1. 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
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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%)
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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
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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
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5. Oral Prep Phase of Swallowing
Tongue strength & movement
Facial palsy
Edentulous
Drooling
Pocketing
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6. Oral Phase of Swallowing
Tongue strength & movement
Impaired vocal quality
Facial palsy
Plate elevation
Gag reflex
Cough
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7. Pharyngeal Phase of Swallowing
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8. 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%
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9. 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
important for taste to posterior tongue, sensory and motor functions of the pharynx
CN X -- Vagus
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
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10. Analysis of BOLD responses during volitional swallow
(Blood-Oxygen-Level-Dependent fMRI)
GI Motility online (May 2006) | doi: /gimo8

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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
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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
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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
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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)
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15. 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, probability that patient does not have dysphagia
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16. 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
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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
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18. 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)
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19. 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
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20. 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
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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.
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References
Perry L * Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001; 16:7-18
Kidd D, Lawson J, Nesbitt R, MacMahon J. The natural history and clinical consequences of aspiration in acute stroke. QJM ;88:
Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke. Evidence report/technology assessment Ref. Type: Report
Mann G & Hankey G. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia 2000;16:
Massey R & Jedlicka D. The Massey bedside swallowing screen. Journal of Neuroscience Nursing 2002;24(5):
Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10:
Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10:
DePippo K, Holas MS, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology 1992;49:
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:
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23. For Copies of This Lecture
ASA International Stroke Conference CD-ROM
American Association Of Neuroscience Nursing Online Resource Area
THANK YOU!!
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