel
with an increase in the incidence of should be employed.
pneumonia. The risk of developing
pneumonia appears to be 13. There is consensus (Level 3)
proportional to the severity of opinion that for patients on modified
aspiration. diets that a dietitian should be
consulted to ensure that the modified
5. There is limited (Level 2) evidence diet is nutritionally adequate and
that dysphagia screening protocols appropriate, and to consult the stroke
can reduce the incidence of survivor or substitute decision-
pneumonia. maker, to ensure that the modified
diet is as appealing as possible.
6. There is consensus (Level 3) opinion
that acute stroke survivors should be 14. There is limited (Level 2) evidence
NPO until swallowing ability has been that dysphagia diets reduce the
determined. incidence of aspiration pneumonia.
There is moderate (Level 1b)
7. There is consensus (Level 3) opinion evidence that thickened fluids result
that a trained assessor should screen in fewer episodes of aspiration and
all acute stroke survivors for penetration compared with thin fluids
swallowing difficulties. among dysphagic individuals
8. There is consensus (Level 3) opinion
that a speech and language 15. There is limited (Level 2) evidence
pathologist should assess all stroke that patients requiring texture-
survivors who fail swallowing modified diets including thickened
screening and identify the fluids can safely consume thin fluids
appropriate course of treatment. between meals without increasing
their risk of pneumonia.
9. There is consensus (Level 3) opinion
that an individual trained in low-risk 16. There is moderate (Level 1b)
feeding strategies should provide evidence that Nifedipine improves
15. Dysphagia pg. 51 of 60
specific aspects of swallowing feeding tubes.
function following stroke.
24. Although enteral feeding for
17. There is limited (Level 2) evidence dysphagic stroke patients is a well-
that head rotation can improve established practice, there is only
swallowing function in lateral moderate (Level 1b) evidence that its
medullary stroke patients. use reduces the risk of pneumonia.
There is conflicting (Level 4) evidence
18. There is moderate (Level 1b) that nasogastric tubes reduce the risk
evidence that thermal stimulation of pneumonia. There is moderate
does not improve swallowing (Level 1b) evidence that the risk of
mechanics post stroke. developing pneumonia is higher
among ventilated patients fed by a
19. There is moderate (Level 1b) naso-gastric tube compared with a
evidence that a short course of gastrostomy tube.
formal dysphagia therapy does not
alter clinical outcomes. Based on the 25. Based on the results from one
result from a single RCT, there is large, international trial, there is
moderate (Level 1b) evidence that a moderate (Level 1b) evidence that the
one-month dysphagia intervention type of feeding tube (nasogastric or
program does not improve the gastro-enteric) does not affect the
likelihood of returning to a normal odds of death or the combined
diet by six months. However, there is outcome of death or poor functional
also moderate (Level 1b) evidence outcome.
that such a program may reduce the
likelihood of chest infections and 26. There is moderate (Level 1b)
death or institutionalization. evidence that securing naso-gastric
tubes with a tether-like device
20. There is consensus (Level 3) reduces the number of dislodged
opinion that enteral tube feeding be tubes and increases the amount of
used in stroke patients at high risk of required feed and fluids that patients
aspiration or for those who cannot receive.
meet their nutritional need orally.
Enteral feeding should be considered 27. There is moderate (Level 1b)
after a stroke survivor has been NPO evidence that Nifedipine and black
for 48 hours. pepper oil can be used to improve
specific aspects of swallowing
21. There is consensus (Level 3) following stroke.
opinion that if dysphagia is severe
and expected to last more than 6 28. There is strong (Level 1a) evidence
weeks, a gastrostomy or jejunostomy that transcranial magnetic stimulation
feeding tube may be indicated. improves swallowing function post
22. There is limited (Level 2) evidence
that enteral feeding tube can deliver 29. There is moderate (Level 1b)
