Dysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype

doi:10.1016/j.jocn.2006.04.009

Journal of Clinical Neuroscience

Volume 14, Issue 7, July 2007, Pages 630-634

https://doi.org/10.1016/j.jocn.2006.04.009 Get rights and content

Abstract

Dysphagia in stroke is linked with increased risk of pneumonia, increased length of stay and poorer outcomes. This study followed a cohort of 88 acute ischaemic stroke patients admitted to hospitals in Perth, Western Australia, over 30 days. There were 8/88 deaths (9%). Infections were treated in 25/80 survivors (31%). Presence and severity of dysphagia were measured at 2 and 7 days post-stroke. Respiratory tract infections occurred at significantly higher rates for dysphagics (p < 0.05). At 2 days post-stroke, the odds ratio (OR) of chest infection for dysphagics was 1.45 (95% CI = 1.07–1.98). Survivors who were “nil by mouth” 2 days post-stroke were significantly more likely to develop pneumonia (p = 0.01). At 7 days post-stroke, dysphagics were again more likely to develop pneumonia (p = 0.014) with OR = 1.77 (95% CI = 1.26–2.49). The total anterior circulation infarcts demonstrated more severe and prolonged dysphagia than other stroke subtypes.

Introduction

Dysphagia is a common occurrence in acute stroke with a reported incidence between 14–94%.[1], [2], [3], [4], [5], [6] It has been associated with complications such as pneumonia,[1], [7] nutritional compromise,[8], [9], [10] increased length of hospital stay[11], [12] and poorer outcomes.¹²

Dysphagia leading to aspiration of food, fluids or secretions is known to be a contributing factor in pneumonia and aspiration pneumonia.[3], [9], [13] In addition to dysphagia, other factors such as dental caries¹⁴ and tube-feeding¹⁵ can be significant predictors of aspiration pneumonia. Studies have found a high incidence of dysphagia in early stroke,[16], [17], [18] although it can be transient, with difficulties resolving in the acute phase.[1], [3], [4], [16], [18], [19] Chest infection has been reported to occur most commonly in the first month post-stroke.[3], [5]

The aim of this study was to identify clinical and demographic predictors of pneumonia in a cohort of acute ischaemic stroke patients within 30 days post-stroke. The study also sought to identify whether dysphagia is related to a particular stroke subtype, whether one particular subtype is more prone to severe dysphagia and whether there is a greater incidence of chest infection in a particular stroke subtype. Such information identifying high-risk patient groups would be useful to neurologists, medical officers, speech-language pathologists and other health professionals for resource allocation, discharge planning and infection control purposes. It also assists health professionals to better monitor and prevent malnutrition, dehydration and respiratory tract infections in the acute stroke period.

Section snippets

Methods

Patients admitted to the three tertiary hospitals in Perth, Western Australia, between August and October 2003 with a principal diagnosis of ischaemic stroke were eligible to participate in the study. Patients were identified through perusal of daily hospital admission lists. While subjects were approached for consent to participate in the study prospectively, data were obtained retrospectively on outcomes via careful perusal of medical records and from general practitioners. Diagnosis of

Demographics and mortality

Characteristics of the cohort of 88 patients are shown in Table 1. Fifty nine (67%) subjects had experienced a first stroke, 21 (24%) a second stroke. There was no gender difference with respect to prior stroke. During the follow-up period, there were eight deaths (9%) and the mortality rate was comparable to the literature.²³ Among the deaths, six were diagnosed as TACI strokes and two were LACI strokes. All deceased patients were “nil by mouth” on admission to hospital and seven of these were

Dysphagia and risk of chest infection

Sixty-two percent of survivors were prescribed some form of modified diet or thickened fluids or were made “nil by mouth” 2 days after admission to hospital, which is comparable to the literature for subjects with first-ever stroke.[4], [18], [20], [25] The incidence of pneumonia or chest infection of 18% was also similar to that reported previously for subjects with first-ever stroke.[3], [18], [26] However, the current study did not exclude subjects who had a history of previous stroke.

Conclusion

In a cohort of 80 ischaemic stroke survivors the incidence of dysphagia decreased from 62.5% to 51.2% during the first week following admission to hospital. Dysphagia severity was strongly associated with stroke subtype, with TACI strokes incurring the most severe and persistent dysphagia. Survivors who were “nil by mouth” due to a profound swallowing impairment demonstrated a high incidence of respiratory infection, possibly due to aspiration of secretions colonised by bacteria.

