• Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: identification and management of dysphagia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2004 Sep. 38 p. (SIGN publication; no. 78). [154 references]

Dysphagia as a result of stroke

Evaluation
Management
Prevention
Risk Assessment
Screening

Family Practice
Geriatrics
Internal Medicine
Neurology
Nursing
Nutrition
Otolaryngology
Physical Medicine and Rehabilitation
Speech-Language Pathology

Dietitians
Nurses
Occupational Therapists
Physicians
Speech-Language Pathologists

The aim of this guideline is to assist practitioners in reducing the morbidity associated with dysphagia by early detection of swallowing disorders in stroke patients and application of appropriate methods to support food and fluid intake

Stroke patients throughout the care pathway from initial primary care response, through hospital admission, on to continuing care in the community. The emphasis is on patients in the acute setting.

Note: The guideline does not apply to people with neurological conditions other than stroke or to people with subarachnoid haemorrhage.

Evaluation/Assessment

1. Initial clinical evaluation of swallowing and nutrition after stroke:
   • Assessing risk of pneumonia (gag reflex, laryngopharyngeal sensory testing, water swallow test)
   • Swallow screening
   • Assessing risk of undernutrition
   • Nutritional screening
2. Assessment:
   • Clinical bedside assessment (CBA)
   • Instrumental assessment, including modified barium swallow (MBS) using videoflouroscopy and fibre optic endoscopic evaluation of swallowing (FEES) using a flexible nasendoscope
   • Other assessments considered, but not recommended: cervical auscultation (CA) and pulse oximetry
3. Provider training for screening and assessments

Management/Prevention

1. Nutritional interventions:
   • Oral nutritional supplementation (considered, but not recommended)
   • Nasogastric (NG) tube feeding
   • Percutaneous endoscopic gastrostomy (PEG) tube feeding
2. Other management issues:
   • Routine nutritional monitoring and interventions
   • Diet modification
   • Texture modification
   • Delivery of oral hygiene
   • Administration of medicines
   • Assessment of communication, cognitive issues, and capacity for decision making

• Morbidity associated with dysphagia (pneumonia, lower respiratory tract infections, weight changes, undernutrition or reduced nutritional status)
• Risk of aspiration in stroke patients
• Risk of undernutrition in stroke patients
• Benefits, risks, and efficacy of interventions used to evaluate and manage dysphagia, and prevent complications
• Quality of life

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies; high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g., case reports, case series)

4: Expert opinion

Systematic Review with Evidence Tables

Expert Consensus

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

Grade A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

Grade D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

A national open meeting is the main consultative phase of Scottish Intercollegiate Guidelines Network (SIGN) guideline development, at which the guideline development group presents its draft recommendations for the first time. The national open meeting for this guideline was held on 16 May 2002 and was attended by 100 representatives of all the key specialties relevant to the guideline. The draft guideline was also available on the SIGN Web site for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline.

The guideline was also reviewed in draft form by a panel of independent expert referees, who were asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline.

As a final quality control check, the guideline is reviewed by an Editorial Group comprising the relevant specialty representatives on SIGN Council to ensure that the peer reviewers' comments have been addressed adequately and that any risk of bias in the guideline development process as a whole has been minimised.

Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.

The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Initial Clinical Evaluation of Swallowing and Nutrition after Stroke:

C: All stroke patients should be screened for dysphagia before being given food or drink.

Assessing Risk of Pneumonia

B: The water swallow test should be used as a part of the screening for aspiration risk in stroke patients.

C: Clinical history taking should take into account comorbidities and other risk factors (e.g., smoking or respiratory disease) to identify increased risk of developing aspiration pneumonia.

Swallow Screening

D: Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan.

B: A typical swallow screening procedure should include:

• Initial observations of the patient's consciousness level
• Observations of the degree of postural control

If the patient is able to actively cooperate and is able to be supported in an upright position the procedure should also include:

• Observations of oral hygiene
• Observations of control of oral secretions
• If appropriate, a water swallow test

Nutritional Screening

D: Patients' nutritional risk should be established using a valid and reliable screening procedure suitable for stroke patients. Nutritional screening should be repeated at regular interval throughout the episode of care.

D: Nutritional screening should focus on the effects of the stroke on nutritional status (e.g., presence of dysphagia and ability to eat) rather than previous nutritional status.

D: Nutritional risk should be established within 48 hours of admission to hospital.

