Stroke patients are at risk of dysphagia, a swallowing disorder that can lead to poor nutrition, pneumonia, and disability. Aspiration, where swallowed food enters the airway and lungs, is a common problem for people with dysphagia. Stroke patients are screened for their ability to swallow safely, and if they fail, they may not be allowed to eat until a speech-language pathologist evaluates their swallowing function. This is because there is a risk of silent aspiration, where the patient is not aware they are aspirating, and this can lead to aspiration pneumonia. Stroke units should have policies in place to manage dysphagia and reduce the occurrence of pneumonia and other complications associated with aspiration.
Characteristics | Values |
---|---|
Swallowing difficulties | Aspiration pneumonia, malnutrition, disability |
Aspiration | The incursion of food material into the airway and beyond the true vocal cords |
Silent aspiration | Occurs when the patient is not aware of swallowing difficulties |
Dysphagia | A swallowing disorder that affects 23-60% of stroke patients |
NPO | Nothing by mouth |
What You'll Learn
- NPO means 'nothing by mouth' and is used to prevent aspiration pneumonia
- Stroke patients may experience dysphagia, a swallowing disorder that can lead to poor nutrition, pneumonia and disability
- Aspiration is common in people with dysphagia and can occur without the person realising (silent aspiration)
- Swallowing assessments are used to determine a patient's ability to swallow safely and can be done at the bedside or via instrumental investigations
- Dysphagia management focuses on texture modification of food/liquids and swallowing manoeuvres
NPO means 'nothing by mouth' and is used to prevent aspiration pneumonia
NPO, or 'nil per os' in Latin, means 'nothing by mouth' and is a medical instruction to withhold food and fluids. It is used to prevent aspiration pneumonia, which is a major preventable complication, particularly in patients who have had a stroke.
A stroke can affect a person's ability to swallow food, liquids, and even their saliva safely. This is called dysphagia. If a patient has dysphagia, they are at risk of aspiration, which is when food, liquid, or saliva enters the lungs. This can cause aspiration pneumonia, a serious pulmonary complication.
A patient who has had a stroke may not be able to eat or drink until a swallow evaluation is completed. This is because they could choke on food or liquid without displaying outward signs of difficulty, like coughing or gagging. This is known as silent aspiration.
NPO is used to prevent aspiration pneumonia by ensuring that patients with dysphagia do not ingest anything that could enter their lungs. NPO is typically ordered for patients before surgery, and in cases of gastrointestinal bleeding, gastrointestinal blockage, or acute pancreatitis. It is also used for patients who have had a stroke, to prevent aspiration pneumonia.
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Stroke patients may experience dysphagia, a swallowing disorder that can lead to poor nutrition, pneumonia and disability
Dysphagia can also significantly impact a patient's quality of life, as it may cause anxiety and panic during mealtimes and can prevent patients from sharing meals with family and friends. It is important to identify and manage dysphagia to mitigate these risks and improve patient outcomes.
In hospital, stroke patients are screened to determine their ability to swallow safely. If a problem is identified, they may not be allowed to eat until a speech-language pathologist has evaluated their swallowing function. This may include an assessment of the muscles in the mouth and the voice box, as well as determining the best consistency of foods and liquids for the patient to swallow. Adequate nutrition is essential, and if it is not safe for the patient to swallow, a feeding tube may be suggested.
There are a number of therapeutic approaches to managing dysphagia, including compensatory strategies and rehabilitative approaches. Compensatory strategies aim to reduce the symptoms of dysphagia without altering the physiology, while rehabilitative approaches aim to improve swallowing physiology and safety. Some techniques can be used for both compensatory and rehabilitative purposes.
Some common precautions that may help stroke patients swallow more safely include:
- Sitting up straight when eating or drinking
- Modifying the texture of food, such as softening, chopping or pureeing
- Taking small bites and sips
- Clearing all food from the mouth before swallowing
- Avoiding distractions and focusing on eating
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Aspiration is common in people with dysphagia and can occur without the person realising (silent aspiration)
Stroke patients often experience dysphagia, a swallowing disorder that can lead to poor nutrition, pneumonia, and disability if not properly identified and managed. Aspiration is a common problem for people with dysphagia, where food or liquid enters the airway and lungs, causing serious health issues such as pneumonia. This can happen without the person realising, known as silent aspiration, and can occur in up to half of stroke patients with dysphagia.
Aspiration occurs when the normal swallowing process is disrupted, causing food or liquid to enter the trachea instead of the oesophagus. This can happen during the act of swallowing or when the contents come back up from the stomach. The epiglottis, a flap of tissue, usually blocks food and drink from entering the trachea. However, in people with dysphagia, this protective mechanism may be compromised, leading to a higher risk of aspiration.
