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Swallowing screening in acute stroke : an analysis of the clinical predictor of dysphagia

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Mariana Mendes Bahia
Total Authors: 1
Document type: Master's Dissertation
Institution: Universidade Estadual de Campinas (UNICAMP). Faculdade de Ciências Médicas
Defense date:
Examining board members:
Fernando Cendes; Regina Yu Shon Chun; Roberto Oliveira Dantas
Advisor: Li Li Min

Stroke is a leading cause of mortality and disability in Brazil, and dysphagia is one of the most important sequels. Dysphagia is associated with clinical complications, such as pneumonia, malnutrition, and dehydration. Screening is the most popular and valid tool to quickly evaluate dysphagia in acute stroke. Furthermore, reliable clinical predictors improve patients` management, and allows preventive measures. The aims of this study are to identify the presence of oropharyngeal dysphagia in acute stroke, to determine dysphagia frequency and its relationship with stroke severity, and to determine the clinical predictors of oropharyngeal dysphagia in acute stroke from a proposed 2-step dysphagia screen. This is a transversal and quantative study, approved by the Ethical Committee of the University, which involves swallowing evaluation up to 72 hours after the onset of the stroke symptoms. We included consecutive inpatients admitted to the Emergency Unit of a public tertiary hospital in Brazil between April 2012 and August 2013 with diagnosis of first stroke. The diagnosis of stroke was determined by a neurologist and confirmed by CT and/or MRI. Exclusion criteria comprise patients with stroke over to 72 hours, previous stroke, history of other neurologic or psychiatric diseases, previous dysphagia, orotracheal intubation, coma or with decreased level of consciousness. Data were gathered from socio-demographic factors, clinic history, risk factors, stroke data, neurological severity (NIHSS), screening tool, fiberoptic endoscopic evaluation of swallowing, dysphagia severity, and functional oral intake scale. The swallowing screening test was developed for this research and included 2-steps. The first one involves cognitive, speech/language, and structural variables, whereas the second step considers observation during swallowing of pudding, water, and a piece of cookie, sequentially. A binary scoring was used to classify the screening items, and, after that, based on the screening results, patients were categorized into two groups: dysphagic and non-dysphagic. A hundred patients were screened, 53 were male, mean age 64 years old (SD=15), and 87 presented ischemic stroke. Fifty-six patients presented dysphagia. Dysphagia was more frequent in patients with higher age and NIHSS score. Findings showed correlation between stroke severity and dysphagia. The 6 best simple predictors of the presence of dysphagia were tongue, lips and cheeks movement and strength impaired, NIHSS?7, dysarthria, and disorientation. The combination of variables age, NIHSS, dysarthria, lips not sealed, and disorientation was associated with dysphagia in the multivariable analysis. The sensitivity and specificity of the screening were both 84%. The study confirms the high frequency of oropharyngeal dysphagia in acute stroke. The identification of the clinical predictors is important for specific therapies and management strategies, and, consequently, for decreasing morbidity and mortality rates, and preventing pulmonary complications. The screening demonstrated a good balance between psychometric parameters (AU)