Advertisement

The Dysphagia in Stroke Protocol Reduces Aspiration Pneumonia in Patients with Dysphagia Following Acute Stroke: a Clinical Audit

  • Sarah E. Perry
  • Anna Miles
  • John N. Fink
  • Maggie-Lee Huckabee
Original Article

Abstract

Cough reflex testing has been evaluated as a component of the clinical swallowing assessment as a means of identifying patients at risk of aspiration during swallowing. A previous study by our research group found good sensitivity and specificity of the cough reflex test for identifying patients at risk of aspiration post-stroke, yet its use did not decrease pneumonia rates, contrary to previous reports. The aim of this study was to expand on our earlier work by implementing a clinical management protocol incorporating cough reflex testing within the same healthcare setting and compare patient outcomes to those from the original study and to evaluate clinical outcomes in patients with acute stroke who were managed using the Dysphagia in Stroke Protocol (DiSP). Secondarily, to compare those outcomes to historical data prior to implementation of the DiSP. This clinical audit measured outcomes from 284 patients with acute stroke managed per the DiSP, which guides use of videofluoroscopic swallowing study and patient management based on clinical exam with cough reflex testing. Data from our previous trial were included for comparison of pre- and post-DiSP patient outcomes. Data collection took place between November 2012 and April 2016 at four urban hospitals within New Zealand. Following implementation of the DiSP, the rate of aspiration pneumonia (10%) was substantially lower than the pre-DiSP rate (28%), with no pneumonia readmissions within 3 months. Pneumonia-related mortality was unchanged. By 3 months, 81% of the patients were on a normal diet and 67% had returned home, compared to pre-DiSP outcomes of 55% and 55% respectively. Previous work has suggested that simply implementing cough reflex testing in dysphagia management may not be sufficient to improve patient outcomes. The present study adds to this picture by suggesting that the true variable of influence may be the way in which the results of the test are applied to patient care. There is a strong case to support the use of a structured protocol if cough reflex testing is to be implemented in clinical practice.

