This is the current release of the guideline.

This guideline updates a previous version: 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]

Any amendments to the guideline in the interim period will be noted on Scottish Intercollegiate Guidelines Network (SIGN) Web site .

Dysphagia after stroke

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 in Scotland 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/Screening

1. Initial clinical evaluation of swallowing and nutrition after stroke:
   • Assessing risk of pneumonia (assessing risk of aspiration, water swallow test)
   • Swallow screening
   • Assessing risk of undernutrition
   • Nutritional screening
   • Assessing risk of dehydration
2. Assessment:
   • Clinical bedside assessment (CBA)
   • Instrumental assessment, including modified barium swallow (MBS) using videofluoroscopy 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

Therapy/Management

1. Diet modification and use of compensatory techniques
2. Texture modification
3. Dysphagia therapy including muscle-strengthening exercises
4. Oral nutritional supplementation in patients at risk of undernutrition
5. Nasogastric (NG) tube feeding
6. Percutaneous endoscopic gastrostomy (PEG) tube feeding
7. Timing of feeding
8. Consideration of quality of life and ethical issues
9. Routine nutritional monitoring and interventions
10. Oral hygiene
11. Appropriate methods of medication administration
12. Training of staff, patients, and caregivers in feeding techniques
13. Assessment of communicative or cognitive impairment on the management of dysphagia patients

The evidence base for this guideline was synthesised in accordance with Scottish Intercollegiate Guidelines Network (SIGN) methodology. A systematic review of the literature was carried out using an explicit search strategy devised by a SIGN Information Officer. Databases searched include Medline, Embase, Healthstar, Cinahl, and the Cochrane Library. The main part of the strategy was based on that used by the Cochrane Library. The year range covered was 1980–2001. Internet searches were carried out on various Web sites including the New Zealand Guidelines Programme, the United Kingdom Health Technology Assessment programme, and the United States National Guideline Clearinghouse. The Medline version of the main search strategies can be found on the SIGN Web site , in the section covering supplementary guideline material. The main searches were supplemented by material identified by individual members of the development group. All selected papers were evaluated by two members of the group using standard SIGN methodological checklists before conclusions were considered as evidence.

Literature Search for Patients' Issues

At the start of the guideline development process, a SIGN Information Officer conducted a literature search for qualitative and quantitative studies that addressed patient issues of relevance to early management of patients with stroke. Databases searched include Medline, Embase, Cinahl and PsycINFO, and the results were summarised and presented to the guideline development group.

Not stated

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, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews, 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

Once papers have been selected as potential sources of evidence, the methodology used in each study is assessed to ensure its validity. The result of this assessment will affect the level of evidence allocated to the paper, which will in turn influence the grade of recommendation that it supports.

The methodological assessment is based on a number of key questions that focus on those aspects of the study design that research has shown to have a significant influence on the validity of the results reported and conclusions drawn. These key questions differ between study types, and a range of checklists is used to bring a degree of consistency to the assessment process. The Scottish Intercollegiate Guidelines Network (SIGN) has based its assessments on the MERGE (Method for Evaluating Research and Guideline Evidence) checklists developed by the New South Wales Department of Health, which have been subjected to wide consultation and evaluation. These checklists were subjected to detailed evaluation and adaptation to meet SIGN's requirements for a balance between methodological rigor and practicality of use.

The assessment process inevitably involves a degree of subjective judgment. The extent to which a study meets a particular criterion - e.g., an acceptable level of loss to follow up - and, more importantly, the likely impact of this on the reported results from the study will depend on the clinical context. To minimise any potential bias resulting from this, each study must be evaluated independently by at least two group members. Any differences in assessment should then be discussed by the full group. Where differences cannot be resolved, an independent reviewer or an experienced member of SIGN Executive staff will arbitrate to reach an agreed quality assessment.

Evidence Tables

Evidence tables are compiled by SIGN Executive staff based on the quality assessments of individual studies provided by guideline development group members. The tables summarise all the validated studies identified from the systematic literature review relating to each key question. They are presented in a standard format to make it easier to compare results across studies, and will present separately the evidence for each outcome measure used in the published studies. These evidence tables form an essential part of the guideline development record and ensure that the basis of the guideline development group's recommendations is transparent.

