Interpretation of the European guideline for the diagnosis and treatment of post-stroke dysphagia (2021 Edition)_West China Medical Journal

Authors：

YE Wen ¹ , CAI Yuxin ^1,2 , LIU Lingling ¹ ,  FENG Zhen ^1,3,4

1. Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330000, P. R. China;
2. The First Clinical Medical School of Nanchang University, Nanchang, Jiangxi 330000, P. R. China;
3. Department of Comprehensive Rehabilitation, Rehabilitation Hospital Affiliated to Nanchang University, Nanchang, Jiangxi 330000, P. R. China;
4. Jiangxi Provincial Rehabilitation Clinical Medicine Research Center, Nanchang, Jiangxi 330000, P. R. China;

Corresponding author：

FENG Zhen, Email: fengzhenly@sina.com

Keywords：

Dysphagia; diagnosis; treatment; guideline

DOI：

10.7507/1002-0179.202203004

Video：

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With the aging of the population, the incidence of stroke is increasing year by year. More than 50% of stroke patients have post-stroke dysphagia, which not only increases the risk of complications such as aspiration pneumonia, malnutrition and dehydration, but also is associated with poor prognosis and increasing mortality. Due to its high morbidity and high risk of complications, the European Stroke Organization and the European Society for Dysphagia have launched the guideline for the diagnosis and treatment of post-stroke dysphagia (2021 Edition). This guideline mainly raises questions about the screening, assessment, and treatment of post-stroke dysphagia, and answers them based on evidence-based medical evidences. This article mainly interprets this in order to better guide clinical practice.

Citation： YE Wen, CAI Yuxin, LIU Lingling, FENG Zhen. Interpretation of the European guideline for the diagnosis and treatment of post-stroke dysphagia (2021 Edition). West China Medical Journal, 2022, 37(5): 646-651. doi: 10.7507/1002-0179.202203004 Copy