adequate nutrition and hydration to evidence that selective
stroke survivors. decontamination of the digestive tract
can help to reduce the incidence of
23. There is strong (Level 1a) evidence pneumonia.
that intragastric feeding devices are
associated with fewer mechanical 30. There is strong (Level 1a) evidence
failures compared to nasogastric that thermal stimulation does not
15. Dysphagia pg. 52 of 60
improve swallowing function post evidence that electrical stimulation
stroke. can improve swallowing function post
31. There is conflicting (Level 4)
15. Dysphagia pg. 53 of 60
Diagnosis and treatment of swallowing Bach DB, Pouget S, Belle K, Kilfoil M, Alfieri M,
disorders (dysphagia) in acute-care stroke McEvoy J, Jackson G. An integrated team
patients (Evidence report/technology approach to the management of patients. J
assessment No. 8). AHCPR Publication Allied Health 1989; p. 459-468.
No.99-E024 . 1999. Agency for Health Care
Policy and Research, Rockville,MD. Barer DH. The natural history and functional
consequences of dysphagia after
Allison MC, Morris AJ, Park RH, Mills PR. hemispheric stroke. J Neurol Neurosurg
Percutaneous endoscopic gastrostomy tube Psychiatry 1989;52:236-241.
feeding may improve outcome of late
rehabilitation following stroke. J R Soc Med Beavan J, Conroy SP, Harwood R, Gladman JR,
1992;85:147-149. Leonardi-Bee J, Sach T, Bowling T, Sunman
W, Gaynor C. Does looped nasogastric tube
Alzate GD, Coons H, Elliott J, Cary PH. feeding improve nutritional delivery for
Percutaneous gastrostomy for jejunal patients with dysphagia after acute stroke?
feeding: a new technique. AJR A randomised controlled trial. Age Ageing
Anderson MR, O'Connor M, Mayer P, O'Mahony Bounds JV, Wiebers DO, Whisnant JP, Okazaki
D, Woodward J, Kane K. The nasal loop H. Mechanism and timing of deaths from
provides an alternative to percutaneous cerebral infarctions. Stroke 1981;12(4):
endoscopic gastrostomy in high-risk 474-477.
dysphagic stroke patients. Clin Nutr
2004;23:501-506. Broadley S, Croser D, Cottrell J, et al.
Predictors of prolonged dysphagia following
Antonios N, Carnaby-Mann G, Crary M, Miller L, acute stroke. J Clin Neurosci 2003;10:300-
Hubbard H, Hood K, Sambandam R, Xavier 305.
A, Silliman S. Analysis of a physician tool for
evaluating dysphagia on an inpatient stroke Brown M, Glassenberg M. Mortality factors in
unit: the modified Mann Assessment of patients with acute stroke. JAMA
Swallowing Ability. J Stroke Cerebrovasc Dis 1973;224:1493-1495.
Bulow M, Speyer R, Baijens L, Woisard V,
Arai T, Yasuda Y, Takaya T, et al. ACE Ekberg O. Neuromuscular electrical
inhibitors and symptomless dysphagia. stimulation (NMES) in stroke patients with
Lancet 1998;352:115-116. oral and pharyngeal dysfunction. Dysphagia
Arai T, Sekizawa K, Yoshimi N, Toshima S,
Fujiwara H. Cabergoline and silent aspiration Carnaby G, Hankey GJ, Pizzi J. Behavioural
in elderly patients with stroke. J Am Geriatr intervention for dysphagia in acute stroke: a
Soc 2003;51:1815-1816. randomised controlled trial. Lancet Neurol
Arms R, Dines D, Tinstman T. Aspiration
pneumonia. Chest 1974;65:136-139. Carnaby-Mann GD, Crary MA. Examining the
evidence on neuromuscular electrical
Aviv JE. Prospective, randomized outcome stimulation for swallowing: a meta-analysis.
study of endoscopy versus modified barium Arch Otolaryngol Head Neck Surg
swallow in patients with dysphagia. 2007;133:564-571.
Laryngoscope 2000; 110(4):563-574.
Chen YM, Ott DJ, Peele VN, Gelfand DW.
