The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. Methods We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. Results Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se. Conclusions The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Detection of poststroke oropharyngeal dysphagia with swallowing screening by ultrasonography

There are currently no standard evaluation tools for poststroke neurogenic oropharyngeal dysphagia. We previously suggested calculating the relative movements of the hyoid bone and larynx by ultrasonography to evaluate swallowing movement. Swallowing movement is altered in neurogenic oropharyngeal dysphagia. Therefore, the present study aimed to verify whether an ultrasonographic evaluation of swallowing movement facilitates the detection of neurogenic oropharyngeal dysphagia. Eighteen healthy male elderly participants (the healthy group) and 18 male stroke patients diagnosed with neurogenic oropharyngeal dysphagia (the dysphagia group) were enrolled. Participants swallowed 5 mL of liquid and water with an adjusted viscosity and the movements of the hyoid bone and larynx were visualized by ultrasonography. The results obtained revealed significant differences in laryngeal duration (static phase), laryngeal displacement (elevation phase), and the hyoid bone–laryngeal motion ratio (HL motion ratio) between the two groups. A multiple regression analysis was performed to adjust for confounding factors, and laryngeal duration (static phase) and the HL motion ratios were identified as factors affecting dysphagia. In the receiver operation characteristic curve of the two variations, the area under the curve for laryngeal duration (static phase) was 0.744 and the cut-off was 0.26 sec with 72.2% sensitivity and 88.9% specificity; the area under the curve for the HL motion ratio was 0.951 and the cut-off was 0.56 with 88.9% sensitivity and 88.9% specificity. Therefore, the objective evaluation of hyoid bone and larynx movements during swallowing by ultrasonography facilitated the detection of neurogenic oropharyngeal dysphagia.

Swallowing Screening: Purposefully Different From an Assessment Sensitivity and Specificity Related to Clinical Yield, Interprofessional Roles, and Patient Selection

Purpose The purpose of this clinical focus article is to summarize the goal and process by which identification of individuals at risk for having feeding problems or dysphagia is clinically screened across the life span by speech-language pathologists (SLPs). The topic of this clinical focus article was presented at the Charleston Swallowing Conference in Chicago, Illinois, in July 2018. The contents of this clinical focus article offer an expanded summary of information discussed at this meeting with focus on critical considerations to guide clinical decisions by SLPs regarding the optimal feeding and dysphagia screening approach and process. Conclusion Screening is a critical first step in the identification of individuals at risk for feeding problems and dysphagia across the life span. Understanding the difference between screening and assessment objectives as well as having the knowledge, skills, and clinical competency to implement psychometrically sound screening approaches is a recommended clinical practice standard for SLPs working with these clinical populations. This clinical focus article summarizes critical considerations for identifying individuals at risk for feeding problems and dysphagia across the life span to guide clinicians working with dysphagia populations.

The Relationship between Texture-Modified Diets, Mealtime Duration, and Dysphagia Risk in Long-Term Care

Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modified diets. Dysphagia has been shown to be associated with longer mealtime duration, and the use of texture-modified diets has been associated with reduced nutritional intake. The current study aimed to determine if the degree of diet modification affected mealtime duration and to examine the correlation between texture-modified diets and dysphagia risk. Data were collected from 639 LTC residents, aged 62–102 years. Nine meal observations per resident provided measures of meal duration, consistencies consumed, coughing and choking, and assistance provided. Dysphagia risk was determined by identifying residents who coughed/choked at meals, were prescribed thickened fluids, and/or failed a formal screening protocol. Degree of texture modification was derived using the International Dysphagia Diet Standardization Initiative Functional Diet Scale. There was a significant association between degree of diet modification and dysphagia risk (P < 0.001). However, there was no association between diet modifications and mealtime duration, even when the provision of physical assistance was considered. Some residents who presented with signs of swallowing difficulties were not prescribed a texture-modified diet. Swallowing screening should be performed routinely in LTC to monitor swallowing status and appropriateness of diet prescription. Physical assistance during meals should be increased.

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

Background: Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. Methods: In this prospective register-based study (“Stroke Register of Northwestern Germany”), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. Results: Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2–5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0–3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0–3.2], p < 0.001). The order of magnitude of these end points did not change over time. Conclusion: Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.