Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up

Dysphagia

Umay, E., Eyigor, S., et al. (2022).

Dysphagia, 37(2), 217-236.

This consensus-based guideline provides recommendations for the management, screening, and assessment of individuals with post-stroke dysphagia in Turkey. Of note, these recommendations may be impacted by practice-related differences between the US and Turkey (i.e., an overall lack of speech-language pathologists, reduced access to instrumental swallowing evaluations). This guideline is part one of a consensus study. For more information, please see the Notes on this Article section.

Turkish Society of Physical Medicine and Rehabilitation (PMR)-Dysphagia Working Group

This guideline is part one of a consensus study of experts in Turkey. Part two of this study is also included in this Evidence Map:<br /> <ul> <li>Umay, E., Eyigor, S., Ertekin, C., Unlu, Z., Selcuk, B., Bahat, G., Karahan, A. Y., Secil, Y., Gurcay, E., Kıylioglu, N., Keles, B. Y., Giray, E., Tikiz, C., Gezer, I. A., Yalıman, A., Sen, E. I., Vural, M., Saylam, G., Akaltun, M. S., Sari, A., &hellip; Karaahmet, O. (2021). Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation. Dysphagia, 36(5), 800&ndash;820. https://doi.org/10.1007/s00455-020-10218-8</li> </ul>

<div>Post-stroke dysphagia management should be performed by a multidisciplinary team (Overall Consensus). Specific recommendations regarding the multidisciplinary team included the following:</div> <ul> <li><span style="color: #333333;">Whenever possible, a multidisciplinary team related to the diagnosis and treatment of dysphagia should be formed at each facility (Overall Consensus). </span></li> <li><span style="color: #333333;">The team should include all healthcare professionals involved from the point of stroke diagnosis to the last step of rehabilitation. The core team should consist of neurology, physical medicine and rehabilitation, and otolaryngology specialists. If a speech language pathology team is available within a facility, they should be included in the core team. Other branches may be added based on availability/access. This may include professionals from geriatric medicine, gastroenterology, radiology, anesthesia, dentistry, nursing, physiotherapy, nutritional medicine, psychology, occupational therapy, home care services, and social work (Overall Consensus). </span></li> <li><span style="color: #333333;">The multidisciplinary team should include the patient and their care partners/family.&nbsp;</span><span style="color: #333333;">Clinicians should ensure that patients and their care partners/family remain informed throughout the recovery process, as this will allow them to take supportive and active roles in diagnosis, treatment, and follow-up&nbsp;(Overall Consensus). </span></li> <li><span style="color: #333333;">Since an assessment of swallowing functions is part of the neurological examination, a neurologist should manage dysphagia in the acute period&nbsp;(Approaching Consensus).</span></li> <li><span style="color: #333333;">Physical medicine and rehabilitation specialists should have active roles in the dysphagia care team in order to coordinate the rehabilitation program of each patient who is medially stable in the subacute to chronic periods </span><span style="color: rgb(51, 51, 51);">(Approaching Consensus).</span></li> <li><span style="color: #333333;">All healthcare personnel, including emergency physicians, should be trained in the diagnosis and evaluation of dysphagia management (Overall Consensus).</span></li> </ul>

<div>The following recommendations were made for post-stroke dysphagia evaluation:</div> <ul> <li><span style="color: #333333;">All stroke patients should be evaluated for dysphagia prior to oral intake in order to reduce the risk of aspiration and pneumonia (Overall Consensus). </span></li> <li><span style="color: #333333;">Dysphagia evaluation should occur as soon as possible in the acute period. Timing may vary depending on medical stabilization and other factors&nbsp;</span><span style="color: rgb(51, 51, 51);">(Approaching Consensus to Overall Consensus)</span><span style="color: #333333;">.</span></li> <li><span style="color: #333333;">Stroke patients should also be evaluated for dysphagia in the subacute and chronic periods. This should occur whether or not a patient eats by mouth or has received prior dysphagia treatment&nbsp;</span><span style="color: rgb(51, 51, 51);">(Overall Consensus)</span><span style="color: #333333;">.</span></li> <li><span style="color: #333333;">Evaluation should be performed by a specialized, trained clinician </span><span style="color: rgb(51, 51, 51);">(Overall Consensus)</span><span style="color: #333333;">.</span></li> <li><span style="color: #333333;">In the acute, subacute, and chronic periods, dysphagia evaluations should include screening tests, a detailed history, and physical examination&nbsp;(Overall Consensus).</span></li> </ul>

<div>At any stage of recovery, questionnaire screening tools for individuals with post-stroke dysphagia can be used. These should include the following signs and symptoms:</div> <ul> <li><span style="color: #333333;">voice change (e.g., wet voice, hoarse voice); </span></li> <li><span style="color: #333333;">throat clearing; </span></li> <li><span style="color: #333333;">multiple swallowing movements for one bolus; </span></li> <li><span style="color: #333333;">a delay in pharyngeal swallowing; </span></li> <li><span style="color: #333333;">presence of oral residue; </span></li> <li><span style="color: #333333;">coughing/choking during feeding; </span></li> <li><span style="color: #333333;">decreased laryngeal elevation; and </span></li> <li><span style="color: #333333;">facial flushing during feeding (Overall Divergence to Overall Consensus).</span></li> </ul>

