NOD - Screening testovi i naša iskustva
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1 NOD - Screening testovi i naša iskustva Klinika za neurologiju, KBC Zagreb D. Bažadona, K. Starčević
2 NOD moždani infarkt najčešći je uzrok neurogene orofaringealne disfagije % bolesnika sa akutnim moždanim infarktom ima poteškoće sa gutanjem značajno povišena stopa mortaliteta Martino R. et al. (2005). Dysphagia after stroke incidence, diagnosis, and pulmonary complications. Stroke, 36(12),
3 NOD KOMPLIKACIJE ASPIRACIJSKA PNEUMONIJA MALNUTRICIJA DEHIDRACIJA PODLOŽNOST DRUGIM BOLESTIMA Tippett D. C. (2011). Clinical challenges in the evaluation and treatment of individuals with poststroke dysphagia. Topics in stroke rehabilitation, 18(2),
4 ASPIRACIJSKA PNEUMONIJA u akutnoj fazi moždanog infarkta >50% bolesnika ima disfagiju oko 50% razvije kroničnu disfagiju 50% bolesnika sa disfagijom aspirira 1/3 razvije pneumoniju koja zahtjeva liječenje 6-7 puta povećan rizik za razvoj pneumonije u disfagičnih bolesnika aspiracijska pneumonija povećava smrtnost 3 puta Hinchey J. A. et al. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), Katzan I. L. et al. (2003). The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology, 60(4), Singh S. et Hamdy S. (2006). Dysphagia in stroke patients. Postgraduate medical journal, 82(968),
5 UTJECAJ NA PREHRANU disfagija promjene u komunikaciji kognitivne promjene pareza/plegija sa narušavanjem kontrole posture ili pomicanja ekstremiteta promijenjen/odsutan osjet vidno oštećenje promjene u percepciji dispraksija Perry L. (2001). Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing, 10(4),
6 RIZIČNI FAKTORI promjena stanja svijesti promjene u govornoj ekspresiji ili razumijevanju moždani infarkt u dominantnoj hemisferi recidivni moždani infarkt visoki Rankin indeks niski Barthel indeks na temelju subjektivnog dojma pacijenata ne možemo procijenjivati o mogućnosti gutanja Baroni A. F. F. B. et al. (2012). Risk factors for swallowing dysfunction in stroke patients. Arquivos de gastroenterologia, 49(2),
7 bedside swallowing tests posljedice disfagije i pneumonije: produljenje hospitalizacije moguća ponovna hospitalizacija povećana invalidnost povećan mortalitet rana detekcija smetnji gutanja poboljšava ishod i smanjuje incidenciju pneumonije unutar nekoliko sati od prijema u bolnicu procjena sposobnosti gutanja potrebna prije dopuštanja bolesniku da jede ili pije Adams H. P. et al. (2007). Guidelines for the Early Management of Adults With Ischemic Stroke. A Guideline From the American Heart Association/American Stroke Association Stroke Council. Circulation, 115(20), e478 e534.
8 Ickenstein G. W. et al. (2010). Pneumonia and in hospital mortality in the context of neurogenic oropharyngeal dysphagia (NOD) in stroke and a new NOD step wise concept. Journal of neurology, 257(9), Perry L. et Love C. P. (2001). Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia, 16(1), bedside swallowing tests screeninig test: visoka senzitivnost visoka specifičnost jednostavan za korištenje, brzo provođenje jeftin nizak rizik, prihvaćen od strane pacijenata ponovljivi rezultati provode ga: logopedi liječnici sestre svrha: otkrivanje disfagije daljnja dg. obrada sigurnost prehrane
9 Schepp S.K. et al. (2012). Swallowing Screens After Acute Stroke A Systematic Review. Stroke 43:
10 bedside swallowing tests Barnes Jewish Hospital Stroke Dysphagia Screen Modified Mann Assessment of Swallowing Ability (MMASA) Swallowing Screen Conducted by Emergency Physicians Toronto Bedside Swallowing Screening Test (TOR-BSST) Gugging Swallowing Screen (GUSS) Schepp S.K. et al. (2012). Swallowing Screens After Acute Stroke A Systematic Review. Stroke 43:
11 Barnes Jewish Hospital Stroke Dysphagia Screen Edmiaston J. et al. (2010). Validation of a Dysphagia Screening Tool in Acute Stroke Patients. Am J Crit Care. 19:
12 Barnes Jewish Hospital Stroke Dysphagia Screen
13 Modified Mann Assessment of Swallowing Ability (MMASA) Antonios N. et al. (2010). Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the Modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis. 19:49 57.
