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

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

• Literatur

• 1 Prosiegel M, Bartolome G, Biniek R et al. Rehabilitation neurogener Dysphagien. In: Diener HC. Leitlinien für Diagnostik und Therapie in der Neurologie. Thieme; 2008. www. dgn.org
• 2 Ickenstein GW, Kelly PJ, Furie KL et al. Predictors of feeding gastrostomy tube removal in stroke patients with dysphagia. J Stroke & Cerebrovas Dis 2003; 12 (04) 169-174
• 3 Doty R, Bosma JR. An electromyografic analysis of reflex deglutition. J Neurophysiol 1965; 19: 44-60
• 4 Martin R, Goodyear BG, Gati JS et al. Cerebral cortical representation of automatic and volitional swallowing in humans. J Neurophysiol 2000; 85: 938-950
• 5 Mosier K, Patel R, Liu W-C et al. Cortical representation of swallowing in normal adults: functional implications. Laryngoscope 1991; 109: 1417-1423
• 6 Mu L, Sander I. Sensory nerve supply of the human oro- and laryngopharynx: a preliminary study. Anat Rec 2000; 258: 406-420
• 7 Pedersen AM, Bardow A, Jensen SB et al. Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion. Oral Dis 2002; 8: 1117-1129
• 8 Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344: 665-671
• 9 Kikuchi R, Watabe N, Konno T et al. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med 1994; 150: 251-253
• 10 Loeb M, McGeer A, McArthur M et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of longterm care facilities. Arch Intern Med 1999; 159: 2058-2064
• 11 Perry L. Screening swallowing function of patients with acute stroke. Part one: Identifications, implementation and initial evaluation of screening tool for use by nurses. J Clin Nurs 2001; 10 (04) 463 -473
• 12 Nakagawa T, Sekizawa K, Arai H et al. High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med 1997; 157: 321-324
• 13 Mann G, Hankey G, Cameron D. Swallowing disorder following acute stroke: prevalence and diagnastic accurancy. Cerebrovasc Dis 2000; 10: 380-386
• 14 Medizinischer Dienst der Spitzenverbände der Krankenkassen e. V. Projektgruppe P39: Grundsatzstellungnahme Ernährung und Flüssigkeitsversorgung: Älterer Menschen Juli 2003
• 15 Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin . der Deutschen Gesellschaft für Geriatrie und der Deutschen Gesellschaft für Neurologie: Enterale Ernährung bei Patienten mit Schlaganfall. Aktuel Ernähr Med 2007; 29: 198-225
• 16 Phillips PA, Bretherton M, Johnston CI et al. Reduced osmotic thirst in healthy elderly men. Am J Physiol 1991; 261: 166-171
• 17 Ickenstein GW, Hofmayer A, Lindner-Pfleghar B et al. Standardisation of diagnostic and therapeutic procedures for neurogenic oropharyngeal dysphagia (NOD). Neurol & Rehabil 2009; 15 (05) 290-300
• 18 Ickenstein GW, Hofmayer A, Lindner-Pfleghar B et al. Manual for the NOD step-wise concept – Standardisation of diagnostic and therapeutic procedures for neurogenic oropharyngeal dysphagia (NOD). Neurol & Rehabil 2009; 15 (06) 342-354
• 19 Hinchey JA, Shephard T, Furie K et al. Stroke Practise Improvement Network Investigators. Formal dysphagia screening protocols prevent pneumonia. Stroke 2005; 36 (09) 1972-1976
• 20 Middleton S, McElduff P, Ward J et al. QASC Trialists Group. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378 (9804) 1699-1706
• 21 Ickenstein GW, Riecker A, Höhlig C et al. Pneumonia and in-hospital mortality in the context of neurogenic oropharyngeal dyspahgia (NOD) in stroke and a new NOD step-wise concept. J Neurology 2010; 257: 1492-1501
• 22 De Pippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Archives of Neurology 1992; 49 (12) 1259-1261
• 23 Daniels SK, McAdam CP. Clinical Assessment of Swallowing and Prediction of Dysphagia Serverity. American Journal of Speech-Language. Pathology 1997; 6: 17-23
• 24 Suiter DM, Leder SB. Clinical Utility of the 3-ounce Water Swallow Test. Dysphagia 2008; 23: 244-250
• 25 Ickenstein GW, Stein J, Ambrosi D et al. Predictors of survival after severe dysphagic stroke. J Neurol 2005; 252: 1510 -1516
• 26 National Outcomes Measurement System (NOMS) . ASHA 1998–2008. Rockville, Maryland:
• 27 Prosiegel M, Heintze M, Wagner-Sonntag E et al. Schluckstörungen bei neurologischen Patienten: Eine prospektive Studie zu Diagnostik, Störungsmustern, Therapie und Outcome. Nervenarzt 2002; 73: 364-370
• 28 Ekberg O, Nylander G. Cineradiography of the pharyngeal stage of deglutition in 150 individuals without dysphagia. Br J Radiol 1982; 55: 253-257