Aviv JE, Kaplan ST, Thomson JE, Spitzer J, Oropharynx in patients with cerebrovascular
Diamond B, Close LG. The safety of flexible disease: evaluation with videofluoroscopy.
endoscopic evaluation of swallowing with Radiology 1990;176:641-643.
sensory testing (FEESST): an analysis of
500 consecutive evaluations. Dysphagia Chong MS, Lieu PK, Sitoh YY, Meng YY, Leow
2000; 15(1):39-44. LP. Bedside clinical methods useful as
screening test for aspiration in elderly
15. Dysphagia pg. 54 of 60
patients with recent and previous strokes. thick consistency in stroke patients. Nutr
Ann Acad Med Singapore 2003;32:790-794. Clin Pract 2009;24:414-418.
Churchill M, Grimm S, Reding M. Risks of Dziewas R, Ritter M, Schilling M, et al.
diuretic usage following stroke. Neurorehabil Pneumonia in acute stroke patients fed by
Neural Repair 2004;18:161-165. nasogastric tube. J Neurol Neurosurg
Clayton J, Jack CI, Ryall C, Tran J, Hilal E,
Gosney M. Tracheal pH monitoring and Dziewas R, Warnecke T, Hamacher C, et al. Do
aspiration in acute stroke. Age Ageing 2006; nasogastric tubes worsen dysphagia in
35(1):47-53. patients with acute stroke? BMC Neurol
Collins MJ, Bakheit AM. Does pulse oximetry
reliably detect aspiration in dysphagic stroke Ebihara T, Ebihara S, Maruyama M et al. A
patients? Stroke 1997; 28(9):1773-1775. randomized trial of olfactory stimulation
using black pepper oil in older people with
Crary MA, Carnarby GD, Groher ME, Helseth E. swallowing dysfunction. J Am Geriatr Soc.
Functional Benefits of Dysphagia Therapy 2006;54:1401-1406.
Using Adjunctive sEMG Biofeedback.
Dysphagia 2004;19:160-164. Edmiaston J, Connor LT, Loehr L, Nassief A.
Validation of a Dysphagia screening tool in
Daniels SK, McAdam CP, Brailey K, Foundas acute stroke patients. Am J Crit Care
AL. Clinical assessment of swallowing and 2010;19:357-364.
prediction of dysphagia severity. American
Journal of Speech-Language Pathology Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri
1997;6:17-24. F, Zingarelli A, Pedace C, Lenzi L.
Oropharyngeal dysphagia after stroke:
Daniels SK, Brailey K, Priestly DH, Herrington incidence, diagnosis, and clinical predictors
LR, Weisberg LA, Foundas AL. Aspiration in in patients admitted to a neurorehabilitation
patients with acute stroke. Arch Phys Med unit. J Stroke Cerebrovasc Dis 2009;18:329-
Rehabil 1998;79:14-19. 335.
Dennis M. The FOOD (Feed or Ordinary Diet) Finegold SM. Aspiration pneumonia. Reviews
Trial. 1997 North American Stroke Meeting, of Infectious Diseases 1991;13 (Suppl
Montreal, Quebec, October 18, 1997. 9):S737-742.
Dennis MS, Lewis SC, Warlow C. Effect of Finestone HM, Greene-Finestone LS, Wilson
timing and method of enteral tube feeding ES, Teasell RW. Malnutrition in stroke
for dysphagic stroke patients (FOOD): a patients on the rehabilitation service at
multicentre randomised controlled trial. follow-up: prevalence and predictors. Arch
Lancet 2005;365:764-772. Phys Med Rehabil 1995;76:310-316.
DePippo KL, Holas MA, Reding MJ, Mandel FS, Finestone HM, Greene-Finestone LS, Wilson
Lesser ML. Dysphagia therapy following ES, Teasell RW. Prolonged length of stay
stroke: A controlled trial. Neurology and reduced functional improvement rate in
1994;44:1655-1660. malnourished stroke rehabilitation patients.
Arch Phys Med Rehabil 1996;77:340-345.
