Dysphagia After Stroke . Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Results— Of the 2. Of these, 2. 4 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (3. Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3. CI, 2. 0. 7, 4. 8. RR, 1. 1. 5. 6; 9. CI, 3. 3. 6, 3. 9. Conclusions— The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research. Dysphagia is a commonly documented morbidity after stroke, but its reported frequencies are widely discrepant, ranging between 1. The presence of dysphagia has been associated with an increased risk for pulmonary complications. There is emerging evidence that early detection of dysphagia in patients with acute stroke reduces not only these complications but also reduces length of hospital stay and overall healthcare expenditures. An accurate estimate of the incidence of dysphagia and its increased risk for pulmonary consequences in the stroke population will be critical to guide the design of future research aiming to assess benefits of dysphagia interventions. Dealing With Dysphagia. Nutrition support can be helpful in constructing a healthy diet for those with. Most swallowing problems can be treated, although the treatment you receive will depend on the type of dysphagia you have. Dysphagia; epidemiology; outcomes; risk factors; Dysphagia is a commonly documented morbidity after stroke, but its reported frequencies are widely. Dysphagia refers to a difficulty in swallowing. There are many potential causes but the condition may occur after a stroke or a neurological disorder. Clinical and cognitive predictors of swallowing recovery. Patients who had demonstrated dysphagia after a previ-ous. But your doctor may restrict your diet. If left untreated, dysphagia can. Difficulty Swallowing After Stroke (Dysphagia). Nutrition Tips for Stroke. The right diet can help. Cerebral, cerebellar, or brain stem strokes can impair swallowing physiology. Cerebral lesions can interrupt voluntary control of mastication and bolus transport during the oral phase. Cortical lesions involving the precentral gyrus may produce contralateral impairment in facial, lip, and tongue motor control, and contralateral compromise in pharyngeal peristalsis. Cerebral lesions causing impairments in cognitive function such as concentration or selective attention may also impair control of swallowing. Brain stem strokes are less common than cortical lesions but result in the largest swallowing compromise. Brain stem lesions can affect sensation of the mouth, tongue, and cheek, timing in the trigger of the pharyngeal swallow, laryngeal elevation, glottic closure, and cricopharyngeal relaxation. Regardless of lesion location, because stroke is more common in the elderly,1. The elderly poststroke patient might no longer be able to compensate for normal changes in skeletal muscle strength that reduce mastication. Therefore, single or multiple aspects of the swallow may be impaired depending on stroke type and patient age. The presence of dysphagia is identified using 1 of 3 types of diagnostic techniques. An initial screening test is commonly administered to a newly admitted stroke patient, which serves to identify the likely presence or absence of dysphagia. This procedure is a cursory examination and therefore can be administered and interpreted with only basic clinical swallowing training. If the presence of dysphagia is suspected, a more comprehensive test is administered at bedside by a more extensively trained swallowing clinician. This examination includes a cranial nerve assessment and swallowing trials using a variety of texture- modified liquids and solids. Results from the clinical examination may indicate the need for further testing with instrumentation. The most common instrumental test assessing swallowing function is videofluoroscopy. During the videofluoroscopic assessment of swallowing (VFS), the patient is placed in the sitting position and radiopaque materials of different liquid and food textures are presented. The VFS clearly shows the swallow physiology from the lips to the esophagus, thereby capturing even minor abnormities in movement or frank aspiration. Of these 3 diagnostic techniques, the VFS is the only technique that can visualize the entire swallow and, as a result, is often used as the gold standard by which the accuracy of the other techniques is compared. In this systematic review of the published literature, we report on the frequency of dysphagia in the adult stroke patient and estimate the accompanying increased risk for pneumonia. Additionally, we examine how variations in study design, patient characteristics, and stroke type influence the reported dysphagia incidence rate. Methods. The primary condition of interest was “oropharyngeal dysphagia,” defined by abnormal swallowing physiology of the upper aerodigestive tract and as detected from clinician testing including screening, clinical bedside, or instrumental tests. Aspiration was defined to be a sign of dysphagia. Our premise was that dysphagic patients with aspiration have more severe dysphagia than dysphagic patients without aspiration. The primary outcome of interest was “pneumonia,” defined by abnormal lung status detected from clinical testing. Data Sources. An extensive search of peer- reviewed abstracts published from 1. May 2. 