Abdulmassih EMS, Filho EDM, Santos RS, Jurkiewicz AL. Evolution of Patients with Oropharyngeal Dysphasia in Hospital Environment.
Int. Arch. Otorhinolaryngol. 2009;13(1):55-62
Introdução: A disfagia orofaríngea de etiologia neurogênica pode causar risco clínico nutricional e comprometimento laringo traqueal por aspiração, podendo culminar em broncopneumonia aspirativa. Esta condição está presente na rotina das avaliações do fonoaudiólogo que atua em ambiente hospitalar junto a pacientes pós acidente vascular encefálico (AVE). Objetivo: O objetivo deste estudo foi avaliar a evolução de pacientes portadores de disfagia orofaríngea neurogênica pós AVE, durante o período de internação até o momento da alta hospitalar, analisando grau da disfagia no pré-tratamento; diagnóstico instrumental; condutas fonoaudiológicas; condições do paciente na alta hospitalar. Método: Foram estudados 39 pacientes no período de dezembro de 2003 a junho de 2004, com queixa de dificuldade de deglutição sugestiva de disfagia. Foi elaborado um protocolo padronizado para a coleta dos dados clínicos. Conclusão: Os resultados permitiram concluir que: houve prevalência da disfagia de grau moderado, seguida pelos graus leve e severo; no diagnóstico instrumental ocorreu à prevalência de aspiração laríngea, seguida de alteração na fase orofaríngea, penetração laríngea, alteração na fase oral da deglutição; nas condutas fonoaudiológicas a manipulação de alimentos apresentou excelente resultado seguida das manobras posturais e das manobras protetivas; na alta hospitalar a prevalência foi de sujeitos que apresentaram estado clínico de nível bom, alimentando-se por via oral, com algumas modificações posturais e/ou da consistência alimentar sem o uso de sonda, seguido pelos que apresentaram nível regular, iniciando com dieta via oral fazendo uso de sonda, mas com possibilidade de retirada entre 30 a 60 dias do período hospitalar.
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Suntrup S, Marian T, Schröder JB, Suttrup I, Muhle P, Oelenberg S, Hamacher C, Minnerup J, Warnecke T, Dziewas R.
Intensive Care Med. 2015 Sep;41(9):1629-37. doi: 10.1007/s00134-015-3897-8. Epub 2015 Jun 13.
Treatment of post-stroke dysphagia is notoriously difficult with different neurostimulation strategies having been employed with a variable degree of success. Recently, electrical pharyngeal stimulation (EPS) has been shown to improve swallowing function and in particular decrease airway aspiration in acute stroke. We performed a randomized controlled trial to assess EPS effectiveness on swallowing function in severely dysphagic tracheotomized patients.
All consecutive stroke patients successfully weaned from the respirator but with severe dysphagia precluding decannulation were screened for eligibility. Eligible patients were randomized to receive either EPS (N = 20) or sham stimulation (N = 10) over three consecutive days. Primary endpoint was ability to decannulate the patient. Swallowing function was assessed using fiberoptic endoscopy. Patients having received sham stimulation were offered EPS treatment during unblinded follow-up if required. Investigators were blinded to the patient’s study group allocation.
Both groups were well matched for age, stroke severity, and lesion location. Decannulation after study intervention was possible in 75 % of patients of the treatment group and in 20 % of patients of the sham group (p < 0.01). Secondary outcome parameters did not differ. No adverse events occurred.
In this pilot study, EPS enhanced remission of dysphagia as assessed with fiberoptic endoscopic evaluation of swallowing (FEES), thereby enabling decannulation in 75 % of patients.
Ribeiro PW, Cola PC, Gatto AR, da Silva RG, Luvizutto GJ, Braga GP, Schelp AO, de Arruda Henry MA, Bazan R.
J Stroke Cerebrovasc Dis. 2015 Jul 14. pii: S1052-3057(15)00254-2. doi: 10.1016/j.jstrokecerebrovasdis.2015.05.009. [Epub ahead of print]
The present study aimed to evaluate the relation between the National Institutes of Health Stroke Scale (NIHSS) score and the presence of laryngeal penetration and/or laryngotracheal aspiration in ischemic stroke patients and to verify what factors are predictors of the occurrence of pneumonia in the evaluated patients.