1.	Michou E, Hamdy S. Cortical input in control of swallowing. Curr Opin Otolaryngol Head Neck Surg, 2009, 17(3): 166-171.
2.	Jean A. Brain stem control of swallowing: neuronal network and cellular mechanisms. Physiol Rev, 2001, 81(2): 929-969.
3.	Katagiri S, Shiba T, Tohara H, et al. Re-initiation of oral food intake following enteral nutrition alters oral and gut microbiota communities. Front Cell Infect Microbiol, 2019, 9: 434.
4.	Vilardell N, Rofes L, Arreola V, et al. A comparative study between modified starch and xanthan gum thickeners in post-stroke oropharyngeal dysphagia. Dysphagia, 2016, 31(2): 169-179.
5.	Dziewas R, Michou E, Trapl-Grundschober M, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J, 2021, 6(3): LXXXIX-LXXCXV.
6.	Joundi RA, Martino R, Saposnik G, et al. Predictors and outcomes of dysphagia screening after acute ischemic stroke. Stroke, 2017, 48(4): 900-906.
7.	Hoffmann S, Malzahn U, Harms H, et al. Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke. Stroke, 2012, 43(10): 2617-2623.
8.	Ntaios G, Bornstein NM, Caso V, et al. The European Stroke Organisation Guidelines: a standard operating procedure. Int J Stroke, 2015, 10(Suppl A100): 128-135.
9.	Wirth R, Smoliner C, Jäger M, et al. Guideline clinical nutrition in patients with stroke. Exp Transl Stroke Med, 2013, 5(1): 14.
10.	Jeyaseelan RD, Chae J. National Institutes of Health Stroke Scale (NIHSS) as an early predictor of poststroke dysphagia. PM R, 2015, 7(6): 593-598.
11.	Lin WC, Huang CY, Lee LF, et al. Initial National Institute of Health Stroke Scale to early predict the improvement of swallowing in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis, 2019, 28(10): 104297.
12.	Labeit B, Mueller H, Muhle P, et al. Predicting dysphagia with National Institute of Health Stroke Scale: distinction between infra- and supratentorial region is essential. Cerebrovasc Dis, 2018, 46(3/4): 152-160.
13.	Bax L, McFarlane M, Green E, et al. Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke. J Stroke Cerebrovasc Dis, 2014, 23(3): e195-e200.
14.	Radhakrishnan SK, Anandakuttan A. A combined approach of bedside clinical examination and flexible endoscopic evaluation of swallowing in poststroke dysphagia: a pilot study. Ann Indian Acad Neurol, 2013, 16(3): 388-393.
15.	Dziewas R, Auf dem Brinke M, Birkmann U, et al. Safety and clinical impact of FEES - results of the FEES-registry. Neurol Res Pract, 2019, 1: 16.
16.	Hwang JM, Cheong YS, Kang MG, et al. Recommendation of nasogastric tube removal in acute stroke patients based on videofluoroscopic swallow study. Ann Rehabil Med, 2017, 41(1): 9-15.
17.	Langmore S. History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 2017, 32(1): 27-38.
18.	Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 2005, 36(12): 2756-2763.
19.	Bolivar-Prados M, Rofes L, Arreola V, et al. Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia. Neurogastroenterol Motil, 2019, 31(11): e13695.
20.	Rofes L, Arreola V, Mukherjee R, et al. The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia. Aliment Pharmacol Ther, 2014, 39(10): 1169-1179.
21.	Newman R, Vilardell N, Clavé P, et al. Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). Dysphagia, 2016, 31(2): 232-249.
22.	Park JS, Oh DH, Chang MY, et al. Effects of expiratory muscle strength training on oropharyngeal dysphagia in subacute stroke patients: a randomised controlled trial. J Oral Rehabil, 2016, 43(5): 364-372.
23.	Bakhtiyari J, Sarraf P, Nakhostin-Ansari N, et al. Effects of early intervention of swallowing therapy on recovery from dysphagia following stroke. Iran J Neurol, 2015, 14(3): 119-124.
24.	Eom MJ, Chang MY, Oh DH, et al. Effects of resistance expiratory muscle strength training in elderly patients with dysphagic stroke. NeuroRehabilitation, 2017, 41(4): 747-752.
25.	Guillén-Solà A, Messagi Sartor M, Bofill Soler N, et al. Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: a randomized controlled trial. Clin Rehabil, 2017, 31(6): 761-771.
26.	Fraga BF, Almeida ST, Santana MG, et al. Efficacy of myofunctional therapy associated with voice therapy in the rehabilitation of neurogenic oropharyngeal dysphagia: a pilot study. Int Arch Otorhinolaryngol, 2018, 22(3): 225-230.
27.	Kim YK, Lee KY, Lee SH. Efficacy of a 4-week swallowing rehabilitation program combined with pyriform sinus ballooning in patients with post-stroke dysphagia. Ann Rehabil Med, 2018, 42(4): 542-550.
28.	Moon JH, Hahm SC, Won YS, et al. The effects of tongue pressure strength and accuracy training on tongue pressure strength, swallowing function, and quality of life in subacute stroke patients with dysphagia: a preliminary randomized clinical trial. Int J Rehabil Res, 2018, 41(3): 204-210.
29.	Park JS, An DH, Oh DH, et al. Effect of chin tuck against resistance exercise on patients with dysphagia following stroke: a randomized pilot study. NeuroRehabilitation, 2018, 42(2): 191-197.
30.	Li CM, Wang TG, Lee HY, et al. Swallowing training combined with game-based biofeedback in poststroke dysphagia. PM R, 2016, 8(8): 773-779.
31.	Byeon H. Effect of the masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke. J Phys Ther Sci, 2016, 28(7): 2069-2071.
32.	常玲, 贺彭兰, 周振中, 等. 针刺结合功能性电刺激治疗急性脑卒中后吞咽困难疗效观察. 中国针灸, 2014, 34(8): 737-740.
33.	Dennis MS, Lewis SC, Warlow C, et al. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet, 2005, 365(9461): 755-763.
34.	Sørensen RT, Rasmussen RS, Overgaard K, et al. Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. J Neurosci Nurs, 2013, 45(3): 139-146.
35.	Murray J, Scholten I. An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation. Gerodontology, 2018, 35(1): 18-24.
36.	Wagner C, Marchina S, Deveau JA, et al. Risk of stroke-associated pneumonia and oral hygiene. Cerebrovasc Dis, 2016, 41(1/2): 35-39.
37.	Ebihara T, Ebihara S, Yamazaki M, et al. Intensive stepwise method for oral intake using a combination of transient receptor potential stimulation and olfactory stimulation inhibits the incidence of pneumonia in dysphagic older adults. J Am Geriatr Soc, 2010, 58(1): 196-198.
38.	Ahn YH, Sohn HJ, Park JS, et al. Effect of bihemispheric anodal transcranial direct current stimulation for dysphagia in chronic stroke patients: a randomized clinical trial. J Rehabil Med, 2017, 49(1): 30-35.
39.	中国卒中吞咽障碍与营养管理共识专家组, 中国卒中学会, 国家神经系统疾病临床医学研究中心, 等. 中国卒中吞咽障碍与营养管理手册. 中国卒中杂志, 2019, 14(11): 1153-1169.