DePippo KL, Holas MA, Reding MJ. The Burke
dysphagia screening test: validation of its Finestone HM, Fisher J, Greene-Finestone LS,
use in patients with stroke. Arch Phys Med Teasell RW, Craig ID. Sudden death in the
Rehabil 1994;75:1284-1286 dysphagic stroke patient--a case of airway
obstruction caused by a food bolus: a brief
DePippo KL, Holas MA, Reding MJ. Validation of report. Am J Phys Med Rehabil
the 3-oz water swallow test for aspiration 1998;77:550-552.
following stroke. Arch Neurol 1992;49:1259-
1261. Finestone HM, Foley NC, Woodbury MG,
Greene-Finestone L. Quantifying fluid intake
Diniz PB, Vanin G, Xavier R, Parente MA. in dysphagic stroke patients: A preliminary
Reduced incidence of aspiration with spoon- comparison of oral and nonoral strategies.
Arch Phys Med Rehabil 2001;82:1744-1746.
15. Dysphagia pg. 55 of 60
Foley N, Teasell R, Salter K, Kruger E, Martino screening protocols prevent pneumonia.
R. Dysphagia treatment post stroke: a Stroke 2005; 36(9):1972-1976.
systematic review of randomised controlled
trials. Age Ageing 2008;37:258-264 Hinds NP, Wiles CM. Assessment of swallowing
and referral to speech and language
Freed ML, Freed L, Chatburn RL, Christian M. therapists in acute stroke. QJM
Electrical stimulation for swallowing 1998;91:829-835
disorders caused by stroke. Respir Care
2001; 46(5):466-474. Hinsdale JC, Lipkowitz GS, Pollock TW, Hoover
EL, Jaffe BM. Prolonged enteral nutrition in
Garon BR, Engle M, Ormiston C. Reliability of malnourished patients with nonelemental
the 3 oz water swallow test utilizing cough feeding: reappraisal of surgical technique,
reflex as sole indicator of aspiration. J Neuro safety and costs. Am J Surg 1985;149:334-
Rehab 1995;9:143. 338.
Garon BR, Engle M, Ormiston C. A randomized Holas MA, DePippo KL, Reding MJ. Aspiration
control trial to determine the effects of and relative risk of medical complications
unlimited oral intake of water in patients following stroke. Arch Neurol
with identified aspiration. J Neurol Rehabil 1994;51:1051-1053.
Horner J, Massey EW. Silent aspiration
Gordon C, Hewer RL, Wade DT. Dysphagia in following stroke. Neurology 1988;38:317-
acute stroke. Br Med J 1987;295:411-414. 319(a).
Gosney M, Martin MV, Wright AE. The role of Horner J, Massey EW, Riski JE, Lathrop DL,
selective decontamination of the digestive Chase KN. Aspiration following stroke:
tract in acute stroke. Age Ageing 2006; Clinical correlates and outcome. Neurology
Gottlieb D, Kipnis M, Sister E, Vardi Y, Brill S. Hull MA, Rawlings J, Murray FE, Field J,
Validation of the 50 ml3 drinking test for McIntyre AS, Mahida YR, Hawkey CJ, Allison
evaluation of post-stroke dysphagia. Disabil SP. Audit of outcome of long-enteral
Rehabil 1996; 18(10):529-532. nutrition by percutaneous endoscopic
gastrostomy. Lancet 1993;341:869-872.
Goulding R, Bakheit AM. Evaluation of the
benefits of monitoring fluid thickness in the Huxley EJ, Viroslav J, Gray WR, Pierce AK.
dietary management of dysphagic stroke Pharyngeal aspiration in normal adults and
patients. Clin Rehabil 2000;14:119-124. patients with depressed consciousness. Am
J Med 1978;64:564-568.
Groher ME. Bolus management and aspiration
pneumonia in patients with pseudobulbar James A, Kapur K, Hawthorne AB. Long-term
dysphagia. Dysphagia 1987;1(4):215-216. outcome of percutaneous endoscopic
gastrostomy feeding in patients with
Gustke RF, Varma RR, Soergel KH. Gastric dysphagic stroke. Age Ageing
reflux during profusion of the proximal small 1998;27(6):671-676.
bowel. Gastroenterology 1970;59:890-895.
