Department of Neurology & Stroke Unit, HELIOS General Hospital Aue, Dresden University of Technology, Aue, Germany.
J Stroke Cerebrovasc Dis. 2012 Oct;21(7):569-76. doi: 10.1016/j.jstrokecerebrovasdis.2011.01.004. Epub 2011 Jun 16.
Stroke is the most frequent cause of neurogenic oropharyngeal dysphagia (NOD). In the acute phase of stroke, the frequency of NOD is greater than 50% and, half of this patient population return to good swallowing within 14 days while the other half develop chronic dysphagia. Because dysphagia leads to aspiration pneumonia, malnutrition, and in-hospital mortality, it is important to pay attention to swallowing problems. The question arises if a prediction of severe chronic dysphagia is possible within the first 72 hours of acute stroke.
On admission to the stroke unit, all stroke patients were screened for swallowing problems by the nursing staff within 2 hours. Patients showing signs of aspiration were included in the study (n = 114) and were given a clinical swallowing examination (CSE) by the swallowing/speech therapist within 24 hours and a swallowing endoscopy within 72 hours by the physician. The primary outcome of the study was the functional communication measure (FCM) of swallowing (score 1-3, tube feeding dependency) on day 90.
The grading system with the FCM swallowing and the penetration-aspiration scale (PAS) in the first 72 hours was tested in a multivariate analysis for its predictive value for tube feeding-dependency on day 90. For the FCM level 1 to 3 (P < .0022) and PAS level 5 to 8 (P < .00001), the area under the curve (AUC) was 72.8% and showed an odds ratio of 11.8 (P < .00001; 95% confidence interval 0.036-0.096), achieving for the patient a 12 times less chance of being orally fed on day 90 and therefore still being tube feeding-dependent.
We conclude that signs of aspiration in the first 72 hours of acute stroke can predict severe swallowing problems on day 90. Consequently, patients should be tested on admission to a stroke unit and evaluated with established dysphagia scales to prevent aspiration pneumonia and malnutrition. A dysphagia program can lead to better communication within the stroke unit team to initiate the appropriate diagnostics and swallowing therapy as soon as possible.
中风是神经源性口咽吞咽困难（NOD）最常见的原因。在中风的急性期，NOD 的频率大于 50%，其中一半患者在 14 天内恢复良好吞咽，而另一半则发展为慢性吞咽困难。由于吞咽困难会导致吸入性肺炎、营养不良和院内死亡率增加，因此关注吞咽问题非常重要。问题是是否可以在急性中风的前 72 小时内预测严重的慢性吞咽困难。
在中风病房入院时，护理人员在 2 小时内对所有中风患者进行吞咽问题筛查。出现吸入迹象的患者被纳入研究（n=114），并在 24 小时内由吞咽/言语治疗师进行临床吞咽检查（CSE），在 72 小时内由医生进行吞咽内镜检查。研究的主要结局是第 90 天的功能性沟通测量（FCM）吞咽评分（1-3 分，管饲依赖）。
在多变量分析中，我们测试了前 72 小时内 FCM 吞咽和渗透-吸入量表（PAS）的分级系统对第 90 天管饲依赖的预测价值。对于 FCM 水平 1-3（P<.0022）和 PAS 水平 5-8（P<.00001），曲线下面积（AUC）为 72.8%，并显示出 11.8 的优势比（P<.00001；95%置信区间 0.036-0.096），这意味着患者第 90 天经口进食的机会减少 12 倍，仍然依赖管饲。
我们的结论是，急性中风前 72 小时内的吸入迹象可以预测第 90 天的严重吞咽问题。因此，应在中风病房入院时对患者进行测试，并使用已建立的吞咽困难量表进行评估，以预防吸入性肺炎和营养不良。吞咽障碍计划可以促进中风病房团队内更好的沟通，以便尽快启动适当的诊断和吞咽治疗。