1. Michou E, Hamdy S. Cortical input in control of swallowing. Curr Opin Otolaryngol Head Neck Surg, 2009, 17(3): 166-171.
2. Jean A. Brain stem control of swallowing: neuronal network and cellular mechanisms. Physiol Rev, 2001, 81(2): 929-969.
3. Katagiri S, Shiba T, Tohara H, et al. Re-initiation of oral food intake following enteral nutrition alters oral and gut microbiota communities. Front Cell Infect Microbiol, 2019, 9: 434.
4. Vilardell N, Rofes L, Arreola V, et al. A comparative study between modified starch and xanthan gum thickeners in post-stroke oropharyngeal dysphagia. Dysphagia, 2016, 31(2): 169-179.
5. Dziewas R, Michou E, Trapl-Grundschober M, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J, 2021, 6(3): LXXXIX-LXXCXV.
6. Joundi RA, Martino R, Saposnik G, et al. Predictors and outcomes of dysphagia screening after acute ischemic stroke. Stroke, 2017, 48(4): 900-906.
7. Hoffmann S, Malzahn U, Harms H, et al. Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke. Stroke, 2012, 43(10): 2617-2623.
8. Ntaios G, Bornstein NM, Caso V, et al. The European Stroke Organisation Guidelines: a standard operating procedure. Int J Stroke, 2015, 10(Suppl A100): 128-135.
9. Wirth R, Smoliner C, Jäger M, et al. Guideline clinical nutrition in patients with stroke. Exp Transl Stroke Med, 2013, 5(1): 14.
10. Jeyaseelan RD, Chae J. National Institutes of Health Stroke Scale (NIHSS) as an early predictor of poststroke dysphagia. PM R, 2015, 7(6): 593-598.
11. Lin WC, Huang CY, Lee LF, et al. Initial National Institute of Health Stroke Scale to early predict the improvement of swallowing in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis, 2019, 28(10): 104297.
12. Labeit B, Mueller H, Muhle P, et al. Predicting dysphagia with National Institute of Health Stroke Scale: distinction between infra- and supratentorial region is essential. Cerebrovasc Dis, 2018, 46(3/4): 152-160.
13. Bax L, McFarlane M, Green E, et al. Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke. J Stroke Cerebrovasc Dis, 2014, 23(3): e195-e200.
14. Radhakrishnan SK, Anandakuttan A. A combined approach of bedside clinical examination and flexible endoscopic evaluation of swallowing in poststroke dysphagia: a pilot study. Ann Indian Acad Neurol, 2013, 16(3): 388-393.
15. Dziewas R, Auf dem Brinke M, Birkmann U, et al. Safety and clinical impact of FEES - results of the FEES-registry. Neurol Res Pract, 2019, 1: 16.
16. Hwang JM, Cheong YS, Kang MG, et al. Recommendation of nasogastric tube removal in acute stroke patients based on videofluoroscopic swallow study. Ann Rehabil Med, 2017, 41(1): 9-15.
17. Langmore S. History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 2017, 32(1): 27-38.
18. Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, 2005, 36(12): 2756-2763.
19. Bolivar-Prados M, Rofes L, Arreola V, et al. Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia. Neurogastroenterol Motil, 2019, 31(11): e13695.
20. Rofes L, Arreola V, Mukherjee R, et al. The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia. Aliment Pharmacol Ther, 2014, 39(10): 1169-1179.
21. Newman R, Vilardell N, Clavé P, et al. Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD). Dysphagia, 2016, 31(2): 232-249.