Jayasekeran V, Singh S, Tyrrell P, Michou E,
Hanning C, Wuttge-Hanning A, Hormann M, Jefferson S, Mistry S, Gamble E, Rothwell J,
Hermann I. A cinematographic study of the Thompson D, Hamdy S. Adjunctive
pathologic mechanism of aspiration functional pharyngeal electrical stimulation
pneumonia. Fortschv Rontgenstr reverses swallowing disability after brain
1989;159(3):260-267. lesions. Gastroenterology 2010;138:1737-
Heart and Stroke Foundation of Ontario.
Improving Recognition and Management of Jean A. Brain stem control of swallowing:
Dysphagia in Acute Stroke. 2002. neuronal network and cellular mechanisms.
Physiol Rev 2001;81:929-969
Hinchey JA, Shephard T, Furie K, Smith D,
Wang D, Tonn S. Formal dysphagia
15. Dysphagia pg. 56 of 60
Johnson ER, McKenzie SW, Sievers A. compared with fiberoptic endoscopic
Aspiration pneumonia in stroke. Arch Phys examination of swallowing (FEES) in
Med Rehabil 1993;74:973-976. determining the risk of aspiration in acute
stroke patients. Dysphagia 2001; 16(1):1-6.
Khedr EM, bo-Elfetoh N, Rothwell JC.
Treatment of post-stroke dysphagia with Lim KB, Lee HJ, Lim SS, Choi YI.
repetitive transcranial magnetic stimulation. Neuromuscular electrical and thermal-tactile
Acta Neurol Scand 2009;119:155-161. stimulation for dysphagia caused by stroke:
a randomized controlled trial. J Rehabil Med
Khedr EM, bo-Elfetoh N. Therapeutic role of 2009;41:174-178.
rTMS on recovery of dysphagia in patients
with lateral medullary syndrome and Lin LC, Wang SC, Chen SH, Wang TG, Chen
brainstem infarction. J Neurol Neurosurg MY, Wu SC. Efficacy of swallowing training
Psychiatry 2010;81:495-499. for residents following stroke. J Adv Nurs
Kidd D, Lawson J, Nesbitt R, MacMahon J. The
natural history and clinical consequences of Linden P, Siebens AA. Dysphagia: predicting
aspiration in acute stroke. Quarterly J Med laryngeal penetration. Arch Phys Med
1995;88:409-413. Rehabil 1983;64:281-284.
Kobayashi H, Nakagawa T, Sekizawa K, Arai H, Logemann JA. Evaluation and treatment of
Sasaki H. Levodopa and swallowing reflex. swallowing disorders. San Diego, CA:
Lancet 1996; 348(9037):1320-1321. College-Hill Press, 1983.
Kostadima E, Kaditis AG, Alexopoulos EI, Logemann JA, Kahrilas PJ, Kobara M, Vakil NB.
Zakynthinos E, Sfyras D. Early gastrostomy The benefit of head rotation on
reduces the rate of ventilator-associated pharyngoesophageal dysphagia. Arch Phys
pneumonia in stroke or head injury patients. Med Rehabil 1989;70:767-771.
Eur Respir J 2005; 26(1):106-111.
Logemann JA, Veis S, Colangelo L. A screening
Langdon PC, Lee AH, Binns CW. High incidence procedure for oropharyngeal dysphagia.
of respiratory infections in 'nil by mouth' Dysphagia 1999;14:44-51
tube-fed acute ischemic stroke patients.
Neuroepidemiol 2009;32:107-113. Lucas CE, Yu P, Vlahos A, Ledgerwood AM.
Lower esophageal sphincter dysfunction
Langmore SE, Terpenning MS, Schork A, Chen often precludes safe gastric feeding in
Y, Murray JT, Lopatin D, Loesche WJ. stroke patients. Arch Surg 1999;134:55-
Predictors of aspiration pneumonia: how 58.
important is dysphagia? Dysphagia 1998
Spring;13(2):69-81. Mann G, Hankey GJ, Cameron D. Swallowing
function after stroke: prognosis and
Leder SB, Espinosa JF. Aspiration risk after prognostic factors at 6 months. Stroke
acute stroke: comparison of clinical 1999;30:744-748.
examination and fiberoptic endoscopic
evaluation of swallowing. Dysphagia 2002; Mann G. The Mann Assessment of Swallowing
17(3):214-218. Ability: MASA. Philadelphia:Delmar
Thompson Learning. 2002.