Acknowledgement

This study was made possible by the cooperation and assistance of the Speech Pathology Departments at Fremantle, Royal Perth and Sir Charles Gairdner Hospitals in Western Australia. Their contributions are gratefully acknowledged.

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Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study
2023, Rehabilitacion
Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization.
This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality.
Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48 h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions.
Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p < 0.001), in severe stroke (p < 0.001) and in the hemorrhagic subtype (p = 0.008). An association was found with dysarthria and aphasia (p = 0.003; p = 0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p < 0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p < 0.001).
The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.
La disfagia es una complicación frecuente posterior a un evento cerebrovascular, que puede provocar graves secuelas pulmonares. La detección temprana de la disfagia y el riesgo de aspiración puede reducir la morbilidad, la mortalidad y la duración de la hospitalización.
Este estudio pretende identificar asociaciones entre la disfagia y la enfermedad cerebrovascular aguda, y evaluar la prevalencia y el impacto de las complicaciones pulmonares en los reingresos y en la mortalidad.
Estudio observacional retrospectivo basado en 250 historias clínicas de pacientes con enfermedad cerebrovascular aguda: historia clínica, examen neurológico, pruebas de imagen y Gugging Swallowing Screen (GUSS) en las primeras 48 h. Los pacientes fueron seguidos durante 3 meses a través de las historias clínicas para estimar la mortalidad a los 3 meses y los reingresos.
De las 250 historias clínicas analizadas, 102 (40,8%) fueron evaluados por disfagia. La prevalencia de disfagia fue del 32,4%. El riesgo fue mayor en los pacientes de mayor edad (p < 0,001), en el ictus grave (p < 0,001) y en el subtipo hemorrágico (p = 0,008). Se encontró asociación con la disartria y la afasia (p = 0,003; p = 0,017). Las infecciones del tracto respiratorio se produjeron en el 14,4% de todos los pacientes (grupo GUSS 11,8% vs. grupo sin GUSS 16,2%), y en el 75% de los que tenían disfagia grave (p < 0,001). La mortalidad a los 3 meses fue del 24,2% en pacientes disfágicos, especialmente alta en el grupo de disfagia grave (75%; p < 0,001).
El tipo de enfermedad cerebrovascular, las puntuaciones NIHSS y GCS, edad, disartria y afasia fueron factores asociados de forma significativa a la disfagia. La prevalencia de infecciones del tracto respiratorio fue mayor en los pacientes sin registro GUSS, y no se observó significación estadística en los reingresos relacionados. La mortalidad a los 3 meses fue superior en el grupo de disfagia grave.
Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis
2022, Archives of Physical Medicine and Rehabilitation
To investigate whether respiratory muscle training is capable of reducing the occurrence of respiratory complications and improving dysphagia (swallowing or cough function) after stroke.
Cochrane Library, Excerpta Medical Database (EMBASE), PUBMED, and Web of Science were searched for studies published in English; the China Biology Medicine (CBM), China Science and Technology Journal Database (VIP), China National Knowledge Infrastructure (CNKI), and Wanfang Database were searched for studies published in Chinese up to August 10, 2021.
Eleven randomized control trials (RCTs) (N=523) met the inclusion criteria were included in this systematic review.
Data and information were extracted by two reviewers independently and disagreements was resolved by consensus with a third coauthor. Primary outcome was the occurrence of respiratory complications, secondary outcomes would be represented by swallowing and cough function. The quality of each included RCT were assessed by Cochrane risk-of-bias criteria and the GRADE evidence profile was provided to present information about the body of evidence and judgments about the certainty of underlying evidence for each outcome.
Respiratory muscle training reduced the risk of respiratory complications (relative risk, 0.51; 95% confidence interval [CI], 0.28-0.93; I²=0%; P=.03; absolute risk difference, 0.068; number need to treat, 14.71) compared with no or sham respiratory intervention. It also decreased the liquid-type Penetration-Aspiration Scale scores by 0.81 (95% CI, –1.19 to –0.43; I²=39%; P<.0001). There was no significant association between respiratory muscle training and Functional Oral Intake Scale (FOIS) scores, cough function: increased FOIS scores by 0.47 (95% CI, –0.45 to 1.39; I²=55%; P=.32), decreased peak expiratory cough flow of voluntary cough by 18.70 L per minute (95% CI, –59.74 to 22.33; I²=19%; P=.37) and increased peak expiratory cough flow of reflex cough by 0.05 L per minute (95% CI, –40.78 to 40.87; I²=0%; P>.99).