Additional details can be found in the companion document titled "SIGN 50: A Guideline Developers' Handbook" (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50]), available from the SIGN Web site .

Synthesising the Evidence

Guideline recommendations are graded to differentiate between those based on strong evidence and those based on weak evidence. This judgment is made on the basis of an (objective) assessment of the design and quality of each study and a (perhaps more subjective) judgment on the consistency, clinical relevance and external validity of the whole body of evidence. The aim is to produce a recommendation that is evidence-based, but which is relevant to the way in which health care is delivered in Scotland and is therefore implementable.

It is important to emphasise that the grading does not relate to the importance of the recommendation, but to the strength of the supporting evidence and, in particular, to the predictive power of the study designs from which that data was obtained. Thus, the grading assigned to a recommendation indicates to users the likelihood that, if that recommendation is implemented, the predicted outcome will be achieved.

Considered Judgment

It is rare for the evidence to show clearly and unambiguously what course of action should be recommended for any given question. Consequently, it is not always clear to those who were not involved in the decision making process how guideline developers were able to arrive at their recommendations, given the evidence they had to base them on. In order to address this problem, the Scottish Intercollegiate Guidelines Network (SIGN) has introduced the concept of considered judgment.

Under the heading of considered judgment, guideline development groups summarise their view of the total body of evidence covered by each evidence table. This summary view is expected to cover the following aspects:

• Quantity, quality, and consistency of evidence
• External validity (generalisability) of study findings
• Directness of application to the target population for the guideline
• Any evidence of potential harms associated with implementation of a recommendation
• Clinical impact (i.e., the extent of the impact on the target patient population, and the resources required by the National Health Service [NHS] in Scotland to treat them in accordance with the recommendation)
• Whether, and to what extent, any equality groups may be particularly advantaged or disadvantaged by the recommendations made
• Implementability (i.e., how practical it would be for the NHS in Scotland to implement the recommendation)

The group is finally asked to summarise its view on all of these issues, both the quality of the evidence and its potential impact, before making a graded recommendation. This summary should be succinct, and taken together with its views of the level of evidence represent the first draft of the text that will appear in the guideline immediately before a graded recommendation.

Additional detail about SIGN's process for formulating guideline recommendations is provided in Section 7 of the companion document titled "SIGN 50: A Guideline Developers' Handbook." (Edinburgh [UK]: Scottish Intercollegiate Guidelines Network. [SIGN publication; no. 50], available from the SIGN Web site ).

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, or randomised controlled trial (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

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

National Open Meeting

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 website for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline.

Specialist Review

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. SIGN is very grateful to all of these experts for their contribution to this guideline.

SIGN Editorial Group

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

Aspiration Risk

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

Other Risk Factors

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.

Swallow Screening Procedures

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.

D: Assessment of nutritional risk should be carried out within the first 48 hours with regular re-assessment thereafter during the patient's recovery and be recorded prior to any discharge.

D: Assessment of a patient's nutritional risk should include an assessment of their ability to eat independently and a periodic record of their food consumption.

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

D: Ongoing monitoring of nutritional status should include a combination of the following parameters:

• Biochemical measures (i.e., low pre-albumin, impaired glucose metabolism)
• Swallowing status
• Unintentional weight loss
• Eating assessment and dependence
• Nutritional intake

Nutritional Screening Procedures

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 CBA 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.

Effect of Therapy on Patient Outcome

Diet Modification and Use of Compensatory Techniques

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

Texture Modification

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

Dysphagia Therapy

Biofeedback

D: All patients who have dysphagia for more than one week should be assessed to determine their suitability for a rehabilitative swallowing therapy programme. Consideration should be given to:

• The nature of the underlying swallowing impairment
• Patient suitability in terms of motivation and cognitive status

B: Patients with dysphagia should have an oropharyngeal swallowing rehabilitation programme that includes restorative exercises in addition to compensatory techniques and diet modification.

Nutritional Interventions

Oral Nutritional Supplementation

C: Following nutritional screening, those identified as undernourished, and those at risk of becoming undernourished, should be referred to a dietitian and considered for prescription of oral nutritional supplements as part of their overall nutritional care plan.