Leder SB, Suiter DM. Effect of nasogastric
tubes on incidence of aspiration. Arch Phys Mamun K, Lim J. Role of nasogastric tube in
Med Rehabil 2008;89:648-651 preventing aspiration pneumonia in patients
with dysphagia. Singapore Med J
Lien HC, Chang CS, Chen GH. Can 2005;46:627-631
percutaneous endoscopic jejunostomy
prevent gastroesophageal reflux in patients Martino R, Pron G, Diamant N. Screening for
with preexisting esophagitis? Am J oropharyngeal dysphagia in stroke:
Gastroenterol 2000; 9512):3439-3443. insufficient evidence for guidelines.
Lim SH, Lieu PK, Phua SY, Seshadri R,
Venketasubramanian N, Lee SH et al. Martino R, Silver F, Teasell R, et al. The
Accuracy of bedside clinical methods Toronto Bedside Swallowing Screening Test
15. Dysphagia pg. 57 of 60
(TOR-BSST): development and validation of neurological dysphagia. Br Med J
a dysphagia screening tool for patients with 1992;304:1406-1409.
stroke. Stroke 2009;40:555-561.
Park CL, O'Neill PA, Martin DF. A pilot
Meadows J. Dysphagia in unilateral cerebral exploratory study of oral electrical
lesions. J Neurol Neurosurg Psychiatry stimulation on swallow function following
1973;36:853-860. stroke: an innovative technique. Dysphagia
Milazzo LS, Bouchard J, Lund DA. The
swallowing process: effects of aging and Perez I, Smithard DG, Davies H, Kalra L.
stroke. Physical Medicine and Pharmacological treatment of dysphagia in
Rehabilitation: State of the Art Reviews stroke. Dysphagia 1998;13:12-16.
Perlman PW, Cohen MA, Setzen M, et al. The
Muller-Lissner SA, Fimmel CJ, Will N, et al. risk of aspiration of pureed food as
Effect of gastric and transpyloric tubes on determined by flexible endoscopic evaluation
gastric emptying and duodenogastric reflux. of swallowing with sensory testing.
Gastroenterology 1982;83:1276-1279. Otolaryngol Head Neck Surg 2004;130:80-
Nakajoh K, Nakagawa T, Sekizawa K, Matsui T,
Arai H, Sasaki H. Relation between incidence Permsirivanich W, Tipchatyotin S, Wongchai M,
of pneumonia and protective reflexes in et al. Comparing the effects of rehabilitation
post-stroke patients with oral or tube swallowing therapy vs. neuromuscular
feeding. J Intern Med 2000;247:39-42. electrical stimulation therapy among stroke
patients with persistent pharyngeal
Nilsson H, Ekberg O, Olsson R, Hindfelt B. dysphagia: a randomized controlled study. J
Dysphagia in stroke: a prospective study of Med Assoc Thai 2009;92:259-265.
quantitative aspects of swallowing in
dysphagic patients. Dysphagia 1998; Perry L. Screening swallowing function of
13(1):32-38. patients with acute stroke. Part one:
Identification, implementation and initial
Nishiwaki K, Tsuji T, Liu M, Hase K, Tanaka N, evaluation of a screening tool for use by
Fujiwara T. Identification of a simple nurses. J Clin Nurs 2001; 10(4):463-473.
screening tool for dysphagia in patients with
stroke using factor analysis of multiple Poels BJ, Brinkman-Zijlker HG, Dijkstra PU,
dysphagia variables. J Rehabil Med 2005; Postema K. Malnutrition, eating difficulties
37(4):247-251. and feeding dependence in a stroke
rehabilitation centre. Disabil Rehabil
Norton B, Horner-Ward M, Donnelly MT, Long 2006;28:637-643.