D: Results from the nutritional screening process should guide appropriate referral to a dietitian for assessment and management.

D: Nutritional screening should cover:

• Body mass index (BMI)
• Ability to eat
• Appetite
• Physical condition
• Mental condition

Assessment:

Clinical Bedside Assessment

B: A standardised clinical bedside assessment (CBA) should be used by a professional skilled in the management of dysphagia (currently speech and language therapists).

B: The clinical bedside assessment developed and tested by Logemann, or a similar tool, is recommended.

Instrumental Assessment

C: The modified barium swallow test and fibre optic endoscopic evaluation of swallow are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings.

Training for Screening and Assessments:

Screening

D: A training package for nurses should include:

• Risk factors for dysphagia
• Early signs of dysphagia
• Observation of eating and drinking habits
• Water swallow test
• Monitoring of hydration
• Monitoring weight and nutritional risk

Assessment

D: All staff involved in the detection and management of dysphagia should be trained according to the recommendations of the relevant professional body.

D: Standard criteria should be established for the interpretation of the results of radiological and fibre optic assessments.

Nutritional Interventions:

Tube Feeding

D: Patients in the early recovery phase should be reviewed weekly by the multidisciplinary team to ascertain if longer term (>4 weeks) feeding is required.

B: Feeding via percutaneous endoscopic gastrostomy (PEG) is the recommended feeding route for long-term (>4 weeks) enteral feeding. Patients requiring long-term tube feeding should be reviewed regularly.

D: Patient's and carer's perceptions and expectations of PEG feeding should be taken into account and the benefits, risks and burden of care fully explained before initiating feeding.

Other Management Issues:

Effect of Regular Review on Patient Outcome

D: Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual swallowing function and dietary intake, by a professional skilled in the management of dysphagia.

Effect of Therapy on Patient Outcome

D: Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment.

D: Texture modified food should be attractively presented and appetising. Patients should have a choice of dishes.

Other Considerations

D: Good oral hygiene should be maintained in patients with dysphagia, particularly in those with PEG or nasogastric (NG) tubes, in order to promote oral health and patient comfort.

D: Hospital and community pharmacists or medicines information centres should be consulted by the professional managing the patient's dysphagia on the most appropriate method of administering medication.

Care of Patients with Dysphagia

D: Staff, carers and, patients should be trained in feeding techniques. This training should include:

• Modifications of positioning and diet
• Food placement
• Management of behavioural and environmental factors
• Delivery of oral care
• Management of choking

The Effect of Communicative or Cognitive Impairment on the Management of Dysphagia Patients

D: Communication, cognitive function, and the capacity for decision making should be routinely assessed in patients with dysphagia.

Definitions:

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1 -: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies; high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g., case reports, case series)

4: Expert opinion

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A: At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

Algorithms are provided in the original guideline document for:

• Swallow screening procedure
• Clinical bedside assessment
• Oral care
• Assessment of patient suitability for a percutaneous endoscopic gastrostomy (PEG) tube
• Postdischarge monitoring for patients on home enteral tube feeding

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Implementation of a systematic programme of diagnosis and management of dysphagia within an acute stroke management plan can reduce the occurrence of pneumonia.
• Starting tube feeding early may reduce case fatality and that unless there are strong practical reasons why a percutaneous endoscopic gastrostomy (PEG) tube should be used, early tube feeding should be via a nasogastric (NG) tube.
• Routine nutritional monitoring and interventions (i.e., regular weighing, nutritional analysis, staff attention to swallowing, texture modified diets, and tube feeds) contribute to improvements in nutrition and ensure that dysphagia is not associated with undernutrition in patients surviving beyond one month.
• Diet modification and use of postures or manoeuvres have been shown to be effective in specific individuals using videofluoroscopy and are standard management of dysphagia following stroke.
• Good oral hygiene can prevent oral and dental disease and reduce the risk of aspiration pneumonia.