This meta-analysis provided evidence that respiratory muscle training is effective in reducing the risk of respiratory complications and improving dysphagia by reducing penetration or aspiration during swallowing liquid bolus after stroke. However, there was no sufficient evidence to determine that respiratory muscle training improves cough function. Additional multicenter studies using larger patient cohorts are required to validate and support these findings. Furthermore, long-term follow-up studies should be performed to measure outcomes, while avoiding bias due to confounding factors such as heterogeneity of the etiologies of dysphagia.
Outcomes of Dysphagia Following Stroke: Factors Influencing Oral Intake at 6 Months After Onset
2021, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
A recent study reported that 18% of stroke survivors had decreased swallowing efficiency several months after stroke onset.14 High mortality and high frequency of complications including pneumonia have also been reported in stroke survivors with dysphagia.6,22 –25 Longitudinal evaluation of patients is necessary as slow improvement or worsening swallowing function should be identified in the acute phase.
This study aimed to describe recovery of dysphagia after stroke. We determined the proportion of stroke survivors with dysphagia on admission, discharge, and 6 months after stroke. Additionally, the factors affecting oral feeding 6 months after stroke were explored.
A total of 427 acute stroke patients were recruited prospectively. Presence of dysphagia was evaluated on admission, weekly until recovery was achieved, and at discharge. We compared stroke survivors with dysphagia who had complete recovery, who had dysphagia but achieved oral feeding, and who required tube feeding. Patient-reported eating ability was evaluated at 6 months. Patients who achieved oral feeding by 6 months were compared to those who had persistent tube feeding need.
Fifty-five percent of stroke survivors had dysphagia on initial evaluation (3.1 ± 1.4 days after admission) and 37% at discharge (21.1 ± 12.4 days). At 6 months, 5% of patients required tube feeding. Among those who had dysphagia at initial evaluation, 32% had resolution of dysphagia within two weeks, 44% had dysphagia but started oral feeding before discharge, and 23% required alternative means of alimentation (nasogastric tube feeding, percutaneous endoscopic gastrostomy, parental nutrition) throughout hospitalization. At 6 months, 90% of stroke survivors who achieved oral feeding by discharge continued with oral feeding. Patients who achieved oral feeding after discharge had less cognitive impairments on admission and a higher speech therapist intervention rate after discharge.
More than half of stroke survivors had dysphagia but the vast majority were able to return to oral feeding by 6 months. Cognitive function and dysphagia rehabilitation interventions were associated with return to oral feeding after hospital discharge.
Initial National Institute of Health Stroke Scale to Early Predict the Improvement of Swallowing in Patients with Acute Ischemic Stroke
2019, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Dysphagia is a common poststroke morbidity, affecting 37%-78% of patients with stroke.1 In the acute stage, initial dysphagia results in negative outcomes such as prolonged hospital stays,2 aspiration pneumonia,3,4 and mortality.5 In the chronic stage, persistent dysphagia6,7 affects the long-term functional outcome of patients with stroke.8,9
Objectives: To study the applicability of National Institutes of Health Stroke Scale (NIHSS) in early predicting the prognosis of poststroke dysphagia in an acute ward. Methods: This is an observational retrospective cohort study including adult patients with ischemic stroke. Patients with various factors affecting swallowing were excluded to obtain a representative sample of 165 patients. The main outcome measure was the improvements of oral intake function. Results: The scores of facial palsy (NIHSS item 4) (odds ratio [OR]: 0.484, 95% confidence interval [CI]: 0.279-0.838, P = .0096] and language/aphasia (NIHSS item 9) (OR: 0.562, 95% CI: 0.321-0.982, P = .0430) demonstrated significantly negative effects on the early improvement of dysphagia. Moreover, the improved patients had a 4.14-fold (95% CI: 2.53-11.23, P = .005) increased odds of returning home compared with nonimproved patients. Conclusions: Our findings provide evidence that early improvement of poststroke dysphagia was significantly associated with a favorable discharge destination and NIHSS items of facial palsy and language/aphasia can be used at the onset of stroke to identify dysphagic patients at risk of achieving limited improvement. These findings provide valuable prognostic indicators for clinicians to make a precise outcome prediction at very early stage.