Tube Feeding

Timing of 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.

Quality of Life and Ethical Issues

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.

Other Considerations

Oral Hygiene

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.

Medication

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 behavioral 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:

Level 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, or RCTs with a low risk of bias

1 -: Meta-analyses, systematic reviews, 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

Grade 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, 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
• Oral care protocol
• 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").

Morbidity associated with dysphagia can be reduced by early detection of swallowing disorders in stroke patients and application of appropriate methods to support food and fluid intake.

Contraindications for placement of a percutaneous endoscopic gastronomy tube include:

• International normalized ratio (INR) >1.5
• Platelets <50x10⁹/L
• Intra-abdominal cancer or ascites
• Previous gastric surgery (excluding vagotomy/pyloroplasty)
• Varices
• Active peritoneal sepsis
• Obstructing oral or oesophageal cancer

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 must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgment should be arrived at following discussion of the options with the patient, covering 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.

Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (product licence). This is known as "off label" use. It is not unusual for medicines to be prescribed outwith their product licence and this can be necessary for a variety of reasons.

Generally the unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience.

Medicines may be prescribed outwith their product licence in the following circumstances:

• For an indication not specified within the marketing authorisation
• For administration via a different route
• For administration of a different dose

'Prescribing medicines outside the recommendations of their marketing authorisation alters (and probably increases) the prescribers' professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using such medicines.'*

Any practitioner following a Scottish Intercollegiate Guidelines Network (SIGN) recommendation and prescribing a licensed medicine outwith the product licence needs to be aware that they are responsible for this decision, and in the event of adverse outcomes, may be required to justify the actions that they have taken.

Prior to prescribing, the licensing status of a medication should be checked in the current version of the British National Formulary (BNF).

*Guidance on prescribing. In: The British National Formulary No. 59. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2010.

Implementation of national clinical guidelines is the responsibility of each National Health Service (NHS) Board and is an essential part of clinical governance. Mechanisms should be in place to review care provided against the guideline recommendations. The reasons for any differences should be assessed and addressed where appropriate. Local arrangements should then be made to implement the national guideline in individual hospitals, units and practices.

Auditing Current Practice

A first step in implementing a clinical practice guideline is to gain an understanding of current clinical practice. Audit tools designed around guideline recommendations can assist in this process. Audit tools should be comprehensive but not time consuming to use. Successful implementation and audit of guideline recommendations requires good communication between staff and multidisciplinary team working.

The guideline development group has identified key points to audit to assist with the implementation of this guideline.  Refer to section 9.1 of the original guideline for a list of these key audit points.

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

Scottish Executive Health Department

Guideline Development Group

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 John's 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.

This is the current release of the guideline.

This guideline updates a previous version: 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]

Any amendments to the guideline in the interim period will be noted on Scottish Intercollegiate Guidelines Network (SIGN) Web site .

Electronic copies: Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site .

The following are available:

• Quick reference guide: Management of patients with stroke: identification and management of dysphagia. Scottish Intercollegiate Guidelines Network, 2010 June. 2 p. Available in Portable Document Format (PDF) from the Scottish Intercollegiate Guidelines Network (SIGN) Web site .
• SIGN 50: A guideline developer's handbook. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network. (SIGN publication; no. 50). Available from the SIGN Web site .
• Appraising the quality of clinical guidelines. The SIGN guide to the AGREE (Appraisal of Guidelines Research & Evaluation) guideline appraisal instrument. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, 2001. Available from the SIGN Web site .

Additional resources, including a sample clinical bedside assessment form and guidelines on texture modification and fluid thickness, are available in the original guideline document .

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. This NGC summary was updated by ECRI Institute on September 10, 2010.

Scottish Intercollegiate Guidelines Network (SIGN) guidelines are subject to copyright; however, SIGN encourages the downloading and use of its guidelines for the purposes of implementation, education, and audit.

Users wishing to use, reproduce, or republish SIGN material for commercial purposes must seek prior approval for reproduction in any medium. To do this, please contact sara.twaddle@nhs.net.

Additional copyright information is available on the SIGN Web site .