Effect of Dysphagia Screening Strategies on Clinical Outcomes After Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Abstract

Introduction— Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an evidence review committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke. Methods— The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions with increased dysphagia screening rates and reporting outcomes of pneumonia, death, or dependency. Results— Three RCTs were identified. One RCT found that a combined nursing quality improvement intervention targeting fever and glucose management and dysphagia screening reduced death and dependency but without reducing the pneumonia rate. Another RCT failed to find evidence that pneumonia rates were reduced by adding the cough reflex to routine dysphagia screening. A smaller RCT randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation; however, the study was small and at risk for bias. Conclusions— There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing the rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.

Impact of the systematic use of the Gugging Swallowing Screen in patients with acute ischaemic stroke

“…SAP occurred in 13.6% of patients [95% confidence interval (CI), 8. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18].9%] at a median time of 3 days after stroke (IQR, 2-4) and there was no difference in its occurrence between the pre-GUSS and GUSS periods (12.5% vs. 15.1%, P = 0.490). The characteristics of patients according to the occurrence of SAP are described in Table S1.…”

“…Among the final population of patients (n = 344), 204 were admitted during the pre-GUSS period and 140 during the GUSS period. Median age was 71 years (IQR, 59-79), 178 were male (51.7%) and median National Institutes of Health Stroke Scale score was 11 (IQR, [6][7][8][9][10][11][12][13][14][15][16][17][18]. Baseline characteristics of the study population according to the inclusion period are detailed in Table 1.…”

Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review

“…A recently published review found insufficient evidence to determine the effect of DSP [39]. However Smith et al [39] included only randomized controlled trials and did not focus specifically on pneumonia as an outcome.…”

“…However Smith et al [39] included only randomized controlled trials and did not focus specifically on pneumonia as an outcome. Our review found emerging evidence that EDS is associated with lower incidence of SAP and supports current guidelines that all patients should be screened for dysphagia on admission before oral intake.…”

Dysphagia: Interprofessional Management, Impact, and Patient‐Centered Care

“…Of 216 patients with a nothing‐by‐mouth status, 13.9% still developed pneumonia. A systematic review concluded that there is insufficient evidence that current dysphagia screening protocols reduce risk for pneumonia, death, or dependency after stroke . Therefore, ideally, bedside screening measures should lead to supplemental evaluation with instrumental assessment for a comprehensive, thorough examination of oropharyngeal anatomy and physiology, as indicated and available.…”