Factors Influencing Oral Intake Improvement and Feeding Tube Dependency in Patients with Poststroke Dysphagia
2019, Journal of Stroke and Cerebrovascular Diseases
Objective: To assess ischemic stroke patients regarding the relationship between lesion locations, swallowing impairment, medical and demographic factors and (1) oral intake improvement and (2) feeding tube dependency at discharge from their acute hospital stay. Methods: We conducted an exploratory, retrospective observational longitudinal cohort study of acute, first-ever, ischemic stroke patients. Patients who had an initial nonoral feeding recommendation from a speech and language pathologist and who underwent a modified barium swallow study within their hospital stay were included. Oral intake status was measured with the Functional Oral Intake Scale (FOIS) as the change in FOIS during the hospital stay and as feeding tube dependency at hospital discharge. Associations were assessed with multiple linear regression modeling controlling for age, comorbidities, and hospital length of stay. Results: We included 44 stroke patients. At hospital discharge, 93% of patients had oral intake restrictions and 30% were feeding tube dependent. Following multiple linear regression modeling, age, damage to the left superior frontal gyrus, dorsal anterior cingulate gyrus, hypothalamus, and nucleus accumbens were significant predictors for FOIS change. Feeding tube dependency showed no significant associations with any prognostic variables when controlling for confounders. Conclusions: The vast majority of patients with an initial nonoral feeding recommendation are discharged with oral intake restrictions indicating a continued need for swallowing assessments and treatment after discharge. Lesion locations associated with motivation, reward, and drive to consume food as well as swallowing impairment, higher age, and more comorbidities were related to less oral intake improvement.
Rehabilitation of Swallowing and Cough Functions Following Stroke: An Expiratory Muscle Strength Training Trial
2016, Archives of Physical Medicine and Rehabilitation
To determine the effect of expiratory muscle strength training (EMST) on both cough and swallow function in stroke patients.
Prospective pre-post intervention trial with 1 participant group.
Two outpatient rehabilitation clinics.
Adults (N=14) with a history of ischemic stroke in the preceding 3 to 24 months.
EMST. The training program was completed at home and consisted of 25 repetitions per day, 5 days per week, for 5 weeks.
Baseline and posttraining measures were maximum expiratory pressure, voluntary cough airflows, reflex cough challenge to 200μmol/L of capsaicin, sensory perception of urge to cough, and fluoroscopic swallow evaluation. Repeated measures and 1-way analyses of variance were used to determine significant differences pre- and posttraining.
Maximum expiratory pressure increased in all participants by an average of 30cmH₂O posttraining. At baseline, all participants demonstrated a blunted reflex cough response to 200μmol/L of capsaicin. After 5 weeks of training, measures of urge to cough and cough effectiveness increased for reflex cough; however, voluntary cough effectiveness did not increase. Swallow function was minimally impaired at baseline, and there were no significant changes in the measures of swallow function posttraining.
EMST improves expiratory muscle strength, reflex cough strength, and urge to cough. Voluntary cough and swallow measures were not significantly different posttraining. It may be that stroke patients benefit from the training for upregulation of reflex cough and thus improved airway protection.

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Clinical studyDysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype

Abstract

Introduction

Section snippets

Methods

Demographics and mortality

Dysphagia and risk of chest infection

Conclusion

Acknowledgement

Arch Phys Med Rehabil

J Crit Care

Am J Clin Nutr

J Clin Neurosci

J Neurol Sci

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Lancet

J Clin Epidemiol

Chest

J Stroke Cerebrovasc Dis

Dysphagia in lateral medullary syndrome (Wallenberg’s syndrome): an acute disconnection syndrome in premotor neurons related to swallowing activity?

Stroke

The natural history and clinical consequences of aspiration in acute stroke

Q J Med

The natural history of dysphagia following a stroke

Dysphagia

Swallowing disorders following acute stroke: prevalence and diagnostic accuracy

Cerebrovasc Dis

Dysphagia in stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients

Dysphagia

Dysphagia therapy following stroke: a controlled trial

Neurology

Impact of premorbid undernutrition on outcome in stroke patients

Stroke

A model for management of patients with stroke during the acute phase. Outcomes and economic implications

Stroke

Clinical study
Dysphagia in acute ischaemic stroke: severity, recovery and relationship to stroke subtype