Interventions for dysphagia in acute stroke

Bath PMW, Bath-Hextall FJ, Smithard D

Published Online:

January 21, 2009

Difficulties in swallowing occur in up to half of people experiencing a non-fatal stroke. Although some spontaneously recover this function in the first two weeks, many continue to have problems that interfere with physical function, nutrition, recovery and quality of life. Because of the inability to swallow safely, fluid can also get into the airways causing chest infections and pneumonia. People can be fed through a tube, inserted either up the nose and into the stomach (nasogastric tube) or through the skin of the abdomen into the stomach (percutaneous endoscopic gastrostomy). Nasogastric tubes are easy to insert but many people find them uncomfortable and pull them out. Two controlled trials (49 patients) looked at the effectiveness of the two types of feeding tubes. The tube through the abdomen was associated with fewer deaths and treatment failures. This tube does require an operation and may be associated with chest infections and infection around the insertion site but does not irritate the patient. From two trials (85 patients), formal swallowing therapy did not significantly reduce dysphagia compared with standard treatment and in 17 patients the drug nifedipine was ineffective.

Abstract (click to read)

Background:

It is unclear how dysphagic patients should be fed and treated after acute stroke.

Objectives:

To assess the effect of different management strategies for dysphagic stroke patients, in particular how and when to feed, whether to supplement nutritional intake, and how and whether to treat dysphagia.

Search strategy:

We searched the Cochrane Stroke Group trials register, MEDLINE, EMBASE, ISI, and existing review articles. We contacted researchers in the field and equipment manufacturers. Date of the most recent searches: March 1999.

Selection criteria:

Unconfounded truly or quasi randomised controlled trials in dysphagic patients with acute/subacute (within three months) stroke.

Data collection and analysis:

Three reviewers independently applied the trial inclusion criteria. Two reviewers assessed trial quality and extracted the data.

Main results:

Percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) feeding: two trials (49 patients) suggest that PEG reduces end-of-trial case fatality (Peto odds ratio (OR) 0.28, 95% confidence interval (CI) 0.09 to 0.89) and treatment failures (OR 0.10, 95% CI 0.02 to 0.52), and improves nutritional status, assessed as weight (weighted mean difference (WMD) +4.1 kg, 95% CI -4.3 to +12.5), mid-arm circumference (WMD +2.2 cm, 95% CI -0.5 to +4.9) or serum albumin (WMD +7.0 g/l, 95% CI +4.9 to +9.1) as compared with NGT feeding; two larger studies are ongoing. Timing of feeding: no completed trials; one large study is ongoing. Swallowing therapy for dysphagia: two trials (85 patients) suggest that formal swallowing therapy does not significantly reduce end-of-trial dysphagia rates (OR 0.55, 95% CI 0.18 to 1.66). Drug therapy for dysphagia: one trial (17 patients); nifedipine did not alter end-of-trial case fatality or the frequency of dysphagia. Nutritional supplementation: one trial (42 patients) found a non-significant trend to a lower case fatality, and significantly increased energy and protein intake; one large trial is ongoing and data is awaited from two other studies. Fluid supplementation: one trial (20 patients) found that supplementation did not alter the time to resolution of dysphagia.

Authors' conclusions:

Too few studies have been performed, and these have involved too few patients. PEG feeding may improve outcome and nutrition as compared with NGT feeding. Further research is required to assess how and when patients are fed, and the effect of swallowing or drug therapy on dysphagia.

This record should be cited as:

Bath PMW, Bath-Hextall FJ, Smithard D. Interventions for dysphagia in acute stroke. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000323. DOI: 10.1002/14651858.CD000323

Assessed as up to date:

June 15, 1999

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Primary Review Group:

Stroke Group

Health topics:

Heart & circulation > Stroke > Prevention & treatment of complications

Neurology > Stroke > Prevention & treatment of complications

Gastroenterology > Dysphagia

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Interventions for dysphagia in acute stroke

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