RG, Holmes GK. A randomized prospective
comparison of percutaneous endoscopic Power ML, Fraser CH, Hobson A, et al.
gastrostomy and nasogastric tube feeding Evaluating oral stimulation as a treatment
after acute dysphagic stroke. BMJ for dysphagia after stroke. Dysphagia
1996;312: 13-16. 2006;21:49-55
Odderson IR, Keaton JC, McKenna BS. Ramsey DJ, Smithard DG, Kalra L. Early
Swallow management in patients on an assessments of dysphagia and aspiration
acute stroke pathway: quality is cost risk in acute stroke patients. Stroke 2003;
effective. Arch Phys Med Rehabil 34(5):1252-1257.
Ramsey DJ, Smithard DG, Kalra L. Can pulse
Paciaroni M, Mazzotta G, Corea F, Caso V, oximetry or a bedside swallowing
Venti M, Milia P et al. Dysphagia following assessment be used to detect aspiration
Stroke. Eur Neurol 2004; 51(3):162-167. after stroke? Stroke 2006;37:2984-2988.
Park RHR, Allison MC, Lang J, Spence E, Morris Robbins J, Levine RL, Maser A, Rosenbek JC,
AJ, Danesh BJZ, Russel RJ, Mills PR. Kempster GB. Swallowing after unilateral
Randomized comparison of percutaneous stroke of the cerebral hemisphere. Arch
endoscopic gastrostomy and nasogastric Phys Med Rehabil 1993;74:1295-1300.
tube feeding in patients with persisting
15. Dysphagia pg. 58 of 60
Robbins J, Kays SA, Gangnon RE et al. The Sherman B, Nisenboum JM, Jesberger BL,
effects of lingual exercise in stroke patients Morrow CA, Jesberger JA. Assessment of
with dysphagia. Arch Phys Med Rehabil. dysphagia with the use of pulse oximetry.
2007;88:150-158. Dysphagia 1999; 14(3):152-156.
Rosenbek JC, Robbins J, Fishback B, Levine RL. Shimizu T, Fujioka S, Otonashi H, Kondo M,
Effects of thermal application on dysphagia Sekizawa K. ACE inhibitor and swallowing
after stroke. J Speech Hear Res difficulties in stroke. A preliminary study. J
1991;34:1257-1268. Neurol 2008;255:288-289.
Rosenbek JC, Robbins J, Willford WO, Kirk G, Silver F, Norris J, Lewis A, Hachinski V. Early
Schiltz A, Sowell TW, Deutsch SE, Milanti FJ, mortality following stroke: a retrospective
Ashford J, Gramigna GD, Fogarty A, Dong K, review. Stroke 1984;15(3):492-496.
Rau MT, Prescott TE, Lloyd AM, Sterkel MT,
Hansen JE. Comparing treatment intensities Smith HA, Lee SH, O'Neill PA, Connolly MJ. The
of tactile-thermal application. Dysphagia combination of bedside swallowing
1998;13:1-9. assessment and oxygen saturation
monitoring of swallowing in acute stroke: a
Rowat AM, Wardlaw JM, Dennis MS, Warlow safe and humane screening tool. Age Ageing
CP. Does feeding alter arterial oxygen 2000; 29(6):495-499.
saturation in patients with acute stroke?
Stroke 2000; 31(9):2134-2140. Smithard DG, O'Neill PA, Park C, Morris J,
Wyatt R, England R, Martin DF.
Ryu JS, Park SR, Choi KH. Prediction of Complications and outcome after acute
laryngeal aspiration using voice analysis. Am stroke. Does dysphagia matter? Stroke
J Phys Med Rehabil 2004;83:753-757 1996;27:1200-1204.
Scmidt EV, Smirnov VE, Ryabova VS. Results Smithard DG, Smeeton NC, Wolfe CD. Long-
of the seven-year prospective study of term outcome after stroke: does dysphagia
stroke patients. Stroke 1988;19(8):942- matter? Age Ageing. 2007;36:90-94.
Splaingard ML, Hutchins B, Sulton LD,
Schmidt J, Holas M, Halvorson K, Reding M. Chaudhuri G. Aspiration in rehabilitation
Videofluroscopic evidence of aspiration patients: videofluoroscopy vs bedside
predict pneumonia and death but not clinical assessment. Arch Phys Med Rehab
dehydration following stroke. Dysphagia 1988;69:637-640.
