What is the best course of action for an elderly woman with a history of hypertension and hyperlipidemia, on statin, who had an acute right-sided stroke, weak cough, and is at risk for aspiration pneumonia?

Video Fluoroscopic Swallow Study (VFSS) Should Be Obtained Now

The patient should undergo a video fluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) immediately, as she has failed bedside dysphagia screening by coughing during evaluation and requires instrumental assessment to guide safe feeding strategies and prevent aspiration pneumonia. 1

Rationale for VFSS/FEES Over Other Options

Why Not Prophylactic Antibiotics (Option 1)?

• Do not initiate antibiotics prophylactically for aspiration risk alone without evidence of actual pneumonia. 2
• The patient currently has normal vital signs (temperature 36.7°C, no fever, normal respiratory rate of 12) and normal bloodwork, indicating no active infection. 2
• Pneumonia should be diagnosed based on clinical signs (fever, elevated respiratory rate, hypoxia) plus chest imaging findings before starting antibiotics. 2
• Prophylactic antibiotics are not recommended and may lead to antibiotic resistance without proven benefit in preventing aspiration pneumonia. 2

Why VFSS/FEES Is the Correct Next Step (Option 2)?

• The American Heart Association/American Stroke Association guidelines mandate that patients who fail bedside dysphagia screening must undergo comprehensive instrumental swallowing evaluation by a speech-language pathologist within 24 hours. 3
• This patient has multiple high-risk features for severe dysphagia and aspiration: right-sided middle cerebral artery stroke, left hemiparesis (3/5 leg strength, 4/5 arm strength), weak cough, and observed coughing during bedside swallow evaluation. 3
• Bedside clinical swallow evaluation alone is insufficient to guide treatment decisions, as there is inadequate evidence linking these assessments to clinically meaningful outcomes. 1
• VFSS or FEES serves dual purposes: (1) diagnosing the specific swallowing impairments and aspiration risk, and (2) determining which therapeutic interventions (postural changes, dietary modifications, swallowing maneuvers) will eliminate aspiration during oral intake. 1
• Instrumental assessment can identify "silent aspiration" (aspiration without cough), which occurs frequently in stroke patients and cannot be detected by bedside evaluation alone. 3

Why Not Fiberoptic Airway Evaluation (Option 3)?

• Fiberoptic evaluation of the airway (laryngoscopy) is not the appropriate test for dysphagia assessment. 1
• FEES (fiberoptic endoscopic evaluation of swallowing) is different from simple airway visualization—it specifically evaluates swallowing function by observing pharyngeal and laryngeal anatomy during actual eating and drinking. 1
• The question likely conflates airway evaluation with FEES; the correct instrumental assessment is VFSS or FEES for swallowing, not isolated airway examination. 1

Why Not Acid Suppression Medication (Option 4)?

• Acid suppression (proton pump inhibitors or H2 blockers) does not prevent aspiration pneumonia and is not indicated for dysphagia management. 1
• While gastroesophageal reflux may contribute to aspiration risk in some patients, the immediate priority is to assess swallowing safety instrumentally before considering adjunctive therapies. 1
• There is no evidence supporting acid suppression as a primary intervention for post-stroke dysphagia or aspiration prevention. 1

Immediate Management Algorithm

Current Status (Hospital Day 2)

• Patient remains strictly NPO (nothing by mouth, including no oral medications) until instrumental swallowing assessment is completed. 3
• Maintain IV hydration and provide medications via IV route only. 3
• Keep head of bed elevated at least 30 degrees to reduce aspiration risk. 4

Next Steps After VFSS/FEES

• If VFSS/FEES shows safe swallowing with compensatory strategies: Implement specific interventions identified during the study (chin-down posture, head rotation, thickened liquids, modified diet consistency) and initiate oral intake cautiously with continued monitoring. 1
• If VFSS/FEES shows unsafe swallowing despite compensatory maneuvers: Maintain NPO status and place nasogastric tube for enteral nutrition if dysphagia expected to last 7-14 days, or consider PEG tube if dysphagia anticipated beyond 14 days. 3
• Postural changes during VFSS can eliminate aspiration in 77% of dysphagic patients, making instrumental assessment essential for identifying effective compensatory strategies. 1

Additional Supportive Measures

Multidisciplinary Team Approach

• Patients with dysphagia should be managed by organized multidisciplinary teams including physician, nurse, speech-language pathologist, dietitian, and physical/occupational therapists. 1
• This approach has been shown to decrease aspiration pneumonia rates from 6.4% to 0% in stroke patients. 1

Oral Hygiene Protocol

• Implement systematic oral care with chlorhexidine mouth rinse to reduce pneumonia risk after stroke (Class IIb recommendation). 2
• Oral care interventions have been shown to reduce the risk of pneumonia and fatal pneumonia in post-stroke patients. 1

Monitoring for Pneumonia Development

• Continue monitoring temperature every 4 hours and obtain chest imaging immediately if fever develops (temperature >37.5°C or >99.6°F). 4
• Early mobility and pulmonary care help prevent atelectasis and pneumonia. 2
• If pneumonia is diagnosed, initiate appropriate antibiotic therapy promptly, as pneumonia increases mortality risk (HR 2.2) and unfavorable outcomes (OR 3.8) in stroke patients. 2

Common Pitfalls to Avoid

• Do not assume that a preserved gag reflex means safe swallowing—this is unreliable, and many patients with intact gag reflexes still aspirate. 3
• Do not rely on bedside water swallow test alone—multi-item protocols combined with instrumental assessment are required for accurate diagnosis. 3
• Do not delay instrumental swallowing assessment beyond 24 hours after failed bedside screening, as early evaluation is associated with better outcomes and reduced aspiration pneumonia risk. 3
• Do not assume tube feeding prevents aspiration—aspiration risk persists even with nasogastric or PEG tubes. 3

Note on Statin Continuation

• The patient is already on statin therapy for hyperlipidemia, which should be continued. 5
• Continued statin use in acute ischemic stroke patients may reduce the risk of post-stroke pneumonia (OR 0.31,95% CI 0.10-0.94). 5