national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
6.20.3.2 Sources
B Any stroke patient with severe communication difficulties but reasonable cognition
and language function should be assessed for and provided with appropriate
alternative or augmentative communication strategies or aids.
A Aichert and Ziegler 2008; Brendel and Ziegler 2008; Wambaugh et al 2006a;
Wambaugh et al 2006b; consensus
B Consensus; Wambaugh et al 2006a; Wambaugh et al 2006b
6.21 Swallowing problems: assessment and management
The majority of patients presenting with dysphagia following stroke will recover, in part
due to bilateral cortical representation of neurological pathways (Hamdy et al 1998).
However, a proportion will have persistent abnormal swallowing physiology and
continued aspiration at 6 months (Mann et al 1999a). A small proportion of patients
with dysphagia, particularly those with brainstem lesions, will have chronic severe
swallowing difficulties. Patients with persistent swallowing problems may avoid eating in
social settings, and thus lose the physical and social pleasures normally associated with
food.
Aspiration and silent aspiration are common after stroke. There is good evidence that the
investigation of dysphagia using instrumental assessments that provide direct imaging for
evaluation of swallowing physiology, helps to predict outcomes and improve treatment
planning.
Evidence to recommendations
A number of treatments are available for the management of dysphagia in acute stroke,
and several are controversial. Despite this, there is an expanding body of evidence in
relation to dysphagia therapy programmes and a reduced risk of pneumonia in the acute
stage of stroke (Foley et al 2008; Speyer et al 2010). Evidence with respect to alternative
treatment modalities such as transcranial magnetic stimulation, black pepper oil,
nifedipine and biofeedback are showing promising results for treatment of those with
chronic dysphagia, although more research is needed (Teasell et al 2011). Other
treatments such as neuromuscular electrical stimulation or acupuncture show equivocal
results. Treatments such as thermal tactile stimulation have no supportive evidence in the
literature (Teasell et al 2011; Foley et al 2008).
6.21.1 Recommendations
A Until a safe swallowing method has been established, all patients with identified
swallowing difficulties should:
● be considered for alternative fluids with immediate effect
● have a comprehensive assessment of their swallowing function undertaken by a
specialist in dysphagia
● be considered for nasogastric tube feeding within 24 hours
● be referred for specialist nutritional assessment, advice and monitoring
100 © Royal College of Physicians 2012