00. 5 was conducted using multiple databases (Medline, Embase, Cochrane Database of Systematic Reviews, Mantis, Pascal, and Sci Search), the terms “deglutition disorders” and “cerebrovascular disorders,” and limited to “human” articles. To reduce investigator selection bias, all relevant search terms were defined a priori. Bibliographies of abstracted references and recent volumes of related journals (ie, Dysphagia, Archives of Physical Medicine and Rehabilitation, and Stroke) were manually searched. Relevant Internet addresses were also searched, such as the Agency for Health Care Policy and Research, Effective Stroke Care, Joint Commission on Accreditation of Healthcare Organizations, and the National Library of Medicine. Also included were additional articles known to the authors but not identified in the search. Inclusions/Exclusions. Only original research articles evaluating the swallowing ability of consecutively enrolled adult (ie, . Retrospective and prospective studies were included. The review was also restricted to articles that reported the incidence of dysphagia using clearly described method(s). If the incidence of pneumonia was reported, the criteria by which it was defined had to be reported. Studies that enrolled patients after swallowing screening or referral to speech language pathology for swallowing assessment were considered to have a higher likelihood for dysphagia and were therefore excluded. Also excluded were editorials, review articles, and case series, including original reports that profiled < 1. Patient- reported symptoms of dysphagia and pneumonia were not considered accurate or reliable and were excluded. Non- English articles were translated using standardized software and native speakers. Where necessary, authors were contacted to clarify ambiguities in study methods or data interpretation. Data Abstraction and Analysis. Two authors (R. M. Any differences were resolved by consensus. Every selected article was appraised for design strengths and flaws according to the criteria established by Sackett et al. Overall, poorly designed studies were considered less persuasive and were rated lower than well- designed prospective studies. Proper methodology was considered to include blinding and documented reliability of diagnostic interpretations, along with proper accounting of all patients eligible and enrolled. The incidence of dysphagia was compared between or within studies according to the evaluation method (ie, initial screening, or clinical or instrumental assessment) and according to recovery continuum (ie, acute or rehabilitation). Incidence was defined as the first identification of dysphagia from clinician testing. Any further follow- up identification in the same patients was not within the scope of this study. Likewise, pneumonia incidence was defined as the first identification from clinician testing. The software Review Manager (Rev. Man) 4. 2. 19 was used to calculate the relative risk (RR) and 9. CI of developing pneumonia associated with dysphagia and aspiration after stroke. A random- effects model, which produces wider and more conservative CIs, was chosen. Because the risk for pneumonia was expected to positively correlate with dysphagia severity, separate analyses were conducted to assess the pneumonia risk among all patients with dysphagia and only those with more severe dysphagia identified on the basis of confirmed aspiration. The RR of developing pneumonia was considered to be statistically significant if the 9. CI did not include one. Results. Literature Retrieved. A total of 2. 77 citations addressing swallowing and stroke patients were identified (Figure 1). Of these, 9. 1 were eliminated because they were reviews, editorials, or nonpeer- reviewed publications, for a total of 1. Of these, 8. 2 were eliminated because they were case series of < 1. The articles of the remaining 1. Of these, 6. 8 were eliminated because they included patients with known dysphagia or those referred for assessment because of suspected dysphagia. An additional 1. 2 articles were eliminated: 5. A total of 2. 4 articles were accepted for review. Data sources retrieved. Methodological Quality and Characteristics of Included Studies. All 2. 4 studies had consecutive enrollment of patients, 2. Generally, data were complete for all enrolled patients with 2 exceptions. Of all 2. 4 studies, only 1 study. The characteristics of enrolled patients varied among selected studies. Half (1. 2 of 2. 4) of the studies included patients with mixed acute ischemic strokes. The exceptions were the following: 3 studies. Two studies. 32,3. Seventeen studies limited enrollment to only conscious patients, whereas 4 studies. Of these, 3 studies. If known, obtunded patients were excluded from the calculations.
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November 2017
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