<div>Swallowing screening should include standardized screeners that include all three types of food texture (i.e., solid, semi-solid, and liquid) and a standardized questionnaire (Approaching Consensus to Overall Consensus). The following screening tests are not recommended:</div> <ul> <li><span style="color: #333333;">standardized, questionnaire-based screening tests designed to evaluate the risk of dysphagia (Overall Divergence to Approaching Consensus); </span></li> <li><span style="color: #333333;">water-only swallow tests alone or combined with pulse oximeter (Approaching Consensus); </span></li> <li><span style="color: #333333;">standardized water-only swallow tests alone or combined with questionnaires&nbsp;(Overall Divergence to Approaching Consensus); and </span></li> <li><span style="color: #333333;">screening tests using a single food texture alone or combined with questionnaires&nbsp;(Overall Divergence).</span></li> </ul>

<div>The following risk factors should be considered as part of the history &amp; physical for patients with suspected post-stroke dysphagia:</div> <ul> <li><span style="color: #333333;"><strong>premorbid properties</strong> including age and history of respiratory disease, neurodegenerative disease, head and neck cancer, pneumonia, or malnutrition;&nbsp;</span></li> <li><span style="color: #333333;"><strong>stroke-related features</strong>&nbsp;including location, severity, and need for additional medical procedures such as tracheostomy, intubation, and mechanical ventilation;</span></li> <li><span style="color: #333333;"><strong>swallowing symptoms</strong> including complaints of swallowing difficulty, need to clear throat weight loss;</span></li> <li><span style="color: #333333;"><strong>physical exam and findings</strong> including consciousness level, head control, sitting balance, voluntary coughing ability; and&nbsp;</span></li> <li><span style="color: #333333;"><strong>medical results</strong> from supportive laboratory/imaging (Overall Divergence to Overall Consensus).</span></li> </ul>

<div>Recommendations regarding patient follow-up included:</div> <ul> <li><span style="color: #333333;">Assessment follow-up times and intervals should be patient specific (Overall Consensus).&nbsp;</span></li> <li><span style="color: #333333;">In the acute period, patients should be followed daily, until dysphagia is stabilized&nbsp;(Overall Consensus). </span></li> <li><span style="color: #333333;">During hospitalization, dysphagia should be followed weekly after dysphagia stabilizes&nbsp;(Approaching Consensus to Overall Consensus). </span></li> <li><span style="color: #333333;">Dysphagia should be followed monthly in the subacute period (3&ndash;6 months) and bimonthly in the chronic period (6&ndash;12 months; Overall Consensus).</span></li> <li><span style="color: #333333;">Follow-up should be done according to the protocols used in diagnosis&nbsp;(Overall Consensus).</span></li> </ul>

<div>Post-stroke, all patients should undergo a physical examination of the oropharyngeal region, respiratory system, and musculoskeletal system (e.g., postural&ndash;structural deformity, muscle weakness). A detailed medical medical history should also be taken (Approaching Consensus to Overall Consensus).</div>

<div>The following recommendations were provided regarding the use of instrumental swallowing evaluations as screening tools for post-stroke dysphagia:</div> <ul> <li><span style="color: #333333;">Electroneuromyography (ENG) and videofluoroscopy (VF) are not recommended for use as screening tools for post-stroke dysphagia. Flexible fiberoptic endoscopic evaluation of swallowing (FEES) may be considered. The use of instrumental tools for screening purposes </span><span style="color: #333333;">depends on facility conditions, device availability, and clinician experience with these tools (Overall Divergence to Approaching Consensus).&nbsp;</span></li> <li><span style="color: #333333;">FEES should be used for screening if there is risk of silent aspiration, doubt in the bedside screening test, or if the patient is at high risk for dysphagia. This is not recommended for VF and ENG (Overall Divergence to Overall Consensus).</span></li> </ul>

<div>Clinicians should use the following symptoms/signs/risk factors to identify post-stroke patients at risk of aspiration/silent aspiration during clinical screening and assessment:</div> <ul> <li><span style="color: #333333;">hypoxia (decrease in oxygen saturation);</span></li> <li><span style="color: #333333;">wet and hoarse voice during feeding;</span></li> <li><span style="color: #333333;">the presence of wet and hoarse voice overall;</span></li> <li><span style="color: #333333;">the presence of persistent cough;</span></li> <li><span style="color: #333333;">the absence of voluntary cough;</span></li> <li><span style="color: #333333;">a history of multiple pneumonias;</span></li> <li><span style="color: #333333;">increased breathing rate; and</span></li> <li><span style="color: #333333;">the need to clear the throat&nbsp;(Overall Consensus).</span></li> </ul>

<div>Clinicians should use the following symptoms/findings/risk factors to screen for post-stroke patients at high risk of dysphagia:</div> <ul> <li>the presence of comorbidities;</li> <li>a history of medical procedures;</li> <li>the presence of dysarthria, dysphonia, apraxia;</li> <li>the absence of voluntary cough;</li> <li>the presence of coughing with feeding; and</li> <li>lack of oral sensation (Overall Consensus).&nbsp;</li> </ul>

<div>The following recommendations were provided for post-stroke dysphagia evaluation:</div> <ul> <li><span style="color: #333333;">VF and FEES should be used for dysphagia evaluation according to patients' characteristics, hospital conditions, clinician experience, and device status (Overall Consensus). </span></li> <li><span style="color: #333333;">VF, FEES, and electromyography should be used to determine the severity of dysphagia and to plan for therapy and follow-up. These tools should be used to evaluate the impacts of bolus consistency, texture and volume modification, and compensatory techniques (Overall Consensus).</span></li> <li><span style="color: #333333;">Ultrasonography, cervical accelerometry, and manometry are promising methods to evaluate swallowing for research purposes&nbsp;(Overall Consensus).</span></li> </ul>