This was an observational study of ischemic stroke in the acute or subacute phases. Neurologic examination included anamnesis, Bamford classification, and application of the NIHSS. Speech therapy evaluation was carried out after clinical stabilization of the patient, and all individuals who were considered dysphagic were sent for examination by means of videofluoroscopic recordings. The parameters observed in the objective examination were the presence of laryngeal penetration and/or laryngotracheal aspiration. The pneumonia data were obtained in accordance with local protocols, which were based on international guidelines. The relation of laryngeal penetration and laryngotracheal aspiration with the NIHSS score was assessed by the Mann–Whitney U test, and predictors for the occurrence of pneumonia were analyzed by multiple logistic regression using semiautomatic backward selection. Significance was set at P less than .05.
The relations between laryngeal penetration and the NIHSS score and between laryngotracheal aspiration and the NIHSS score were not statistically significant. The predictors for pneumonia occurrence in the ischemic stroke patients with a clinical diagnosis of dysphagia were age (P = .002; odds ratio [OR], 1.12) and NIHSS score (P = .04; OR, 1.17), whereas laryngeal penetration of liquid (P = .065; OR, 3.70) tended to correlate with pneumonia but not significantly.
There was no relation between the NIHSS score and laryngeal penetration or laryngotracheal aspiration, and the principal predictors of pneumonia in dysphagic patients after ischemic stroke were advanced age and neurologic severity.
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Early identification of dysphagia is associated with lower rates of pneumonia after acute stroke. The Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) was previously developed as a simple bedside screen performed by nurses for sensitive detection of dysphagia and was previously validated against the speech pathologist’s clinical assessment for dysphagia. In this study, acute stroke patients were prospectively enrolled to assess the accuracy of the BJH-SDS when tested against the gold-standard test for dysphagia, the video-fluoroscopic swallow study (VFSS).
Acute stroke patients were prospectively enrolled at a large tertiary care inpatient stroke unit. The nurse performed the BJH-SDS at the bedside. After providing consent, patients then underwent VFSS for determination of dysphagia and aspiration. The VFSS was performed by a speech pathologist who was blinded to the results of the BJH-SDS. Sensitivity and specificity were calculated. Pneumonia rates were assessed across the five year period over which the BJH-SDS was introduced into the Stroke Unit.
A total of 225 acute stroke patients were enrolled. Sensitivity and specificity of the screen to detect dysphagia were 94% and 66%, respectively. Sensitivity and specificity of the screen to detect aspiration were 95% and 50%, respectively. No increase in pneumonia was identified during implementation of the screen (p=0.33).
The BJH-SDS, validated against video-fluoroscopy, is a simple bedside screen for sensitive identification of dysphagia and aspiration in the stroke population.
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Pisegna JM, Kaneoka A, Pearson WG Jr, Kumar S, Langmore SE.
Clin Neurophysiol. 2015 May 9. pii: S1388-2457(15)00309-0. doi: 10.1016/j.clinph.2015.04.069.
The primary aim of this review is to evaluate the effects of non-invasive brain stimulation on post-stroke dysphagia.
Thirteen databases were systematically searched through July 2014. Studies had to meet pre-specified inclusion and exclusion criteria. Each study’s methodological quality was examined. Effect sizes were calculated from extracted data and combined for an overall summary statistic.
Eight randomized controlled trials were included. These trials revealed a significant, moderate pooled effect size (0.55; 95% CI=0.17, 0.93; p=0.004). Studies stimulating the affected hemisphere had a combined effect size of 0.33 (95% CI=-0.52, 1.18; p=0.44), while studies stimulating the unaffected had a much larger, significant pooled effect size (0.70; 95% CI=0.25, 1.15; p=0.002). At long-term follow up, three studies demonstrated a large but non-significant pooled effect size (0.81, p=0.11).
This review found evidence for the efficacy of non-invasive brain stimulation on post-stroke dysphagia. A greater effect size resulted when stimulating the unaffected rather than the affected hemisphere. This finding is in agreement with previous studies implicating the plasticity of cortical neurons in the unaffected hemisphere.
Non-invasive brain stimulation appears to assist cortical reorganization in post-stroke dysphagia but emerging factors highlight the need for more data.
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