What is the management plan for dysphagia (difficulty swallowing) after a stroke?

Management of Dysphagia After Stroke

The management of post-stroke dysphagia requires early screening, comprehensive assessment, and implementation of a structured rehabilitation program including behavioral interventions, swallowing exercises, and appropriate dietary modifications to reduce aspiration risk and improve swallowing function.

Initial Assessment and Screening

• All stroke patients who are awake and alert should be screened for dysphagia before any oral intake is allowed 1
• Patients who fail the initial screening should be kept NPO (nothing by mouth) until they receive a comprehensive assessment, preferably within 3 days of stroke onset 1
• Comprehensive assessment should include:
  • Bedside swallowing evaluation 1
  • Instrumental examination (e.g., videofluoroscopy, FEES) if indicated by clinical signs 1
• The 3-oz water swallow test can accurately predict a patient's ability to tolerate thin liquids, but follow-up instrumental assessment is recommended if the patient fails this test 1

Treatment Approaches

Behavioral Interventions

• Implement a multi-intervention dysphagia program that includes:
  • Modified diet based on swallowing assessment 1
  • Airway protection strategies (chin tuck, head rotation) 1
  • Swallowing exercises (e.g., Shaker exercises, chin tuck against resistance) 1
• Offer swallowing therapy at least 3 times weekly for patients able to participate, continuing as long as functional gains are observed 1
• High-intensity therapy (daily sessions) is associated with better outcomes than low-intensity therapy (three times weekly), including increased likelihood of returning to a normal diet and recovery of swallowing function 2

Compensatory Strategies

• Implement safe feeding strategies:
  • Appropriate diet consistency modifications 1
  • Reducing distractions during meals 1
  • Ensuring proper positioning (seated upright) 1
  • Slow feeding rate with small amounts per bite 1
• Note: While these strategies may reduce aspiration risk, they do not necessarily lead to recovery of swallowing function 1

Swallowing Exercises and Maneuvers

• Implement specific exercises to improve swallowing physiology:
  • Shaker exercises (to improve upper esophageal sphincter opening) 1, 3
  • Chin tuck against resistance 1
  • Effortful swallow, supraglottic swallow, and Mendelsohn maneuver 3
• Consider combining swallowing maneuver training with electromyography biofeedback, which has shown improvement in approximately half of stroke patients 1

Nutritional Management

• For patients unable to maintain adequate nutrition orally:
  • Consider enteral feeding within 7 days of admission, preferably within 24-48 hours 1
  • For longer-term feeding needs, percutaneous endoscopic gastrostomy (PEG) is preferred over nasogastric tubes in the post-acute phase 1
• Provide nutritional supplements for patients with poor or deteriorating nutritional status 1

Oral Hygiene

• Ensure good oral and dental hygiene, particularly for patients with dysphagia 1
• Provide assistance and education for proper oral care, including denture care 1
• Regular oral care helps reduce the risk of aspiration pneumonia 1

Monitoring and Follow-up

• Healthcare professionals should regularly monitor and reassess patients with dysphagia who require modified food and liquids 1
• Continue swallowing therapy as long as the patient demonstrates functional improvements 1
• Monitor for complications such as aspiration pneumonia, malnutrition, and dehydration 1, 4

Interdisciplinary Approach

• Management should involve a specialized rehabilitation team including:
  • Speech-language pathologists for swallowing assessment and therapy 1
  • Dieticians for nutritional management 1
  • Physicians and nurses for medical management and monitoring 1
• Patient and family education should be provided regarding dysphagia management strategies 1

Prognostic Factors

• Factors associated with poorer recovery of swallowing function include:
  • Higher initial risk of aspiration 5
  • Presence of aphasia 5
  • Larger white matter hyperintensity volume 5
  • Acute infarcts in right corona radiata and right superior longitudinal fasciculus 5

Evidence Quality and Limitations

• While swallowing therapy appears to reduce length of hospital stay, dysphagia persistence, and chest infections, evidence quality varies across interventions 6
• Behavioral interventions show moderate evidence for improving swallowing and returning to a normal diet 2, 6
• Limited high-quality evidence exists for specific interventions like thermal or electrical stimulation 1
• The chin-tuck posture, while clinically popular, provides aspiration protection in fewer than 50% of neurogenic dysphagia cases 1