22. Park JS, Oh DH, Chang MY, et al. Effects of expiratory muscle strength training on oropharyngeal dysphagia in subacute stroke patients: a randomised controlled trial. J Oral Rehabil, 2016, 43(5): 364-372.
23. Bakhtiyari J, Sarraf P, Nakhostin-Ansari N, et al. Effects of early intervention of swallowing therapy on recovery from dysphagia following stroke. Iran J Neurol, 2015, 14(3): 119-124.
24. Eom MJ, Chang MY, Oh DH, et al. Effects of resistance expiratory muscle strength training in elderly patients with dysphagic stroke. NeuroRehabilitation, 2017, 41(4): 747-752.
25. Guillén-Solà A, Messagi Sartor M, Bofill Soler N, et al. Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: a randomized controlled trial. Clin Rehabil, 2017, 31(6): 761-771.
26. Fraga BF, Almeida ST, Santana MG, et al. Efficacy of myofunctional therapy associated with voice therapy in the rehabilitation of neurogenic oropharyngeal dysphagia: a pilot study. Int Arch Otorhinolaryngol, 2018, 22(3): 225-230.
27. Kim YK, Lee KY, Lee SH. Efficacy of a 4-week swallowing rehabilitation program combined with pyriform sinus ballooning in patients with post-stroke dysphagia. Ann Rehabil Med, 2018, 42(4): 542-550.
28. Moon JH, Hahm SC, Won YS, et al. The effects of tongue pressure strength and accuracy training on tongue pressure strength, swallowing function, and quality of life in subacute stroke patients with dysphagia: a preliminary randomized clinical trial. Int J Rehabil Res, 2018, 41(3): 204-210.
29. Park JS, An DH, Oh DH, et al. Effect of chin tuck against resistance exercise on patients with dysphagia following stroke: a randomized pilot study. NeuroRehabilitation, 2018, 42(2): 191-197.
30. Li CM, Wang TG, Lee HY, et al. Swallowing training combined with game-based biofeedback in poststroke dysphagia. PM R, 2016, 8(8): 773-779.
31. Byeon H. Effect of the masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke. J Phys Ther Sci, 2016, 28(7): 2069-2071.
32. 常玲, 贺彭兰, 周振中, 等. 针刺结合功能性电刺激治疗急性脑卒中后吞咽困难疗效观察. 中国针灸, 2014, 34(8): 737-740.
33. Dennis MS, Lewis SC, Warlow C, et al. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet, 2005, 365(9461): 755-763.
34. Sørensen RT, Rasmussen RS, Overgaard K, et al. Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. J Neurosci Nurs, 2013, 45(3): 139-146.
35. Murray J, Scholten I. An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation. Gerodontology, 2018, 35(1): 18-24.
36. Wagner C, Marchina S, Deveau JA, et al. Risk of stroke-associated pneumonia and oral hygiene. Cerebrovasc Dis, 2016, 41(1/2): 35-39.
37. Ebihara T, Ebihara S, Yamazaki M, et al. Intensive stepwise method for oral intake using a combination of transient receptor potential stimulation and olfactory stimulation inhibits the incidence of pneumonia in dysphagic older adults. J Am Geriatr Soc, 2010, 58(1): 196-198.
38. Ahn YH, Sohn HJ, Park JS, et al. Effect of bihemispheric anodal transcranial direct current stimulation for dysphagia in chronic stroke patients: a randomized clinical trial. J Rehabil Med, 2017, 49(1): 30-35.
39. 中国卒中吞咽障碍与营养管理共识专家组, 中国卒中学会, 国家神经系统疾病临床医学研究中心, 等. 中国卒中吞咽障碍与营养管理手册. 中国卒中杂志, 2019, 14(11): 1153-1169.

West China Medical Journal

Interpretation of the European guideline for the diagnosis and treatment of post-stroke dysphagia (2021 Edition)

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