Smithard, David Graeme; (1998) Prospective study of swallowing disorders, chest infection, fluid balance and outcome in unselected patients with acute stroke. Doctoral thesis (Ph.D.), University College London (United Kingdom).

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Abstract

Published data suggests that the bedside assessment of swallowing has limited usefulness. There is a paucity of information on the natural history of dysphagia following stroke and the relationship of dysphagia to outcome. This thesis examines the above areas. One hundred and twenty one consecutive acute stroke patients have been prospectively studied. Their swallowing was assessed, using standardised proformas, by both a doctor and a speech and language therapist, nutritional status was also documented (anthropometric and haematological parameters). Assessments were repeated at 7, 28 and 180 days. Where feasible a videofluoroscopy was conducted within 3 days of admission and at day 28. A CT scan was also performed. Outcome measures were the presence of chest infection, mortality, length of stay, disability and institutionalisation. On admission, 31% (32/104) of those assessed by the speech and language therapist, and 50% (61/121) by the doctor had dysphagia, 21% (20/94) were aspirating on videofluoroscopy. Detailed assessment by the speech and language therapist gave a sensitivity of 47%, specificity of 86%, positive predictive value of 50% and a negative predictive value of 85% for aspiration. Multiple logistic regression analysis identified a weak voluntary cough, coughing on 5 mis of water and any alteration of conscious level as the best predictors of aspiration. Patients with dysphagia had a higher incidence of chest infection (p[less-than]0.01), poor nutritional state (p=0.038), mortality (p=0.022), disability (p=0.02), length of stay (p[less-than] 0.001), and institutionalisation (p[less-than]0.05). Dysphagia, but not aspiration, was an independent predictor for mortality and chest infection. Dysphagia was still present in 27% (28/110) at day 7 and 11% (8/73) at six months, 3% (2/73) had developed dysphagia. Twelve patients were aspirating on videofluoroscopy at day 28. In conclusion, dysphagia is common following stroke, may be transient, persist or develop at a later date. The poor reliability of the bedside assessment is confirmed. Dysphagia at the time of stroke is associated with a worse outcome, but the routine use of videofluoroscopy is questioned.

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