• Limitations of modified barium swallow (MBS) include potential difficulty in transporting stroke patients to a radiology department, exposure to radiation, and the limitations of basing management recommendations on a "snapshot" view of swallowing function.
• Nasogastric (NG) tubes: inadvertent placement into the lungs can be a problem, and if unrecognised has serious consequences. Oesophagitis and upper gastrointestinal ulceration may also occur.
• Percutaneous endoscopic gastrostomy (PEG) tubes: Minor complications, such as tube displacement, minor skin infection, tube obstruction and leakage are relatively common with a reported rate of 13 to 62%. Major complications, such as gastric haemorrhage, serious abdominal wall infection, peritonitis and gastric fistula are reported in between 3 to 19% of patients. The procedure related mortality is 0 to 2.5%. Long term mortality following PEG placement is high, presumably reflecting the seriousness of the underlying stroke. Mortality rates at 30 days, 6 months, and 12 months are in the range of 20%, 40%, and 50% respectively.
• Both NG and PEG tubes: with both types of tube feeding gastric intolerance can occur and may limit adequate delivery of nutrition. Gastro-oesophageal reflux and aspiration are common and neither type of tube feeding reduces the risk of aspiration after stroke.

This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or management plan must be made by the appropriate healthcare professional(s), following discussion of the options with the patient, in light of the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

Implementation of national clinical guidelines is the responsibility of each National Health Service (NHS) Health Board and is an essential part of clinical governance. It is acknowledged that every Health Board cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor adherence. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

Key Points for Audit

Data should be collected to confirm that:

• Comorbidities and correctable risk factors are assessed on admission
• Nutritional risk is assessed within 48 hours of admission
• Screening for dysphagia takes place before any food/drink is given
• Screening for dysphagia in inpatients is repeated daily for a minimum of one week after initial assessment
• Criteria are in place to highlight the need for referral to a dietitian or speech and language therapist (SLT) and referral procedures are in place
• Documentation of nutritional management of the patient (including justification of the decision not to feed, consistency of modified diets and monitoring of food and fluid intake) is available
• Non-compliance of patients on modified oral intake does not reflect lack of appropriate care
• The patient has received the modified diet and drinks that have been recommended
• A pharmacist is involved/consulted at an early stage
• Multidisciplinary training programmes are in place
• The timing, institution, and complications of tube feeding (nasogastric [NG] and percutaneous endoscopic gastrostomy [PEG]) are recorded
• Named professional in charge of patients discharged with NG or PEG has been identified
• An oral care protocol is in place
• Patients with persistent dysphagia are reviewed
• The relevant information has been imparted to the patient and family/carer in an appropriate format
• Professionals, patients and carers are aware of the forthcoming Clinical Standards for Stroke Services published by NHS Quality Improvement Scotland

Living with Illness

Effectiveness
Patient-centeredness

• Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: identification and management of dysphagia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2004 Sep. 38 p. (SIGN publication; no. 78). [154 references]

Not applicable: The guideline was not adapted from another source.

2004 Sep

Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]

Scottish Executive Health Department

Not stated

Guideline Development Group: Ms Iris Clarke (Chair), Speech and Language Therapist, Raigmore Hospital, Inverness; Mrs Catherine Dunnet (Secretary), Head of Speech and Language Therapy Service, Glasgow Royal Infirmary; Ms Jane Camp, Clinical Governance Practice Development Nurse, Gartnavel Royal Hospital, Glasgow; Dr David Campbell, General Practitioner, Irvine; Ms Francesca Chappell, Information Officer, SIGN; Dr Ali El-Ghorr, Programme Manager, SIGN; Sister Hazel Fraser, Stroke Coordinator, Queen Margaret Hospital, Dunfermline; Dr Julian Guse, Consultant Radiologist, Monklands Hospital, Airdrie; Dr Ray Holden, Consultant Gastroenterologist, Monklands Hospital, Airdrie; Dr Romana Hunter, Clinical Lecturer, Dundee Dental School; Dr Roberta James, Programme Manager, SIGN; Mrs Morag Ogilvie, Senior Dietitian, St Johnís Hospital, Livingston; Dr Brian Pentland, Consultant Physician, Astley Ainslie Hospital, Edinburgh; Ms Fiona Small, Physiotherapist, Western General Hospital, Edinburgh; Professor David Stott, Consultant in Geriatric Medicine, Glasgow Royal Infirmary; Ms Fiona Strachan, Senior Dietitian, Woodend Hospital, Aberdeen; Ms Gillian Wilson, Speech and Language Therapist, Victoria Infirmary, Glasgow; Mrs Kathryn Wood, Principal Pharmacist, Tayside Primary Care Trust

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

None available

This NGC summary was completed by ECRI on October 22, 2004. The information was verified by the guideline developer on January 26, 2005.