Bedside Assessment of Swallow in a Patient with Recent Stroke

Bedside Assessment of Swallow in a Patient with Recent Stroke Why it matters

Dysphagia is present initially in 78% of patients who have had a stroke; although acute dysphagia improves in about 80% of survivors, its early consequences are severe.

Complications: aspiration leading to stroke-associated pneumonia (SAP), malnutrition, dehydration, longer hospital stay, poorer participation in rehabilitation and worse functional outcome. Dysphagia is associated with significantly higher mortality and morbidity, and with more nursing-home admissions.

South London Stroke Register data show dysphagia at stroke onset was associated with a three- to fivefold increase in institutionalisation at five years.

Delays in bedside dysphagia screening and in comprehensive assessment by a speech and language therapist are associated with a higher risk of stroke-associated pneumonia. Since SAP is one of the main causes of mortality after acute stroke, early dysphagia assessment may prevent deaths and can be implemented even in settings without high-technology specialist stroke care.

Silent aspiration — aspiration without cough or any outward sign of difficulty — occurs in a substantial number of patients, who are at increased risk because clinical swallowing assessments under-diagnose the problem.

The golden rule: keep the patient nil by mouth, including oral medication, until a swallow screen has been passed.

Screening is a pass/fail procedure that identifies who needs comprehensive assessment. It may be conducted by various professionals including a nurse or a speech-language pathologist, but employing a swallow-assessment specialist may reduce the odds of stroke-associated pneumonia.

The patient must be fully conscious and aware — it is very difficult to swallow safely if one is not.

The patient must be able to sit upright and to cough purposefully; if unable to do either, the likelihood of aspiration is increased and a more in-depth assessment is indicated.

Before testing, ensure oral hygiene, correctly fitting dentures, an upright (90°) position with the chin slightly tucked, and suction available at the bedside.

Weak, husky voice (dysphonia); inability to cough voluntarily; a weak cough with no effective expulsion.

Pooling of food or saliva in the mouth or cheek; frequent coughing or choking even on saliva.

History of a recent chest infection; the patient complaining of difficulty swallowing, of having to gulp, of an abnormal sensation, or of difficulty with particular types of food.

Related symptoms: choking during eating or drinking, inability to swallow saliva, nasal regurgitation of food or drink, and discomfort during swallowing.

Assess oral and laryngeal structures and movements, dental state, cognition, posture and any other factor bearing on the safety of oral feeding — lip closure, tongue movement, palatal elevation, jaw movement, voice quality, volitional cough, and laryngeal elevation on palpation during a dry swallow.

Critically: the absence of a gag reflex does not automatically indicate a major swallowing problem, just as the presence of the gag does not indicate a safe swallow. The gag reflex is unreliable and must never be used alone.

The important factors are bolus control, clarity of the voice (is it wet and gurgly after a test swallow?) and effectiveness of the cough (is it firm and effective?).

Try teaspoons of water; if successful, try teaspoons of soft purée; and if that is successful, try foods with more substance.

Observe for: the patient reporting a negative sensation; poor lip closure or degree of leakage; untimely or absent elevation of the larynx; residue in the mouth following the swallow; lack of clarity of voice following the swallow; and choking or coughing before, during or after the swallow.

Formal screening protocols: Water swallow test — several protocols exist; for example the patient drinks 3 oz (90 mL) of water without interruption, and is monitored for completion, coughing, choking and a wet or hoarse vocal quality during or within one minute of completion. Multiple consistency test — stepwise evaluation of non-fluid and fluid textures giving a graded rating (severe, moderate, mild or no dysphagia). Swallowing provocation test — injection of a water bolus through a nasal catheter into the oropharynx; the patient is at risk of aspiration if the swallow reflex takes more than 3 seconds.

Limitations: the water swallow test is sufficient for screening for aspiration after stroke in much of the literature, but its diagnostic accuracy has been questioned — bedside screening is not consistently sensitive, and no bedside protocol has been adequately predictive of aspiration. It nevertheless remains the mainstay because it is safe, straightforward and easily repeated. Pulse oximetry may assist, since decreased blood oxygenation during swallowing has been observed in dysphagic patients.

Fail → remain nil by mouth, start intravenous or nasogastric fluids, and refer to speech and language therapy. A non-instrumental assessment observes swallowing behaviours — fatigue during a meal, signs and symptoms of dysphagia, posture and positioning — but aspiration cannot be observed by this means.

Videofluoroscopy (modified barium swallow) is the gold standard, giving a direct radiographic view of oral, pharyngeal and upper oesophageal function with varied consistencies mixed with barium. It is not feasible as a routine screening option, and it is not infallible — false negatives occur when dysphagia appears only with fatigue after several mouthfuls, and false positives when aspiration is asymptomatic or induced by the tension of the situation or the unpleasantness of the contrast. Findings must be placed in the context of the patient's history.

FEES (fibre-optic endoscopic evaluation of swallowing) is a portable bedside alternative that directly visualises the posterior pharynx, epiglottis, vocal cords and proximal trachea during trials of varied consistencies, and can monitor the effectiveness of therapy — but it does not visualise the oral or oesophageal phase.

Management is interdisciplinary, aimed at protecting the patient from complications, maintaining adequate nutrition, and ensuring the patient and carers understand the deficit. Compensatory techniques and dietary/texture modification under speech and language therapy and dietetic supervision remain the mainstay. Patients with reduced oral sensation, poor buccal control or inadequate laryngeal lift aspirate more on fluids than on semisolids and may be advised to avoid liquids while managing a soft puréed diet; patients with tongue, lip or jaw involvement should avoid foods requiring chewing.

Persistent dysphagia requires alternative nutrition — nasogastric tube early, and percutaneous endoscopic gastrostomy if dysphagia is likely to persist. Other measures include mechanical or thermal pharyngeal stimulation, cortical magnetic stimulation of the swallowing reflex, and electrical pacemakers to trigger laryngeal elevation.

Re-screen daily in the early days — swallow status changes rapidly after stroke. Maintain rigorous oral care throughout.