Screening
Screening for dysphagia is recommended for patients at risk of, or following, aspiration due to suspected dysphagia (including all patients following an acute stroke), in order to prevent aspiration pneumonia. Suspect dysphagia particularly in patients with a history of coughing during swallowing, abnormal swallow time or positions, and difficulty handling secretions, particularly in older patients with a history of pneumonia and multiple comorbidities.
Involve the multidisciplinary team early for any patient with suspected dysphagia and organise a swallowing assessment. Always involve the patient and/or carer in decision-making where possible.[50][51]
Bedside swallowing assessment
An initial screen of swallowing function should be completed by an appropriately trained healthcare professional.[52][53] Screening questions that may be used are:[54]
Do you cough and choke when you eat and drink?
Does it take you longer to eat your meals than it used to?
Have you changed the type of food that you eat?
Does your voice change after eating/drinking?
In addition, organise a specialist swallowing assessment (e.g., by a speech and language therapist).[50] This should include:
A patient interview
A physical examination. A complete neurological examination should be performed, including assessment of the patient’s cortical functions, bulbar muscles, gag reflex, and cough reflex
Assessment for signs of aspiration. This may include observing the patient’s ability to swallow small quantities of water or ice chips.
Video-fluoroscopic swallow assessment
Also known as videofluoroscopy, or modified barium swallow. This is the most commonly used investigation and considered the gold standard for swallowing problems in the UK. For this investigation, the patient swallows barium under fluoroscopic imaging. If the patient has dysphagia, passage or retention of the radiopaque material in the respiratory tract may be seen. Evidence shows that, on videofluoroscopic swallow assessment, 38% of patients with acute stroke had overt aspiration and 67% had silent aspiration.[22] Video-fluoroscopic swallow assessment performed in patients with indwelling tracheostomies on positive-pressure ventilation showed an incidence of aspiration of 50%, and 77% of these patients had silent aspiration.[25]
Flexible endoscopic evaluation of swallowing
Flexible endoscopic evaluation of swallowing (FEES) can be performed by a speech and language therapist at the bedside. A flexible fibre-optic scope is used to look for the presence of food or a thick liquid over the vocal cords; this is evidence that indicates aspiration. FEES also assesses the vocal cord function. In a study of critically ill trauma patients, FEES performed within 24 hours after extubation showed aspiration in 45% of the patients, of whom almost half were silent aspirators. These patients resumed an oral diet at a mean of 5 days after extubation and had no pulmonary complications.[29] FEES avoids exposure to radiation; however, a videofluoroscopic swallow study is non-invasive and more widely available.[55]
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