What is the next step for a patient with a right-sided middle cerebral artery stroke and suspected dysphagia, as evidenced by coughing during a bedside swallow evaluation?

From the Guidelines

I strongly recommend obtaining a videofluoroscopic swallow study (option B) for this 82-year-old stroke patient who demonstrated coughing during her bedside swallow evaluation. This study, also known as a modified barium swallow, is the appropriate next step because it provides a dynamic, real-time assessment of the patient's swallowing function and can identify the presence and severity of dysphagia and aspiration risk, as supported by the guidelines for the early management of patients with acute ischemic stroke 1. The patient's weak cough and coughing during the bedside evaluation suggest possible swallowing difficulties, which is common after stroke, particularly with middle cerebral artery involvement.

Starting antibiotics (option A) would be premature without evidence of aspiration pneumonia. Fiber optic evaluation (option C) is an alternative swallowing assessment but typically used after videofluoroscopy or in specific situations. Starting acid-suppressive medication (option D) would not address the underlying swallowing dysfunction. The videofluoroscopic study will guide appropriate dietary modifications, swallowing strategies, and feeding recommendations to prevent aspiration pneumonia and ensure safe oral intake as the patient recovers from her stroke. According to the guidelines for adult stroke rehabilitation and recovery, early identification of dysphagia through screening can reduce the risk of developing adverse health consequences, such as pneumonia 1.

Some key points to consider in the management of this patient include:

• The importance of sustaining nutrition to prevent dehydration and malnutrition, which can slow recovery 1
• The high risk of pneumonia associated with impairments of swallowing, particularly in patients with brain stem infarctions, multiple strokes, major hemispheric lesions, or depressed consciousness 1
• The need for a thorough assessment of the patient's ability to swallow before allowing oral intake, using tools such as a water swallow test or videofluoroscopic modified barium swallow examination 1
• The potential benefits and risks of different feeding options, including nasogastric tubes, nasoduodenal tubes, and percutaneous endoscopic gastrostomy (PEG) tubes 1.

From the Research

Patient Assessment and Recommendations

The patient is an 82-year-old woman who was admitted to the hospital with acute weakness of the left upper and lower extremities, diagnosed with a right-sided middle cerebral artery stroke. She has hypertension and hyperlipidemia and is currently on atorvastatin and amlodipine. On hospital day 2, she is awake, alert, and oriented, with decreased sensation in the left arm and leg, and weakness in these areas.

Current Status and Findings

• The patient's current vital signs are stable, with a temperature of 36.7°C, pulse rate of 86 per minute, respirations of 12 per minute, and blood pressure of 140/90 mmHg.
• Oxygen saturation is at 94% on room air.
• Cardiopulmonary and abdominal examinations are normal.
• Neurologic examination reveals decreased sensation and strength (3/5) in the left arm and leg.
• Complete blood count, serum creatinine, and serum electrolytes are normal.
• A chest radiograph is normal.
• An MRI confirms a right-sided middle cerebral artery stroke.
• The patient is to start physical therapy and has been observed coughing during a bedside swallow evaluation.

Recommendations Based on Evidence

Given the patient's condition and the observation of coughing during the bedside swallow evaluation, which may indicate aspiration, the following recommendations can be considered:

• Obtain a videofluoroscopic swallow study (VFSS): This is a recommended diagnostic tool for evaluating dysphagia and aspiration, especially in patients with suspected stroke-related swallowing difficulties 2, 3, 4, 5.
• The evidence from 6 suggests that bedside clinical swallow tests are important but may not be as sensitive or specific as other diagnostic methods like FEES (Functional Endoscopic Evaluation of Swallowing) for detecting aspiration. However, in the absence of immediate access to more advanced diagnostic tools, a bedside evaluation is a crucial first step.
• Consider further diagnostic evaluations: Depending on the results of the VFSS and the patient's clinical presentation, further evaluations such as a radionuclide salivagram may be beneficial, especially if there's a high suspicion of aspiration pneumonia that isn't clearly evident on VFSS alone 2, 5.
• Initiate appropriate interventions: Based on the diagnostic findings, interventions such as swallowing therapy, dietary modifications, or the use of alternative feeding methods may be necessary to prevent aspiration pneumonia.
• Monitor for aspiration pneumonia: Given the patient's risk factors, including age, stroke, and observed coughing during swallowing, close monitoring for signs of aspiration pneumonia is essential, and the use of antibiotics may be considered if pneumonia is diagnosed or highly suspected 3, 4.

Diagnostic Approach

The choice between different diagnostic approaches (e.g., VFSS, radionuclide salivagram, fiber optic evaluation of the airway) should be based on the patient's specific presentation, the availability of resources, and the clinical suspicion of aspiration or dysphagia. Each method has its advantages and limitations, and a combination of methods may provide a more comprehensive assessment of the patient's swallowing function and risk of aspiration 2, 5.