Steele CM. Emergency room assessment and
Sellars C, Dunnet C, Carter R. A preliminary intervention for dysphagia: a pilot project. J
comparison of videofluoroscopy of swallow Speech-Language Pathology and Audiology
and pulse oximetry in the identification of 2002;26:100-110
aspiration in dysphagic patients. Dysphagia
1998; 13(2):82-86. Teasell RW, Bach D, McRae M. Prevalence and
recovery of aspiration poststroke: a
Sellars C, Bowie L, Bagg J, et al. Risk factors retrospective analysis. Dysphagia
for chest infection in acute stroke: a 1994;9(1):35-39.
prospective cohort study. Stroke
2007;38:2284-2291 Teasell RW, Marchuk Y, McRae M, Finestone
HM. Pneumonia associated with aspiration
Seki T, Iwasaki K, Arai H, Sasaki H, Hayashi H, following stroke. Arch Phys Med Rehabil
Yamada S et al. Acupuncture for dysphagia 1996;77:707-709.
in poststroke patients: a videofluoroscopic
study. J Am Geriatr Soc 2005; 53(6):1083- Teramoto S, Fukuchi Y. Detection of aspiration
1084. and swallowing disorder in older stroke
patients: simple swallowing provocation test
Sharma JC, Fletcher S, Vassallo M, Ross I.What versus water swallowing test. Arch Phys Med
influences outcome of stroke--pyrexia or Rehabil 2000;81:1517-1519.
dysphagia? Int J Clin Pract 2001 ;55(1):17-
20. Terre R, Mearin F. Oropharyngeal dysphagia
after the acute phase of stroke: predictors
15. Dysphagia pg. 59 of 60
of aspiration. Neurogastroenterol Motil Wang TG, Chang YC, Chen SY, Hsiao TY. Pulse
2006; 18(3):200-205. oximetry does not reliably detect aspiration
on videofluoroscopic swallowing study. Arch
Tobin MJ. Aspiration pneumonia. In: Dantzker Phys Med Rehabil. 2005 Apr;86(4):730-4.
DR (ed). Cardiopulmonary Critical Care.
New York, Grune and Stratton, 1986. Wanklyn P, Cox N, Belfield P. Outcome in
patients who require a gastrectomy after
Trapl M, Enderle P, Nowotny M, et al. stroke. Age and Aging 1995;24:510-514.
Dysphagia bedside screening for acute-
stroke patients: the Gugging Swallowing Warnecke T, Teismann I, Meimann W, et al.
Screen. Stroke 2007;38:2948-2952 Assessment of aspiration risk in acute
ischaemic stroke--evaluation of the simple
Turner WW Jr. Nutritional considerations in swallowing provocation test. J Neurol
the patient with disabling brain disease. Neurosurg Psychiatry 2008;79:312-314.
Warnecke T, Teismann I, Oelenberg S, et al.
Turner-Lawrence DE, Peebles M, Price MF, The safety of fiberoptic endoscopic
Singh SJ, Asimos AW. A feasibility study of evaluation of swallowing in acute stroke
the sensitivity of emergency physician patients. Stroke 2009;40:482-486.
Dysphagia screening in acute stroke
patients. Ann Emerg Med 2009;54:344-8, Westergren A. Detection of eating difficulties
348. after stroke: a systematic review. Int Nurs
Rev 2006; 53(2):143-149.
Veis S, Logemann J. Swallowing disorders in
persons with cerebrovascular accidents. Wu MC, Chang YC, Wang TG, Lin LC.
Arch Phys Med Rehabil 1985;66:373-374. Evaluating Swallowing Dysfunction Using a
100-ml Water Swallowing Test. Dysphagia
Wade DT, Hewer RL. Motor loss and swallowing 2004;19:43-47.
difficulty after stroke: frequency, recovery,
and prognosis. Acta Neurol Scand 1987;
15. Dysphagia pg. 60 of 60