Review of dysphagia in poststroke

Transcription

1 Review of dysphagia in poststroke patients Danielle Thompson, Speech and Language Therapist Northwick Park Hospital With acknowledgement to Mary McFarlane, Principal Speech and Language Therapist, Acute and Stroke Services at Northwick Park Hospital.

2 Aims To understand the incidence of dysphagia in patients post-stroke To understand the normal and abnormal swallow physiology Assessment and management of dysphagia

3 Incidence of dysphagia post-stroke Common morbidity post-stroke Incidence ranges from 25% (Gottlieb et al, 1996) to 81% (Meng, Wang & Lien, 2000)

4 Why is dysphagia a problem? Dysphagia can persist long term It can impact on hydration and nutritional intake The association between dysphagia, pneumonia and mortality in hospitalised patients is well established It can have significant impact on social interactions and quality of life measures

5 The normal swallow - anatomy

6 The stages of the normal swallow Preoral Oral Pharyngeal Oesophageal

7 External influences Preoral Attention Behaviour Cognition

8 Oral phase Food/fluid enters the oral cavity. Breaking down food/fluid with saliva. Rotary and lateral jaw movement.

9 Pharyngeal phase Velopharyngeal seal Laryngeal closure Hyoid and laryngeal elevation UES opening Base of tongue retraction Posterior pharyngeal wall contraction

10 Oesophageal phase Peristaltic wave action propels food and fluid into the stomach. SLTs not usually involved in the assessment and management of this phase.

11 The abnormal swallow Inadequate bolus preparation Anterior leakage Post-swallow oral residue Premature spillage Pre-swallow pharyngeal pooling Reduced epiglottic deflection Post-swallow vallecular/pyriform sinus residue Laryngeal penetration and aspiration

12 Assessment of dysphagia Swallow screen Cough reflex test FEES (fibreoptic endoscopic evaluation of swallowing) VFS (videofluoroscopy)

13 Management of dysphagia Compensatory strategies Therapeutic exercises Modified diet/fluids Thickened fluids Soft/fork mashed/puree

14 Risk feeding Decision is made by the medical team based on SLT information about patient s swallow safety & function Recommendations are made for minimising but not eliminating the risk of aspiration

15 Free water protocol Water ONLY- no other fluids orally No liquid medications/medications with water No water with meals/solids No water for 30 minutes Regular mouth care

16 Fluid modification STAGE 1 FLUIDS: (SYRUP CONSISTENCY) SWALLOW GUIDELINES ADULT SPEECH AND LANGUAGE THERAPY NORTHWICK PARK HOSPITAL 1 SCOOP / 100 mls MIX WITH FORK LEAVE TO STAND FOR 1 MINUTE NB: 0.5 SCOOP = UP TO 5 ML LINE IN THE BLUE SCOOP DIET: MAKE SURE: STOP IF: UPRIGHT AS POSSIBLE AWAKE ALERT COUGHING/CHOKING INCREASED RESPIRATORY RATE REDUCED CHEST STATUS WET BREATHING

17 STAGE 2 FLUIDS: (CUSTARD CONSISTENCY) SWALLOW GUIDELINES ADULT SPEECH AND LANGUAGE THERAPY NORTHWICK PARK HOSPITAL 1.5 SCOOPS / 100 mls MIX WITH FORK LEAVE TO STAND FOR 1 MINUTE NB: 0.5 SCOOP = UP TO 5 ML LINE IN THE BLUE SCOOP DIET: MAKE SURE: STOP IF: UPRIGHT AS POSSIBLE AWAKE ALERT COUGHING/CHOKING INCREASED RESPIRATORY RATE REDUCED CHEST STATUS WET BREATHING

18 SWALLOW GUIDELINES ADULT SPEECH AND LANGUAGE THERAPY NORTHWICK PARK HOSPITAL Fluids: WATER ONLY FREE WATER PROTOCOL GUIDELINES: No water to be given at mealtimes or for 30 minutes after eating No other fluids to be given i.e tea, orange juice. WATER ONLY. No thin food textures i.e. soup, ice cream, cereal and milk Do not give thickened fluids even if coughing STOP if coughing ++ Medications NOT to be taken with water. Please discuss with PHARMACIST if you have any queries. Regular mouth care to keep the mouth clean, especially after mealtime

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21 Linking in with pharmacy SLT recommendations will be made and nursing staff informed. A bedside sign with guidelines will be placed above the patient s bed and details documented in the notes. Nurses/SLT will contact the relevant ward pharmacist to amend the patient s medication as required if there is a presenting dysphagia.