What is the management of right-sided drooling (hemidrooling) after a cerebrovascular accident (CVA) or stroke?

Management of Right-Sided Drooling After Stroke

Glycopyrrolate oral solution is the recommended first-line pharmacological treatment for post-stroke hemidrooling, with dosing initiated at 0.02 mg/kg three times daily and titrated up as needed to control symptoms while monitoring for anticholinergic side effects. 1

Assessment and Diagnosis

Before initiating treatment for post-stroke drooling, a thorough swallowing evaluation is essential:

• A bedside swallow screening should be completed before any oral intake 2
• If the initial swallow screening is abnormal, a complete bedside swallow examination is recommended 2
• Consider videofluoroscopic modified barium swallow examination to assess swallowing function 2
• Evaluate for specific causes of drooling:
  • Impaired swallowing (dysphagia)
  • Decreased oral sensation
  • Poor lip closure
  • Impaired voluntary control of oral muscles
  • Cognitive deficits affecting awareness of saliva

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Positioning: Maintain head and trunk elevation of 20-30 degrees to reduce risk of aspiration 3
• Swallowing therapy:
  • Compensatory strategies including posture changes
  • Swallowing maneuvers (voluntary control techniques)
  • Active exercise programs to improve oral motor control 2
• Behavioral modifications:
  • Heightening sensory input
  • Regular reminders to swallow
  • Oral motor exercises

Step 2: Pharmacological Management

If non-pharmacological interventions are insufficient:

1. First-line: Glycopyrrolate oral solution

   • Starting dose: 0.02 mg/kg three times daily
   • Titrate in increments of 0.02 mg/kg every 5-7 days based on response and side effects
   • Maximum dose: 0.1 mg/kg three times daily (not to exceed 3 mg per dose) 1
   • Administer at least one hour before or two hours after meals 1

2. Alternative pharmacological options:

   • TRPV1 agonists (capsaicinoids) may improve swallow safety by decreasing latency of the swallow reflex 2
   • Dopaminergic agents may help normalize the onset of pharyngeal swallow in post-stroke patients 2

Step 3: Advanced Interventions

For refractory cases:

• Neuromuscular electrical stimulation (NMES) applied together with behavioral swallowing treatment 2
• Pharyngeal electrical stimulation (PES) may improve swallowing function 2
• Consider referral for more invasive interventions if conservative measures fail

Monitoring and Follow-up

• Assess for constipation within 4-5 days of initial dosing or after dose increases of anticholinergic medications 1
• Monitor for common side effects of glycopyrrolate:
  • Dry mouth
  • Constipation
  • Urinary retention
  • Flushing
  • Nasal congestion 1
• Regular reassessment of swallowing function to adjust treatment plan

Special Considerations

• Use glycopyrrolate with caution in patients with renal impairment 1
• Anticholinergic medications may worsen cognitive function in stroke patients
• Avoid high ambient temperatures when using anticholinergic medications due to risk of heat prostration 1
• Patients with impaired swallowing are at increased risk of pneumonia, which is an important cause of death after stroke 2

Patient and Caregiver Education

• Provide education in both interactive and written formats 2
• Ensure proper measurement of liquid medications with appropriate measuring devices 1
• Instruct on recognition of side effects, particularly constipation and urinary retention 1
• Teach caregivers proper positioning techniques during feeding

By following this structured approach to managing post-stroke drooling, clinicians can significantly improve patients' quality of life while minimizing complications and side effects.