• 29 Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia 1988; 2: 216-219
• 30 Schmidt J, Holas M, Halvorson K et al. Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration. Dysphagia 1994; 9: 7-11
• 31 Warnecke T, Teismann I, Oelenberg S et al. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke 2009; 40: 482-486
• 32 Colodny N. Interjudge and intrajudge Reliabilities in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Using the Penetration-Aspiration Scale: A Replication Study. Dyphagia 2002; 17: 308-315
• 33 Murray J, Langmore SE, Ginsberg S et al. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 1996; 11: 99-103
• 34 Rosenbek JC, Robbins JA, Roecker EB et al. A penetration-aspiration scale. Dysphagia 1996; 11: 93-98
• 35 Dziewas R, Warnecke T, Ölenberg S et al. Towards a basic endoscopic assessment of swallowing in acute stroke – development and evaluation of a simple dysphagia score. Cerebrovasc Dis 2008; 26: 41-47
• 36 Ickenstein GW, Höhlig C, Prosiegel M et al. Prediction of outcome in neurogenic dysphagia within 72 h of acute stroke. J Stroke Cerebrovasc Dis 2011; PMID 21683618
• 37 Ickenstein GW, Goldstein R, Stein J et al. Neuronal regeneration after acute stroke with neurogenic oropharyngeal dysphagia (NOD): a Kaplan-Meier survival analysis. Neurol Rehabil 2005; 11 (05) 270-278
• 38 Scottish Intercollegiate Guidelines Network Guideline SIGN 78 Management of Patients with Stroke: Identification and Management of Dysphagia Update 2010
• 39 Ramsey DJ, Smithard DG, Karla L. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke 2003; 34 (05) 1252-1257
• 40 Flowers HL, Skoretz SA, Streiner DL et al. MRI-Based Neuroanatomical Predictors of Dysphagia after Acute Ischemic Stroke. A Systematic Review and Meta-Analysis Cerebrovasc Dis 2011; 32 (01) 1-10
• 41 Linfante I, Llinas R, Schlaug G et al. Diffusion-weighted imaging and National Institutes of Health Stroke Scale in the acute phase of posterior-circulation stroke. Arch Neurol 2001; 58: 621-628
• 42 Takahata H, Tsutsumi K, Baba H et al. Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study. BMC Neurol 2011; 19: 11-16
• 43 Prosiegel M, Aigner F, Diesener P et al. Qualitätskriterien und Standards für die Diagnostik und Therapie von Patienten mit neurologischen Schluck störungen Neurogene Dysphagien – DGNKN Leitlinien 2011 http://www.dgnkn.de/dokumente/dgnkn_leitline_neurologische_schluckstoerung.pdf
• 44 Leder SB, Espinosa JF. Aspiration risk after stroke; comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia 2000; 17: 214-218
• 45 Dziewas R, Schilling M, Konrad C et al. Placing nasogastric tubes in stroke patients with dysphagia: efficiency and tolerability of the reflex placement. J Neurol Neurosurg Psychiatry 2003; 74: 1429-1431
• 46 Prosiegel M, Weber S. Instrumentelle Diagnostik. Springer; 2010: 111-116
• 47 Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5: 31-37
• 48 Frommelt P, Lösslein H. NeuroRehabilitation: Ein Praxisbuch für interdisziplinäre Teams. 2010. Springer Verlag; Berlin-Heidelberg: 3.Auflage
• 49 Kuhlemeier KV, Palmer JB, Rosenberg D. Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients. Dysphagia 2001; 16 (02) 119-122
• 50 Quagliarello V, Ginter S, Han L et al. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis 2005; 40: 1 -6
• 51 Metlay JP, Schulz R, Li YH et al. Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 1997; 157: 1453-1459
• 52 Young M, Marrie TJ. Interobserver variability in the interpretation of chest roentgenograms of patients with possible pneumonia. Arch Intern Med 1994; 154: 2729-2732
• 53 Mac Intosh Cc, Morley JE, Chapman IM. The anorexia of aging. Nutrition 2000; 16: 983-995
• 54 Morley JE. Anorexia of aging: physiologic and pathologic. Am J Clin Nutri 1997; 66: 760-773
• 55 Kondrup SP, Allison M, Elia B et al. ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition. 2003 22. 415-421
• 56 Ekberg O, Hamdy S, Woisard V et al. Social and psychological burden of dysphagia its impact on diagnosis and treatment. Dysphagia 2002; 17: 139-146
• 57 Chollet F, Tardy J, Albucher JF et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol 2011; 10 (02) 123-130
• 58 Mikami K, Jorge RE, Adams Jr HP et al. Effect of antidepressants on the course of disability following stroke. Am J Geriatr Psychiatry 2011; 19 (12) 1007-1015