Keywords

Aspiration pneumonia Dysphagia Deglutition Clinical protocol 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. 1.
    Marik P, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124(1):328–36.CrossRefPubMedGoogle Scholar
  2. 2.
    Finestone H, Greene-Finestone L, Wilson E, Teasell R. Malnutrition in stroke patients on rehabilitation service and follow-up: prevalence and predictors. Arch Phys Med Rehabil. 1995;76:306–10.CrossRefGoogle Scholar
  3. 3.
    Power ML, Hamdy S, Goulermas JY, Tyrrell PJ, Turnbull I, Thompson DG. Predicting aspiration after hemispheric stroke from timing measures of oropharyngeal bolus flow and laryngeal closure. Dysphagia. 2009;24(3):257–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Smith C, Logemann J, Colangelo L, Rademaker A, Pauloski B. Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia. Jan. 1999;14(1):1–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Garon B, Ormiston C, Sierzant T. Silent aspiration: results of 2,000 video fluoroscopic evaluations. J Neurosci Nurs. 2009;41(4):178–85.CrossRefPubMedGoogle Scholar
  6. 6.
    Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 1988;68(8):637–40.Google Scholar
  7. 7.
    Daniels S, Brailey K, Priestly D, Herrington L, Weisberg L, Foundas A. Aspiration in patients with acute stroke. Arch Phys Med Rehabil. 1998;79(1):14–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Antonios N, Carnaby-Mann G, Crary M, Miller L, Hubbard H, Hood K, et al. Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability. J Stroke Cerebrovasc Dis. 2010;19(1):49–57.CrossRefPubMedGoogle Scholar
  9. 9.
    Schrock JW, Bernstein J, Glasenapp M, Drogell K, Hanna J. A novel emergency department dysphagia screen for patients presenting with acute stroke. Acad Emerg Med. 2011;18(6):584–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Edmiaston J, Connor LT, Loehr L, Nassief A. Validation of a dysphagia screening tool in acute stroke patients. Am J Crit Care. 2010;19(4):357–64.CrossRefPubMedGoogle Scholar
  11. 11.
    Martino R, Silver F, Teasell R, Bayley M, Nicholson G, Streiner DL, et al. The Toronto Bedside Swallowing Screening Test (TOR-BSST): development and validation of a dysphagia screening tool for patients with stroke. Stroke. 2009;40(2):555–61.CrossRefPubMedGoogle Scholar
  12. 12.
    S. B. Leder and D. M. Suiter, The Yale swallow protocol: an evidence-based approach to decision making. 2014.Google Scholar
  13. 13.
    Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008;23(3):244–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Addington W, Stephens R, Gilliland K. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. Stroke. 1999;30(6):1203–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Wakasugi Y, Tohara H, Hattori F, Motohashi Y, Nakane A, Goto S, et al. Screening test for silent aspiration at the bedside. Dysphagia. 2008;23(4):364–70.CrossRefPubMedGoogle Scholar
  16. 16.
    L. Leow, L. Beckert, T. Anderson, and M.-L. Huckabee, “Cough reflex and chemo-sensitivity in ageing and Parkinson’s disease.,” Dysphagia, 2011.Google Scholar
  17. 17.
    Miles A, Zeng I, McLauchlan H, Huckabee M-L. Cough reflex testing in dysphagia following stroke: a randomized controlled trial. J Clin Med Res. 2013;5(3):222–33.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Miles A, Moore S, McFarlane M, Lee F, Allen J, Huckabee M-L. Comparison of cough reflex test against instrumental assessment of aspiration. Physiol Behav. 2013;118C:25–31.CrossRefGoogle Scholar
  19. 19.
    Guillén-Solà A, Chiarella SC, Martínez-Orfila J, Duarte E, Alvarado-Panesso M, Figueres-Cugat A, et al. Usefulness of citric cough test for screening of silent aspiration in subacute stroke patients: a prospective study. Arch Phys Med Rehabil. 2015;96(7):1277–83.CrossRefPubMedGoogle Scholar
  20. 20.
    Sato M, Tohara H, Iida T, Wada S, Inoue M, Ueda K. Simplified cough test for screening silent aspiration. Arch Phys Med Rehabil. 2012;93(11):1982–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Wakasugi Y, Tohara H, Nakane A, Murata S, Mikushi S, Susa C, et al. Usefulness of a handheld nebulizer in cough test to screen for silent aspiration. Odontology. 2014;102(1):76–80.CrossRefPubMedGoogle Scholar
  22. 22.
    Monroe M, Manco K, Bennett R, Huckabee M-L. Citric acid cough reflex test: establishing normative data. Speech, Lang Hear. 2014;17(4):216–24.CrossRefGoogle Scholar
  23. 23.
    Mann G, Hankey G, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30(4):744–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Hinchey J, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Lakshminarayan K, Tsai AW, Tong X, Vazquez G, Peacock JM, George MG, et al. Utility of dysphagia screening results in predicting poststroke pneumonia. Stroke. 2010;41(12):2849–54.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Odderson I, Keaton J, McKenna B. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil. 1995;76(December):1130–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Yeh SJ, Huang KY, Wang TG, Chen YC, Chen CH, Tang SC, et al. Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit. J Neurol Sci. 2011;306(1–2):38–41.CrossRefPubMedGoogle Scholar
  28. 28.
    Odderson I, McKenna B. A model for management of patients with stroke during the acute phase. Outcome and economic implications. Stroke. 1993;24(12):1823–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Wilson RD, Howe EC. A cost-effectiveness analysis of screening methods for dysphagia after stroke. Phys Med Rehabil. 2012;4(4):273–82.Google Scholar
  30. 30.
    Wilson RD. Mortality and cost of pneumonia after stroke for different risk groups. J Stroke Cerebrovasc Dis. Jan. 2012;21(1):61–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Miles A, Huckabee ML. Intra- and inter-rater reliability for judgement of cough following citric acid inhalation. Int J Speech Lang Pathol. 2013;15(2):209–15.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Sarah E. Perry
    • 1
    • 2
  • Anna Miles
    • 3
  • John N. Fink
    • 4
  • Maggie-Lee Huckabee
    • 1
  1. 1.Department of Communication DisordersThe University of CanterburyChristchurchNew Zealand
  2. 2.Department of Biobehavioral SciencesTeachers College Columbia UniversityNew YorkUSA
  3. 3.Department of Speech ScienceThe University of AucklandAucklandNew Zealand
  4. 4.Department of NeurologyChristchurch Public HospitalChristchurchNew Zealand

Personalised recommendations