Dysphagia

after stroke
Indonisia 24 of April 2013
Marga Tepper,
physician in Rehabilitation Medicine
University Medical Center Groningen
 Goals
Knowledge about Dysphagia (swallowing
problems) after stroke:
Awareness of swallowing impairments
Prognosis swallowing problems
Normal swallowing
Screening SSART
Choking
Quenstion

Are swallowing problems a problem in

Stroke patients?

Why?

Consequences of malnutrition?
Introduction

General Hospital patients:

Malnutrition 11-62%

Malnutrition is associated
with increased mortality
and morbidity and
prolonged hospital stay.
Question

what is the incidence of malnutrition

in acute hospitalized patients with
stroke?

A: 10-30 %
B: 10-60 %
C: 30-60%
D: 60-100%
Question

what is the incidence of malnutrition

in acute hospitalized patients with
stroke?

A: 10-30 %
B: 10-60 %
C: 30-60%
D: 60-100%
Incidence of clinical dysphagia in patients
with Stroke (Smithard, 1997)
60%

50%

40%
percentage

30%

20%

10%

0%
< 3 days < 7 days after 1 month after 6 month
time
Relation localisation of Stroke
and serious dysphagia

Brain stem stroke causes the most

severe cases of dysphagia due to
damage of the nuclei of the cranial
nerves located in the medulla.

Duration: recovery can take 4 to 6 month!

The normal process of
swallowing
Swallowing a simple act
The normal process of
swallowing
.or a complex action ?
Involved:
5 cranial nerves
48 muscles -
Lips
Tongue
Cheeks
Palate
Larynx
Esophagus
Etc.
The 4 phases of swallowing
The preparatory oral phase
The oral transport phase
The pharyngeal phase
The esophageal phase
Preparatory oral phase

Activation swallowing centre in the brain

Production of saliva
Hold the food in the oral cavity
Preparation of the bolus/ chewing
Oral transport phase
Tongue against palate
Bolus transported backwards
Elevation of the soft palate
Pharyngeal phase
involuntary

1. Velopharyngeal closure
2. Laryngeal elevation
3. Closure of the larynx
4. Pharyngeal contraction
5. Relaxation of the cricopharyngeal
muscle
Esophageal phase
Involuntary neuromuscular control
Peristaltic wave
3 4 cm/sec
Screening of swallowing
 Swallowing assesment, when?
The moment a patient with a stroke
enters your ward

The moment you have to make the

decision: oral or tube feeding

Which team member?

Better to be safe
than sorry
In case of doubt.
Nil By Mouth
Standardized Swallowing
Assessment

1. The basic conditions

2. The actual screening
3. The oral feeding
1 Basic Conditions
Awake
Swallowing saliva
Dry voice
Strong cough
Sitting (with assitence) stable up right
Give information to the patient
2 Actual screening

Offer three teaspoons of water and

Observe if the patient
Coughs after swallowing
Gets dyspnoe
Looses the water from the mouth
Has a wet voice when asked to say /aa/
after swallowing
 If one of these things happen...

Stop the screening

Choose for tube feeding
Do the SSA again after 24 hours

If all went well

Let the patient drink
3 sips of water from a cup
If all went well

3 Start oral feeding

Observe the patient during his first meals

In that case..
Sometimes you observe a fairly good, strong swallow
but the patient coughs because water runs too fast

Refer to neurologist and decide together

with the doctor if its safe to try a thicker
substance
If you would try something thicker, dont
forget to listen to the quality of the voice
after swallowing
 SSART: basic condition
Is the patient awake and alert, or GO NOT FURTHER
responding to speech? AND DO NOT SCREEN

Reassess after 24 hours

Is the patient able to sit Patient Nothing By Mouth

Discuss hydration and nutrition
upright, with head control? (iv / NG-tube)

Does the patient swallow his

saliva?

Is the patient able to produce GO NOT FURTHER

a strong cough?
AND DO NOT
Is the patient able to breathe SCREEN
freely?
Patient Nothing By
Does the patient have a WET or
GURGLY-sounding voice? Mouth

Consult doctor
START WITH ACTUAL SCREENING
 SSART
ACTUAL SCREENING: with patient ALERT AND SIT
UPRIGHT
Give first a
teaspoon swallow, or water
of water No attempts to
leaks straight out
of mouth, or Patient
If no problems Coughing Nothing
after 3 spoons Choking By Mouth,
Breathlessness refer to
Wet/gurgly voice medical
Give three afterwards doctor
sips from a
glass of
water no problems

START observation ORAL FEEDING

 SSART oral feeding
Make sure the patient sit upright you observe any of
If

Supervise patient eating test meal the following signs

Start with a test meal: Coughing
Thick liquid
Choking
Blended hot meal
Let the patient eat by himself if
Breathlessness
hes able to. Otherwise sit next to him to Wet/gurgly voice
help
afterwards
Observe: * Speed
* Leftovers in mouth STOP the meal
Stimulate to swallow twice Refer to the doctor
Repeat assessment
next day

START ORAL FEEDING

 Goals
Knowledge about Dysphagia (swallowing
problems) after stroke:
Awareness of swallowing impairments
Prognosis swallowing problems
Normal swallowing
Screening SSART
Choking
Choking introduction

What is choking

Why is choking dangerous

Signals of choking

How is first aid for choking performed

What is choking?
Choking is the hindrance of breathing

due to an obstruction

of the throat or trachea

Why is choking dangerous?

When choking occurs, breathing is

disrupted. Oxygen cannot reach the lungs
or, subsequently, the brain. If the brain is
deprived of oxygen for more than four
minutes, brain damage or death may
result.
Signals of choking
Hands clutched to the throat

Inability to talk

Difficulty breathing or noisy breathing

Inability to cough forcefully

Skin, lips and nails turning blue or dusky

Loss of consciousness
First aid for choking

First ask the patient: ARE YOU CHOKING?

If the patient can cough or speak:

He or she is getting air

Nothing should be done

Stimulate coughing

Keep observing the patient

First aid for choking

If the patient cannot cough or speak:

First hit 5 times on the patients back,

between scapula

When the object isnt expelled

by hitting, .
Start HEIMLICH Maneuver
Stand behind the person.
Wrap your arms around the waist.
Tip the person forward slightly.
Make a fist with one hand.
Position it slightly above the person's navel.
Grasp the fist with the other hand.
Press hard into the abdomen with a quick, upward
thrust as if trying to lift the person up.
Repeat until the blockage is dislodged.
HEIMLICH Maneuver
HEIMLICH Maneuver
If the patient is sitting on a chair
stand behind him
Follow the same procedure

If the patient is lying down,

kneel beside the patient
and apply pressure on
the abdomen
First aid for choking

When the patient becomes unconscious

START CPR

The chest compressions used in CPR may

dislodge the object
 The Nederlands
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University Medical Centre
Groningen (UMCG)