Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Initial Clinical Evaluation of Swallowing and Nutrition after Stroke:
C: All stroke patients should be screened for dysphagia before being given food or drink.
Assessing Risk of Pneumonia
B: The water swallow test should be used as a part of the screening for aspiration risk in stroke patients.
C: Clinical history taking should take into account comorbidities and other risk factors (e.g., smoking or respiratory disease) to identify increased risk of developing aspiration pneumonia.
Swallow Screening
D: Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan.
B: A typical swallow screening procedure should include:
- Initial observations of the patient's consciousness level
- Observations of the degree of postural control
If the patient is able to actively cooperate and is able to be supported in an upright position the procedure should also include:
- Observations of oral hygiene
- Observations of control of oral secretions
- If appropriate, a water swallow test
Nutritional Screening
D: Patients' nutritional risk should be established using a valid and reliable screening procedure suitable for stroke patients. Nutritional screening should be repeated at regular interval throughout the episode of care.
D: Nutritional screening should focus on the effects of the stroke on nutritional status (e.g., presence of dysphagia and ability to eat) rather than previous nutritional status.
D: Nutritional risk should be established within 48 hours of admission to hospital.
D: Results from the nutritional screening process should guide appropriate referral to a dietitian for assessment and management.
D: Nutritional screening should cover:
- Body mass index (BMI)
- Ability to eat
- Appetite
- Physical condition
- Mental condition
Assessment:
Clinical Bedside Assessment
B: A standardised clinical bedside assessment (CBA) should be used by a professional skilled in the management of dysphagia (currently speech and language therapists).
B: The clinical bedside assessment developed and tested by Logemann, or a similar tool, is recommended.
Instrumental Assessment
C: The modified barium swallow test and fibre optic endoscopic evaluation of swallow are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings.
Training for Screening and Assessments:
Screening
D: A training package for nurses should include:
- Risk factors for dysphagia
- Early signs of dysphagia
- Observation of eating and drinking habits
- Water swallow test
- Monitoring of hydration
- Monitoring weight and nutritional risk
Assessment
D: All staff involved in the detection and management of dysphagia should be trained according to the recommendations of the relevant professional body.
D: Standard criteria should be established for the interpretation of the results of radiological and fibre optic assessments.
Nutritional Interventions:
Tube Feeding
D: Patients in the early recovery phase should be reviewed weekly by the multidisciplinary team to ascertain if longer term (>4 weeks) feeding is required.
B: Feeding via percutaneous endoscopic gastrostomy (PEG) is the recommended feeding route for long-term (>4 weeks) enteral feeding. Patients requiring long-term tube feeding should be reviewed regularly.
D: Patient's and carer's perceptions and expectations of PEG feeding should be taken into account and the benefits, risks and burden of care fully explained before initiating feeding.
Other Management Issues:
Effect of Regular Review on Patient Outcome
D: Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual swallowing function and dietary intake, by a professional skilled in the management of dysphagia.
Effect of Therapy on Patient Outcome
D: Advice on diet modification and compensatory techniques (postures and manoeuvres) should be given following full swallowing assessment.
D: Texture modified food should be attractively presented and appetising. Patients should have a choice of dishes.
Other Considerations
D: Good oral hygiene should be maintained in patients with dysphagia, particularly in those with PEG or nasogastric (NG) tubes, in order to promote oral health and patient comfort.
D: Hospital and community pharmacists or medicines information centres should be consulted by the professional managing the patient's dysphagia on the most appropriate method of administering medication.
Care of Patients with Dysphagia
D: Staff, carers and, patients should be trained in feeding techniques. This training should include:
- Modifications of positioning and diet
- Food placement
- Management of behavioural and environmental factors
- Delivery of oral care
- Management of choking
The Effect of Communicative or Cognitive Impairment on the Management of Dysphagia Patients
D: Communication, cognitive function, and the capacity for decision making should be routinely assessed in patients with dysphagia.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1 -: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies; high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
