EBP Compendium: Summary of Clinical Practice Guideline

Scottish Intercollegiate Guidelines Network
Management of Patients with Stroke: Identification and Management of Dysphagia. A National Clinical Guideline
Scottish Intercollegiate Guidelines Network (2010).
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN), SIGN Publication No. 119, 49 pages.

AGREE Rating: Highly Recommended

Description:

This guideline provides recommendations for the identification, assessment, and management of dysphagia in individuals who have had a stroke. The audience for this guideline includes all personnel in contact with stroke patients at the acute, rehabilitation or community level, however there is an emphasis on acute care. Recommendations are graded A, B, C, D, or "Good Practice Point" based on the strength of supporting evidence. Grade A recommendations are based on evidence from systematic reviews and meta-analyses of randomized controlled trials that are directly relevant to the population. Grade B recommendations include high quality case control or cohort studies or high quality systematic reviews of those studies that are directly applicable to the population, or recommendations extrapolated from Grade A evidence. Grade C recommendations include well conducted case control or cohort studies or recommendations extrapolated from Grade B evidence. Grade D recommendations are based on evidence from non-analytic studies or expert opinion or recommendations extrapolated from Grade C evidence. Good Practice Points are recommendations based on the clinical experience of the guideline development group.

Recommendations:

• Assessment/Diagnosis
  • Assessment Areas
    • Swallowing
      • “All stroke patients should be screened for dysphagia before being given food or drink” (Grade C Evidence) (p. 4).
      • “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” (Grade D Evidence) (p. 5).
      • “A typical swallow screening procedure should include:
        • Initial observations of the patient’s consciousness level
        • Observations and 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” (Grade A Evidence) (p. 5).
      • “Communication, cognitive function, and the capacity for decision making should be routinely assessed in patients with dysphagia” (Grade D Evidence) (p. 18).
  • Assessment Instruments
    • Swallowing
      • Bedside Swallow Exam
        • “A standardized clinical bedside assessment (CBA) should be used by a professional skilled in the management of dysphagia” (Grade B Evidence) (p. 8).
        • “The CBA developed and tested by Logemann, or a similar tool, is recommended” (Grade B Evidence) (p. 8).
        • “The water swallow test should be used as a part of the screening for aspiration risk in stroke patients” (Grade B Evidence) (p. 4).
      • FEES/Videofluoroscopy - “The modified barium swallow test and fibre optic endoscopic evaluation of swallowing are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings” (Level C Evidence) (p. 9). 
      • Cervical Auscultation - There is insufficient evidence to recommend [cervical auscultation (CA)] for evaluating risk of aspiration and pharyngeal stage dysphagia. Further research is required as to the added value of CA to the [clinical bedside assessment (CBA)], given that it is an inexpensive and readily available test that presents no direct risk to patients" (p. 9).
      • Pulse Oximetry - "Changes in oxygen saturation can occur for a variety of reasons and cannot at this stage be related to the presence of dysphagia or aspiration. The use of pulse oximetry should be investigated further" (p. 9).
• Treatment
  • Swallowing
    • General Findings
      • “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 and patient suitability in terms of motivation and cognitive status” (level D) (p. 13)
      • "An appropriate oral care protocol should be used for every patient with dysphagia, including those who use dentures (see Annex 6)" (p. 17).
      • Patient Perspectives - "Healthcare professionals should be aware of the importance of the social aspects of eating. An inability to eat normally may affect patient morale, lead to feelings of isolation and could contribute to clinical depression" (Good Practice Point) (p. 20).
    • Compensatory Treatments
      • “Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment” (Grade D Evidence) (p. 12).
      • “Patients with dysphagia should have an oropharyngeal swallowing rehabilitation programme that includes restorative exercises in addition to compensatory techniques and diet modification” (Grade B Evidence) (p. 13).
    • Diet Modification
      • "Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment” (Grade D Evidence) (p. 12).
      • Patient Perspectives - “Texture modified food should be attractively presented and appetizing. Patients should have a choice of dishes” (Grade D Evidence) (p. 12).
    • Oral-Motor Treatment - “Patients with dysphagia should have an oropharyngeal swallowing rehabilitation programme that includes restorative exercises in addition to compensatory techniques and diet modification” (Grade B Evidence) (p. 13).
    • Tube Feeding
      • "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" (Grade B Evidence) (p. 15).
      • "The decision to place a PEG should balance the risks and benefits and take into consideration individual patient needs. Patients should also be given the opportunity to decide whether they want to go ahead with a procedure" (Good Practice Point) (p. 16).
      • "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" (Grade D Evidence) (p. 16).
      • "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" (Grade D Evidence) (p. 17). 
        

Keywords: Stroke; Swallowing Disorders

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Added to Compendium: November 2010