European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

TLDR

Post‑stroke dysphagia affects more than half of acute stroke patients and raises the risk of aspiration pneumonia, malnutrition, dehydration, and worsens outcomes and mortality. This guideline is intended to help the multidisciplinary team manage patients with post‑stroke dysphagia. The recommendations were derived from an ESO‑standard operating procedure, using the GRADE framework, systematic reviews and meta‑analyses of 20 key questions, and expert opinion where evidence was lacking. Moderate‑quality evidence supports screening all stroke patients for dysphagia to reduce pneumonia and early death, while low‑quality evidence suggests assessment for those at risk; low‑to‑moderate evidence indicates that dietary changes, behavioural swallowing therapy (including acupuncture), nutritional support, oral care, pharmacological agents, and neurostimulation can improve swallowing function and safety, with some also affecting feeding status or pneumonia.

Abstract

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.