What is the next step in diagnosing dysphagia in a patient with acute ischemic stroke, who is on anticoagulation therapy and atorvastatin, and exhibits coughing during swallow evaluation?

Management of Dysphagia in Acute Ischemic Stroke Patient

The next most appropriate step in diagnosing dysphagia in this patient is to refer her to a speech-language pathologist (SLP) for a formal oral-pharyngeal swallow evaluation. 1

Rationale for SLP Referral

This 72-year-old woman with acute ischemic stroke demonstrates clear signs of dysphagia during bedside swallow evaluation, specifically coughing, which is a significant clinical indicator of aspiration risk. The evidence strongly supports immediate referral to an SLP for several reasons:

1. Clinical signs of aspiration are present: The patient's coughing during swallow evaluation is a direct indicator of potential aspiration 1

2. High-risk population: Stroke patients are at particularly high risk for dysphagia and aspiration pneumonia, with dysphagia present in approximately 32% of acute stroke patients 2

3. Anticoagulation therapy increases risk: The patient is on anticoagulation therapy, which increases the risk of complications if aspiration occurs

Diagnostic Approach Algorithm

1. Initial bedside evaluation (already completed, showed coughing)

   • This is insufficient for complete diagnosis but identified the need for further evaluation

2. SLP referral for formal oral-pharyngeal swallow evaluation (next step)

   • This should be done immediately before allowing oral intake 1

3. Instrumental assessment options (to be determined by SLP):

   • Videofluoroscopic swallow evaluation (VSE)
   • Fiberoptic endoscopic evaluation of swallowing (FEES)

Importance of Formal Evaluation

The guidelines clearly state that patients with cough who are in high-risk groups for aspiration should be referred for a detailed swallowing evaluation by an SLP when they show clinical signs associated with aspiration, such as coughing during a swallow test 1. This recommendation carries a grade B recommendation, indicating substantial benefit despite low evidence.

The SLP evaluation is critical because:

• It provides objective assessment beyond bedside screening
• It can identify silent aspiration (aspiration without cough)
• It helps determine appropriate dietary modifications and compensatory strategies

Pitfalls to Avoid

1. Do not rely solely on bedside evaluation: Bedside evaluations have limited sensitivity for detecting aspiration, particularly silent aspiration

2. Do not allow oral feeding without proper assessment: Despite the patient stating she is hungry, allowing her to eat without proper evaluation could lead to aspiration pneumonia

3. Do not assume coughing is the only indicator: While coughing is significant, a comprehensive evaluation by an SLP can identify other issues that may not be apparent during simple bedside testing

4. Do not delay referral: Early evaluation by an SLP is associated with improved outcomes 3

Expected Outcomes

Following SLP evaluation, management may include:

• Specific dietary consistency recommendations
• Compensatory swallowing techniques
• Positioning strategies
• Potential need for alternative feeding methods if severe dysphagia is identified

The NIHSS score may help predict dysphagia risk, with scores ≥5 indicating higher risk of dysphagia and pneumonia 4, but this does not replace the need for formal SLP evaluation when clinical signs of aspiration are already present.