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Klinische Neurophysiologie 2012; 43(03): 188-195
DOI: 10.1055/s-0032-1309037
Originalia
© Georg Thieme Verlag KG Stuttgart · New York

Neurogene Dysphagie im Rahmen der Neurologischen Komplexbehandlung und strukturelle Komponenten eines Dysphagieprogrammes

Neurogenic Dysphagia in Comprehensive Stroke Unit Care and Structural Components for a Dysphagia Program
G. W. Ickenstein
1   Klinik für Neurologie & Stroke Unit, HELIOS Klinikum Aue, Technische Universität Dresden, Aue
,
S. Isenmann
2   Klinik für Neurologie und klinische Neurophysiologie, HELIOS Klinikum Wuppertal der Universität Witten-Herdecke, Wuppertal
,
F. Ende
1   Klinik für Neurologie & Stroke Unit, HELIOS Klinikum Aue, Technische Universität Dresden, Aue
,
R. Müller
3   Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden
,
U. Bodechtel
4   Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden
,
H. Reichmann
4   Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden
,
A. Meisel
5   Klinik für Neurologie, Centrum für Schlaganfallforschung, Charité Universitätsmedizin Berlin, Berlin
› Author Affiliations
Further Information

Publication History

Publication Date:
10 May 2012 (online)

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Zusammenfassung

Einführung:

Im Rahmen der neurologischen Komplexbehandlung auf der Stroke Unit ist das Management der neurogenen Dysphagie ein wesentlicher Bestandteil, um Komplikationen wie Mangelernährung und Pneumonie zu vermeiden. Ein Dysphagiekonzept zur Untersuchung der neurogenen oropharyngealen Dysphagie (NOD) bei Schlaganfallpatienten sollte etabliert sein. Es wird im Rahmen der Stroke Unit Zertifizierung vom Stroke Unit Team, bestehend aus Pflegekräften, Diätassistenten, Schlucktherapeuten bzw. Ärzten gefordert.

Methodik:

Bezüglich des Schluckscreening durch das Pflegepersonal und Schlucktherapeuten wird ein modifiziertes Schluck-Assessment (MSA) für Schlaganfallpatienten sowie eine standardisierte klinische Schluckuntersuchung (KSU) empfohlen. Die klinische Untersuchung sollte durch eine apparative Diagnostik unterstützt werden wie z. B. die Schluckendoskopie und/oder die Videofluoroskopie.

Ergebnisse:

In Untersuchungen an schwer dysphagischen Schlaganfallpatienten konnte gezeigt werden, dass für die Prädiktion des Outcomes vor allem das Alter des Patienten, die neuroanatomischen Schädigungsmuster sowie die Score-Werte der klinischen sowie apparativen Schluckuntersuchung ausschlaggebend sind. Bezüglich des Outcomes zeigten sich insbesondere die Graduierungsparameter des Funktionellen Kommunikationsindex (FCM) sowie der Penetrations-Aspirations-Skala (PAS) im Rahmen einer multivariaten Analyse mit dem Endpunkt Sondenpflichtigkeit am Ende der Neurorehabilitation (FCM 1–3 am Tag 90) mit einer AUC von 73% als valide. In einer longitudinalen Untersuchung zur Einführung eines Dysphagieprogramms auf einer zertifizierten Stroke Unit, zeigte sich eine signifikant erniedrigte Pneumonierate und Krankenhausmortalität.

Diskussion:

Die Erfassung von Penetration und Aspiration ist neben weiteren Auffälligkeiten wie Leaking und Retentionen eines der wesentlichen Kriterien für die Erfassung des Dysphagiegrades mit anschließendem pathophysiologisch-orientiertem Vorgehen zur funktionellen, schlucktherapeutischen Behandlung einschließlich der Indikationsstellung eines invasiven Vorgehens (PEG-Anlage) bzw. einer enteralen Sondenernährung und/oder Tracheotomie. Ein standardisiertes Dysphagiekonzept trägt dazu bei, Komplikationen wie Aspirationspneumonie und Mangelernährung zu vermeiden und eine bessere Prognoseeinschätzung des Outcome vorzunehmen.

Abstract

Introduction:

An important aim of the Stroke Unit concept is the standardisation of diagnostics in stroke patients in order to help the nursing staff, swallowing therapists, dieticians and doctors for an early identification of neurogenic oropharyngeal dysphagia (NOD). This enables the team to initiate appropriate therapeutic measures and to avoid complications such as aspiration pneumonia and malnutrition.

Methods:

With regard to the clinical assessment of swallowing by nursing staff and swallowing therapists a standardized swallowing assessment for dsyphagic patients and a standardized clinical swallowing examination (CSE) according to validated criteria is recommended. The clinical assessments should be followed by specific technical examinations like the swallowing endoscopy and/or videofluoroscopy.

Results:

Studies with severe dysphagic stroke patients show that age, neuroanatomical lesions and scoring parameters (clinical assessment and technical examination) are important to predict the outcome of patients. With regards to the grading of dysphagic stroke patients the functional communication measure swallowing (FCM) as well as the penetration-aspiration-scale (PAS) show in a multivariate analysis an AUC of 73% for the endpoint “tube-feeding at the end of neurorehabilitation (FCM 1–3 at day 90)”. In a longitudinal study for the implementation of a dyphagia programm in a certified stroke unit a reduced rate of pneumonia and in-hospital-mortality could be seen.

Discussion:

Establishing the degree of penetration and aspiration, as well as further symptoms such as leaking and retention is one of the essential criteria in the assessment of dysphagia with subsequent pathophysiologically-orientated procedures for the functional treatment of the swallowing disorder. This also includes the diagnostic procedures necessary to decide upon invasive treatment (PEG placement) and tube feeding and/or tracheotomy. A standardized dysphagia concept enables the team to avoid complications such as stroke-associated pneumonia (SAP) and lead to a better prediction of outcome with a longterm therapeutical concept.

Schlüsselwörter

neurogene Dysphagie - Schlaganfall - klinische Schluckuntersuchung - Schluckendoskopie

Key words

neurogenic dysphagia - stroke - clinical swallowing examination - swallowing endoscopy
 

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