RECOMMENDATIONS & UPDATES IN THE MANAGEMENT OF POST- STROKE DYSPHAGIA

Transcription

1 RECOMMENDATIONS & UPDATES IN THE MANAGEMENT OF POST- STROKE DYSPHAGIA Feeding in the Acute Stroke Period: - Early initiation of feeding is beneficial w/c decreases the risk of infections, improve survival and reduce disability - Studies show that early resumption of feeding (within 24 hours) is associated with improved outcomes [Class I Level A (FOOD Collaboration Trial)] SELECTION OF A FEEDING ROUTE A. ORAL: for patients who are extubated, awake/alert, following commands AND have intact swallowing ability and adequate GI function B. ENTERAL: for patients who are intubated, unable to swallow OR eat adequate PLUS have adequate small bowel function C. PARENTERAL / CENTRAL: for patients who have inadequate small bowel function OR on whom all forms of enteral access or support are contraindicated AND who have central venous access D. PARENTERAL / PERIPHERAL: for patients who have inadequate small bowel function OR on whom all forms of enteral access are contraindicated PLUS on whom central venous access is contraindicated ** ALL PATIENTS WITH STROKE SHOULD BE SCREENED FOR DYSPHAGIA BEFORE BEING GIVEN FOOD OR DRINK Dysphagia (definition): difficulty in swallowing Classification of Dysphagia: 1. Oropharyngeal problems related to: a) Chewing b) Oral containment of food, liquid or medication c) Manipulation of food, liquid or medication d) Bolus propulsion and transit to esophagus 2. Esophageal a) Obstruction of the esophagus b) Esophageal motility disorders Consequences of dysphagia: Poor nutrition Dehydration Risk for aspiration Decreased enjoyment in eating and drinking Isolation or embarrassment in social situations involving eating

2 DYSPHAGIA SCREENING: Volume- Viscosity Swallow Test: 1. identification of clinical signs of a) Impaired labial efficacy of deglutition i. Labial Seal ii. Oropharyngeal residue iii. Piecemeal deglutition b) Impaired safety i. Wet voice ii. Cough iii. Oxygen saturation (finger pulse- O2 drops >3%)

3 2. Selection of bolus volume/viscosity RESULTS: If we observe signs of impaired safety at liquid viscosity and nectar viscosity is safe: the nmost effective volume of nectar viscosity is recommended If we observe signs of impaired safety at nectar viscosity and pudding viscosity is safe and no residue observed: pudding viscosity is recommended n Patients with a positive test should undergo videofluoroscopy or FEES Instrumental Assessment of Dysphagia: 1. Videofluoroscopic Swallow Studies (VFS) 2. Fiber- Optic Endoscopic Evaluation of Swallowing (FEES) DIETARY MODIFICATIONS IN POST- STROKE DYSPHAGIA Dysphagia categories: Assessment and Management

4 Changing Food Consistency: National Dysphagia Diet

5 Feeding Techniques Sit upright at 90 degree angle Take small bites - approximately ½ to ¾ teaspoon size Take small sips - avoid gulping your beverages Use a slow rate of intake Make sure the mouth is completely empty before taking another bite or sip - avoid washing food down with liquid Chew foods thoroughly before swallowing Avoid talking with food in your mouth Eat in a quiet place with few distractions Severe Dysphagia NGT feeding is the preferred mode of feeding for first month post- stroke for patients who have not recovered functional swallowing PEG tube insertion is recommended for long- term enteral feeding (> 4 weeks) Regular re- assessment of swallowing should be done SUMMARY Malnutrition is a common complication after stroke Early resumption of feeding à better outcomes Dysphagia screening should be routinely done for all stroke patients Diet prescription is based on the medical condition Selection of the feeding route depends on the level of sensorium and results of the bedside dysphagia screening test or VVST Formal evaluation of swallowing is done through FEES or VFS if the patient fails the bedside assessment Food consistency modifications are done to improve safety and efficacy of swallowing Dysphagia rehabilitation is essential in the management of stroke patients with swallowing difficulties Selection of the feeding route depends on the level of sensorium and results of the bedside dysphagia screening test or VVST Formal evaluation of swallowing is done through FEES or VFS if the patient fails the bedside assessment Food consistency modifications are done to improve safety and efficacy of swallowing Dysphagia rehabilitation is essential in the management of stroke patients with swallowing difficulties