What is included in dysphagia management and aspiration pneumonia prevention following middle cerebral artery (MCA) stroke?

Updated: Feb 20, 2018
  • Author: Daniel I Slater, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Answer

The importance of recognizing and proactively managing impaired swallowing should not be underestimated. Dysphagia is seen in 42-67% of patients within the first 72 hours post stroke. [5] Per stroke guidelines, a basic swallow screen should be performed by nursing staff before any initial food or drink is provided to a patient. [6] Patients with findings suggestive of dysphagia, including cough, voice changes, level of consciousness, prolonged mastication, should be further evaluated by a speech therapist. To be clear, the initial screening process is not equivalent to a thorough evaluation of swallowing impairment.

A modified barium swallow or videofluoroscopy is used to ascertain if any feeding is safe and, if so, what consistency of solids and liquids are appropriate. Aspiration is defined as the penetration of food or saliva beyond the vocal chords and is termed silent if the patient is without symptoms such as cough when this penetration occurs. Bedside evaluation for dysphagia is certainly limited by the fact that as many as 40% of patients who aspirate do so silently. Accordingly, modified barium swallow is likely needed in all but a few cases of patients with any suspicion for dysphagia.

Aspiration pneumonia, resultant from penetration of food, saliva, and gastric acid, has very serious ramifications, including high mortality, increased length of hospital stay, and poor functional outcome. [7] Early recognition and treatment of the condition with antibiotics and pulmonary toilet are vital to improving survival. Organisms responsible are often anaerobic and thus require differing antibiotic coverage than typical community-acquired pneumonia. The exact pathophysiology is still somewhat debated, as bronchial inflammation resultant from exposure to gastric acid, as well as bacterial infection, both likely contribute. [8]


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