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Best methods to screen for swallowing difficulties after acute stroke identified

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Researchers who systematically reviewed 35 protocols to screen for swallowing difficulties after acute stroke found only four that met basic requirements for reliability, validity and feasibility.

They are the Barnes Jewish Hospital Stroke Dysphagia Screen (previously called the Acute Stroke Dysphagia Screen, or ASDS); the Modified Mann Assessment of Swallowing Ability; the Emergency Physician Swallowing Screening; and the Toronto Bedside Swallowing Screening Test.

“I think the most important thing for clinicians to know is that there have been sound swallowing screening protocols validated for patients with acute stroke, which are available for use,” Dr. Sara K. Schepp, from University of Washington, Seattle, told Reuters Health.

Dysphagia affects 37% to 78% of patients with acute stroke and increases the risk of aspiration, pneumonia, prolonged hospital stay, disability and death, Dr. Schepp and colleagues note in a report online December 8 in Stroke.

“Even though swallowing screening is no longer a core measure for stroke centers, there is growing evidence that it is an important part of preventing pneumonia, poor outcome, and death in stroke patients. Having simple, validated published screens makes this an easier thing for hospitals to accomplish,” Dr. Schepp said.

Matched against a formal swallowing evaluation as the gold standard, the four protocols the study team identified had high sensitivities of at least 87% and high negative predictive values of at least 91%.

All of these protocols include some assessment of oropharyngeal function, such as dysarthria, dysphonia and asymmetry or weakness of face, tongue and palate; three include an assessment of the ability to swallow water. The four protocols take between 2 and 10 minutes to administer.

“Of the screens we reviewed, all have merits, but I think the Barnes Jewish Hospital Stroke Dysphagia Screen has several advantages over the others,” Dr. Schepp said.

“It is simple and easy to administer, it has been rigorously validated against videofluoroscopy, and the authors are happy to have others use it free of charge,” she added. It takes 2 minutes to administer and can be administered by nurses after a 10-minute training session.

Issues that remain to be elucidated include cost-effectiveness of screening, including costs associated with false-positive results and impact of screening on morbidity, mortality and length of hospital stay.

For example, the researchers report that the positive predictive values of the four protocols ranged from 54% to 77%. Therefore, 23% to 46% of patients screened were falsely identified as having increased risk, they point out.

“Clearly, we still have a lot of work to do to find the best ways to prevent pneumonia in stroke patients,” Dr. Schepp said, “but I think the studies we reviewed – including many which did not meet our criteria for inclusion for one reason or another – are an important step.”

Reference:

Swallowing Screens After Acute Stroke

Stroke. 2012;43.