Dysphagia Update:Evidence, Tools & Practice

Dr. Timothy J. Shephard, CNS, CNRN

Stroke Systems Consulting, Charlottesville, VA

Bon Secours Health System, Richmond, VA

The Author has no disclosures

Definitions

Dysphagia-difficulty swallowing…due to obstruction or motor dysfunction

Aspiration-penetration below the level of the vocal cords

Silent aspiration-penetration below the level of true vocal cords without outward signs of difficulty (~16%)

Facts

Current standards require dysphagia screening prior to any PO intake

Formal dysphagia screening process decreases the rate of pneumonia9

There are multiple tested and validated tools There are multiple barriers to successful

implementation

Evidence ~700,000 new and recurrent strokes in the US

annually Dysphagia clinically present in 42-67% in the first

3 days1, 2

50% of patients with dysphagia experience aspiration1, 2

~33% of patients with dysphagia develop pneumonia requiring treatment2

35% of post stroke deaths caused by pneumonia2

A 3-fold increase in risk of death when diagnosed with pneumonia after stroke3

Oral Prep Phase of Swallowing Tongue strength &

movement Facial palsy Edentulous Drooling Pocketing

Oral Phase of Swallowing

Tongue strength & movement

Impaired vocal quality Facial palsy Plate elevation Gag reflex Cough

Pharyngeal Phase of Swallowing

Screening Methods Used

Initial Awake & alert History NIHSS – screen based on stroke severity and/or suspected

location of lesion On Exam4

Dysarthria – 42% Tongue movement – 42% Gag reflex – 57% Palate elevation – 55% Voluntary cough – 27%

Cranial Nerves for Swallowing CN V -- Trigeminal

contains both sensory and motor fibers that innervate the face important in chewing

CN VII -- Facial contains both sensory and motor fibers important for sensation of oropharynx & taste to anterior 2/3 of tongue

CN IX -- Glossopharyngeal contains both sensory and motor fibers important for taste to posterior tongue, sensory and motor functions of the

pharynx CN X -- Vagus

contains both sensory and motor fibers important for taste to oropharynx, and sensation and motor function to larynx

and laryngopharynx. important for airway protection

CN XII -- Hypoglossal contains motor fibers that primarily innervate the tongue

GI Motility online (May 2006) | doi:10.1038/gimo8

Analysis of BOLD

responses during volitional

swallow(Blood-Oxygen-Level-Dependent

fMRI)

Tools

Massey Bedside Swallow Screen5

N = 25 Clench teeth, close lips, face symmetry, tongue & uvula

midline Gag, cough, secretions, swallow reflex

Plus water challenge (teaspoon & glass) Reported sensitivity & specificity were 100% Tested by research staff

Tools

Standardized Swallowing Assessment (SSA) 6,7

N = 161, 8 item scale Alert, position Cough, control secretions, tongue movement, respiration Vocal quality Water challenge

Repeated testing and validation Poor item agreement (61-69%) with exception of

water challenge (90%) Results not compared to MBS results

Tools

3-0z water swallow test 8

N=44 Secretions, facial palsy, alert, oxygen, History of (asp) pneumonia, dysphagia, stroke

Water challenge Sensitivity & specificity 76% & 59% respectively Increased sensitivity for more severe aspiration Compared to MBS

Tools

STAND Screening Tool for Acute Neurological Dysphagia

N = 97, 21 with MBS, tested in clinical practice Alert, vocal quality/secretions, history Puree & water challenge Allows PO meds if puree challenge passed & SLP consult if

water challenge failed Sensitivity for dysphagia= 92%

92% of patients with dysphagia will be detected with this screen (small chance of false negative)

Specificity for dysphagia = 60% 60% of patients without dysphagia will be ruled out with this screen

(higher risk of false positive)

STAND Predictive Value: Dysphagia

Positive predictive value: the probability that a person has the disease given a positive test result Positive Predictive Value = .90

Based on positive (dysphagia present) screening results, .90 probability that patient has dysphagia.

Negative predictive value: the probability that a person does not have the disease given a negative result Negative Predictive Value = .60

Based on negative (dysphagia absent) screening results, .60 probability that patient does not have dysphagia

STAND Data: Aspiration Sensitivity for aspiration = 90%

90% of patients who will aspirate on MBS will be detected with this screen (small chance of false negative)

Specificity for aspiration = 55% 55% of patients who will not aspirate on MBS will be ruled out

with this screen (higher risk of false positive) Positive Predictive Value = .66

Based on positive (dysphagia present) screening results, .66 probability that patient will aspirate during MBS

Negative Predictive Value =.83 Based on negative (dysphagia absent) screening results, .83

probability that patient will not aspirate during MBS

Tools Analysis

Use a tested and valid tool (or ALL the components of one)

Multiple step tool with automatic STOPS for SLP consult Generally requires:

LOC & history Clearly visible & defined exam items

Absolutely requires water swallow challenge A tool tested for stroke isn’t necessarily adequate for

use with other populations Visible assessment items need clear definitions

Methods for Implementation

Options: location of screening process Emergency Department

Must either perform screen or maintain strict NPO Clearly document PO intake/NPO for indicator abstraction Potential barriers

Emergent need for PO meds (ASA/Plavix?) Patient demand for food/fluids (RRT or consult) Off-service attending MD (order sets, data & education) “CN exam will suffice” (not a CN deficit)

Identified Sources of Resistance

Nursing Leadership Additional training, documentation, liability burden

Application of current research, autonomy in practice More control over PO intake/nutritional status/medication

route Formalized screening process reduces risk

Speech Language Pathology Reduction in consults & control

Reduction in “task” consults Increase in diagnostic (MBS) & treatment consults Data supports additional FTEs

Identified Sources of Resistance

Medicine Resistance to use of screening method, relying on

informal exam findings Pre-printed order sets ED screening before PO Decrease calls/pages for change in PO medication route Decreased complications, LOC, costs

Requires education of standard, benefits of adherence, liability of non-compliance

Summary of Pearls Use a tested & validated tool, the best tool has not been

designed Clinical exam findings need clear definitions & have

limited screening value if not linked to water challenge CN exam alone is least effective form of screening Determine best location for implementation Determine single location for documentation of D/T for

screen and first PO intake. Overcome resistance by highlighting positive clinical

and fiscal impact of implementation SPECIFC to the source of resistance.

References1. Perry L * Love CP. Screening for dysphagia and aspiration in acute stroke: a

systematic review. Dysphagia 2001; 16:7-182. Kidd D, Lawson J, Nesbitt R, MacMahon J. The natural history and clinical

consequences of aspiration in acute stroke. QJM. 1995;88:409-4133. Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care

stroke. Evidence report/technology assessment 8. 2003. Ref. Type: Report4. Mann G & Hankey G. Initial clinical and demographic predictors of swallowing

impairment following acute stroke. Dysphagia 2000;16:208-215.5. Massey R & Jedlicka D. The Massey bedside swallowing screen. Journal of

Neuroscience Nursing 2002;24(5): 25202606. Perry L. Screening swallowing function of patients with acute stroke: Part one.

Journal of Clinical Nursing 2002;10:463-4737. Perry L. Screening swallowing function of patients with acute stroke: Part one.

Journal of Clinical Nursing 2002;10:474-4818. DePippo K, Holas MS, Reding MJ. Validation of the 3-oz water swallow test for

aspiration following stroke. Archives of Neurology 1992;49:1259-1261.9. Hinchey JA, Shephard TJ, Furie K, Smith D, Wang D, Tonn S, For the Stroke

Practice Improvement Investigators. Formal dysphagia screening protocols prevent pneumonia. 2005;36:1972-1976

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