14 Modified Mann Assessment of Swallowing Ability (MMASA) Stanje svijesti 10=budan 8=fluktuirajuće budnosti 5=teško se razbuđuje govorom ili fizičkim kontaktom 2=koma Kooperabilnost 10=kooperabilan 8=fluktuira 5=smanjena kooperabilnost Disanje 10=normalno disanje 8=sputum u gornjim dišnim putevima Ekspresivna disfazija 5=bez abnormalnosti 4=manje poteškoće pronalaska riječi 6=fine bazalne krepitacije 3=ogranjičeno izražavanje 2=bez kooperacije/odgovora 4=grube bazalne krepitacije 2=bez funkcionalnog govora 2=infekcija/učestala sukcija/respiirator 1=nemoguće procijeniti Razumijevanje 10=bez abnormalnosti 8=prati razgovor sa manjim poteškoćama Dizartrija 5=bez abnormalnosti 4=usporen govor uz uklijevanje 6=prati jednostavni razgovor 3=govor razumljiv, ali oštećen Gutanje sline 5=bez abnormalnosti 4=izbacuje u čašicu 3=povremeno curenje sline Pomicanje jezika 10=normalno 8=blagi poremećaj 6=nepotpuno pomicanje 4=povremeno odgovara 2=nerazumljiv govor 2=konstantno curenje sline 4=minimalno pomicanje Snaga jezika 10=normalna snaga 8=minimalna slabost 5=jednostrana slabost 2=izražena slabost 1=ne odgovara 1=nemoguće procijeniti 1= izraženo curenje sline 2=nema pomicanja Refleks za povraćanje 5=bez abnormalnosti 4=smanjen obostrano 3=smanjen jednostrano Refleks za kašljanje 10=bez abnormalnosti 8=pokušaj kašljanja, ali kvalitetom promukli 5=neadekvatni pokušaj kašljanja 2=odsutan jednostrano 2=nema pokušaja kašljanja 1=nema refleksa Nepce 10=bez abnormalnosti 8=blaga asimetrija 6=jednostrana slabost 4=minimalni pokret 2=nema pokreta Antonios N. et al. (2010). Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the Modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis. 19:49 57.
15 Swallowing Screen Conducted by Emergency Physicians Turner Lawrence DE et al. )2009). A feasibility study of the sensitivity of emergency physician dysphagia screening in acute stroke patients. Ann Emerg Med. 54:
16 Swallowing Screen Conducted by Emergency Physicians gušenje, hvatanje zraka promukao, vlažan glas
17 Toronto Bedside Swallowing Screening Test (TOR-BSST) Martino R. et al. (2009). The Toronto Bedside Swallowing Screening Test. Stroke. 40:
18 Toronto Bedside Swallowing Screening Test (TOR-BSST)
19 Gugging Swallowing Screen (GUSS) Trapl M. et al. (2007). Dysphagia bedside screening for acute stroke patients The Gugging Swallowing Screen. Stroke, 38(11),
20 Gugging Swallowing Screen (GUSS)
21 kliničko istraživanje Modified Swallowing Assessment, Helios Kliniken, Fresenius Kabi senzitivnost 97%, specifičnost 90% Klinika za neurologiju, KBC Zagreb Nasumice odabranih 116 bolesnika Perry L. (2001). Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing, 10(4),
22 kliničko istraživanje evaluacija 1. dan 3. dan 7. dan pred otpust broj dana sa NGS razvoj pneumonije korelacija sa disfazijom dizartrijom karotidna VB cirkulacija
23 Modified Swallowing Assessment
24 Modified Swallowing Assessment
25 Modified Swallowing Assessment
26 Modified Swallowing Assessment
27 116 bolesnika median godina 78
28
29 PREDNJA 61% STRAŽNJA 78%
30 DISFAZIJA 21% disfazija disfagija disfazija bez disfagije 79%
31 DIZARTRIJA 27% dizartrija disfagija dizartrija bez disfagije 73%
32
33
34
35 prosjek dana sa NGS 12 maksimalni broj dana sa NGS 60 PEG - 0
36 P+ P- D D- 0 44
37 ZAKLJUČAK svi bolesnici s pneumonijom imali disfagiju disfazija OR 3,41 dizartrija OR 2,75 Stražnja cirkulacija
38 Zahvaljujem na pažnji!
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