Dysphagia is when difficulties occur in the swallowing process. This symptom can be present in the first days after the stroke, manifesting itself with levels of severity, ranging from the difficulty of swallowing only some types of food, to the total impossibility of feeding or hydrating through the mouth, reaching the most serious cases, the difficulty of handling one’s own saliva. Going through a clinical and / or instrumental evaluation, the presence-absence of dysphagia, and the eventual magnitude of the disturbance, is correct.

Screening procedures are generally carried out by professional nurses, if dysphagia is suspected, a specific clinical evaluation is requested, completed by instrumental investigations such as Fibroendoscopy (FESS), swallowing tests of different types of food, or videofluoroscopy (VFSS).

 

Are phoniatrician and speech therapists equivalent in the treatment of dysphagia?

The phoniatrician or the otolaryngologist are doctors who take care of the clinical and instrumental evaluation, thus giving a diagnosis of dysphagia. The speech therapist, after having carried out his language assessment, deals with the treatment of post-stroke dysphagia.

 

How to behave if the structure does not have the right staff to recover from dysphagia?

Dysphagia after a stroke is a disorder that can have serious consequences; therefore, it must be evaluated and treated quickly, requesting specific professional advice.

What are the side effects of PEG?

When mouth feeding is not safe enough, the nutritional need is guaranteed through the Nasogastric Tube (NG tube). When the recovery time of the swallowing function is extended beyond 4 weeks, it is appropriate to resort to a Percutaneous Endoscopic Gastrostomy. PEG does not carry particular side effects, and it is quite tolerated by the patient who does not perceive it as a foreign body, on the other hand, if the patient is confused or very agitated, the NG tube is extracted.

The daily management of PEG is relatively simple, the stoma must be disinfected, the medication is positioned and the tube cleaned with water. Using PEG for the delivery of crushed oral therapy, it can occasionally become obstructed; sparkling water or Coke can help unblock. The presence of PEG is not incompatible with rehabilitative treatment for dysphagia. This offers the advantage of guaranteeing the nutrition of our patient, without having to accelerate in an untimely way the “times” of mouth feeding through.

 

In general, what are the spontaneous recovery periods?

It is difficult to give a correct period of spontaneous recovery, because it is strictly tied to the concept of severity and zone of injury. As we will see, lesions involving the subcortical areas of the trunk and bulb are related to major deficiencies in swallowing. Many factors come into play in spontaneous recovery periods, not only organic but also psychological and environmental. Clinical “mismanagement” often slows down recovery of function.

Are there different recoveries due to the location of the lesion (dx hemisphere, left hemisphere, subcortical bulbo-trunk areas)?

Generally, cortical lesions of the left hemisphere (paralysis of the right part of the body), may also involve language areas, giving rise to a communicational-linguistic deficiency, while lesions in charge of the right hemisphere (paralysis of the left part of the body), can lead to attention difficulties in respect of the space on the injured side.

The functional relapse on swallowing will be in particular compared to the deficiency of the part of the face (right or left) in which a lot of food residues can accumulate and are not perceived by the patient. The location of the right vs left cortical lesion does not seem to be decisive in the recovery of swallowing, but rather the magnitude of the lesion itself. In case of the participation of the subcortical areas (trunk and bulb), swallowing disorders can be of greater magnitude.

 

What are the additional complications in recovery from a dysphagic tracheostomy tube carrier?

In the acute phase, the tracheostomy tube is positioned to ensure breathing (sometimes the patient is connected to a ventilator) and aspiration of tracheobronchial secretions.

With the improvement of the clinical feature and removing the ventilator, the swallowing evaluation is carried out by the expert staff.

The tracheostomy tube itself does not prevent swallowing, but as a result of being a strange device, it impacts swallowing dynamics. Therefore, it must be considered both in the evaluation and in the definition of the therapy.

In incomplete recovery phases, what measures should be taken with food and drink?

Especially in the initial phase, besides part of the face, also part of the tongue is involved and therefore makes it difficult to transport the bolus. For this reason, in the early stages of the disease, a diet based on ground foods is often proposed.

In general, it will be appropriate to eat a soft diet, excluding foods that are difficult to chew or have a double consistency (soup). Liquids are not shaped, can be difficult to handle and the patient cannot retain them in the mouth (they come out from the paretic angle of the mouth), and cannot bring them back, since the middle of the tongue does not move well.

There is a custom of using thickening powders for a long period, which serve to make the liquid thicker (most of the time a caramel consistency is sufficient) or gelling waters, but in milder cases, it may be enough to use cold liquids that are perceived and then better managed.

Posture can also make a difference: the head turned to the injured side and slightly tilted forward, can facilitate swallowing in hemiplegic patients.

 

What can a family member do to help the patient recover from swallowing?

It is not easy to answer this kind of general question. Attempting to make a comparison with the motor aspect, we could say that in order to favor the recovery of our family member’s swallowing, means to not exposing him to dangerous situations, early intercepting the signs and symptoms of dysphagia (coughing during eating, bubbling voice, increased secretions or fever after meals …). , it must be put in the best conditions: environmental (quiet, television off, without distractions), posture (sitting at 90 °), suitable foods and liquids, respecting feeding hours (no fast eating). Family members are a precious resource, great therapeutic allies.

 

Doctor Isabella Koch

Speech therapist since 1987 before I.R.C.C.S. Hospital S.Camillo Foundation in Venice

Master in Deglutology at the University of Turin

University tutor for the course of Degree in Speech Therapy di PD.

We warmly thank Dr. Isabella Koch, for her kind contribution on a subject as delicate as post-stroke dysphagia.