Swallow Assessment

Swallowing problems are common after acute stroke and may be difficult to detect
clinically. 45% of patients are unable to swallow safely on day one and are therefore
at risk of aspiration.
All patients must have a dysphagia screening test on admission before any oral intake.

The protocol for initial dysphagia assessment is summarised below.

Ensure patient is sat upright and alert. The test may be performed by any dysphagia trained
member of staff.
Teaspoonful
of water, feel
for laryngeal
elevation

- no attempts to swallow
Patient NBM
- water leaks straight out of mouth
IV fluids
- coughs
- choking
- breathlessness
- wet or gurgly voice

no problems
give 2nd and 3rd
teaspoonful
of water, feel
for laryngeal
elevation

- coughing
- choking
- breathlessness
- wet or gurgly voice

Patient NBM
IV fluids

- coughing
- choking
- breathlessness
- wet or gurgly voice

Patient NBM
IV fluids

no problems
give half a
glassful of
water, feel
for laryngeal
elevation
normal fluid and diet

If patient fails dysphagia screen on day 1, consider NGT and refer SALT and
dietician. Certainly, by day 3, enteral tube feeding should be initiated in those who
cannot swallow, unless a contraindication exists.
In complex or difficult cases videofluoroscopy may clarify the nature of the dysphagia
and the optimal management.
NB Any patient with ongoing swallowing difficulties requiring a texture modified diet
should be referred to the dietitian and SALT.
1. RCP National Clinical Guidelines for Stroke third edition
(link to order copy- http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=250)

Decision to commence enteral feeding

A new nutritional screening procedure is being implemented in the Trust shortly
(malnutrition universal screening tool, MUST
-http://www.bapen.org.uk/pdfs/must/must_full.pdf ). Up to half of stroke patients
develop dysphagia. Most survivors recover safe swallowing within three weeks.
Dysphagia is associated with aspiration pneumonia and malnutrition. Patients with
severe strokes should not generally have enteral feeding commenced until a full
multidisciplinary assessment and consultant review has taken place. Decisions
should involve patients, and where this is not possible, their family and carers.
If the swallow is unsafe within 24 hours fine bore nasogastric (NG) feeding should be
considered.
There is a risk of re-feeding syndrome if:
Patient has one or more of the following:
1
BMI less than 16 kg/m2
2
unintentional weight loss greater than 15% within the
last 36 months
3
little or no nutritional intake for more than 10 days
4
low levels of potassium, phosphate or magnesium prior
to feeding.
Or patient has two or more of the following:
1
BMI less than 18.5 kg/m2
2
unintentional weight loss greater than 10% within the
last 36 months
3
little or no nutritional intake for more than 5 days
4
a history of alcohol abuse or drugs including insulin,
chemotherapy, antacids or diuretics.

These patients should start a slow regime. They also need thiamine 100mg tds and
vitamin B co strong 2 tds. Monitor potassium, phosphate and magnesium daily
initially.
Any patient who is nil by mouth needs artifical saliva and chlorhexidine mouthwash
regularly (C).
Patients previous medication should be reviewed. Any medication which cannot
safely be stopped must be given by feeding tube or parenterally (see below).
Some patients remove NGTs frequently. In this case a nasal loop device may be
used in some circumstances. Patients receiving NG feeding in whom a prolonged
period of enteral feeding is anticipated should be considered for PEG feeding. Early
PEG feeding is not indicated as it is associated with slightly worse outcomes (FOOD
trial) (A).
NICE guideline enteral nutrition in adults, Feb 2006
http://guidance.nice.org.uk/CG32/guidance/pdf/English/download.dspx
FOOD trial Lancet 2005/365/764-72