The risk of aspiration is always present when a person has dysphagia. In addition to stroke, other conditions that can lead to dysphagia and aspiration include severe dental problems, Parkinson's disease, muscular dystrophies, and cancer in the throat or neck.
Silent aspiration can be challenging to detect, as there may be no overt symptoms. However, some signs and symptoms of aspiration to look out for include:
- Coughing during or after eating or drinking
- A wet or gurgly voice during or after eating or drinking
- Feeling something stuck in the throat or chest
- Difficulty starting a swallow
- Chest discomfort or heartburn
- Fever within 30 minutes to an hour after eating
- Congestion after eating or drinking
To diagnose aspiration, a speech-language pathologist (SLP) may assess the movement of muscles in the mouth and the function of the voice box. They may also evaluate the consistency of foods and liquids that the person can safely swallow. Additionally, tests such as the modified barium swallow test (MBS), fiber-optic endoscopic evaluation of swallowing (FEES), and pharyngeal manometry can help identify aspiration, especially in cases of silent aspiration.
The treatment for aspiration focuses on managing the symptoms of dysphagia and treating its underlying causes. This may include modifying the diet, such as thickening liquids or adjusting food textures, changing body positioning during eating, and performing exercises to strengthen the lips and tongue. In some cases, a feeding tube may be necessary to ensure adequate nutrition and prevent aspiration.
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Swallowing assessments are used to determine a patient's ability to swallow safely and can be done at the bedside or via instrumental investigations
A stroke can affect a person's ability to swallow food, liquids, and even their saliva safely. This is known as dysphagia. If not identified and managed, dysphagia can lead to poor nutrition, pneumonia, and disability.
To prevent these complications, a stroke patient is often placed on NPO status (nothing by mouth) until a swallow evaluation can be completed. This evaluation can be done at the bedside or via instrumental investigations.
Bedside Swallowing Assessments
Bedside swallowing assessments are typically performed by nurses, clinicians, or speech and language therapists. During these assessments, small volumes of food or water are presented to the patient, and the clinician watches for signs of dysphagia and aspiration. These signs can include:
- Loss of liquid from the mouth
- Dyspraxia or poor coordination of muscles
- Facial weakness
- Delayed pharyngeal/laryngeal elevation
- Coughing or throat clearing
- Breathlessness
- Changes in voice quality after swallowing
Instrumental Investigations
Instrumental investigations provide more detailed information on the causes of dysphagia and can include:
- Videofluoroscopic Swallowing Study (VFSS): This test uses a radio-opaque barium liquid to capture moving images of the swallowing process. It allows for the visualisation and quantification of barium through the oral cavity, pharynx, and oesophagus. However, it requires specialised equipment and exposes the patient to low doses of radiation.
- Fibreoptic Endoscopic Evaluation of Swallowing (FEES): This test involves inserting a nasendoscope down to the level of the uvula or soft palate to visualise the hypopharynx and larynx. It can be performed at the bedside with normal meals and does not require radiation. However, it requires skilled operators and specialised equipment, and it does not provide information on the oral phase of swallowing.
- Other assessments: These can include pulse oximetry during swallowing, scintigraphy, ultrasound, and impedance tomography.
Benefits of Combined Approach
Combining bedside assessments with instrumental investigations can provide a more comprehensive evaluation of a patient's swallowing ability. This can help to identify dysphagia early and develop a tailored treatment plan to accelerate organ-specific rehabilitation.
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Dysphagia management focuses on texture modification of food/liquids and swallowing manoeuvres
Texture Modification of Food/Liquids
Texture modification of food and liquids is a common form of intervention for dysphagia. It is important for promoting safe and efficient swallowing and ensuring adequate nutrition. Texture modification can involve changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods.
The International Dysphagia Diet Standardisation Initiative (IDDSI) has developed a standardised framework for labelling texture-modified foods and thickened liquids. This framework consists of a continuum of eight levels, with puréed food at level 4 and liquids at level 3.
Swallowing Manoeuvres
Swallowing manoeuvres can also aid in safe swallowing for individuals with dysphagia. These include:
- Sit up straight when eating or drinking.
- Take small bites and sips.
- Clear all food from your mouth.
- Avoid distractions to focus on eating.
- Use positioning techniques and manoeuvres to redirect the movement of the food.
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Frequently asked questions
NPO stands for "nothing by mouth", meaning the patient is not allowed to eat or drink.
Stroke patients are at risk of dysphagia, a swallowing disorder that can lead to aspiration pneumonia. NPO is a precautionary measure to prevent aspiration until a swallow evaluation can be completed.
Dysphagia is a common complication of stroke, affecting the patient's ability to swallow food and liquids safely. It can lead to poor nutrition, pneumonia, and disability.
The patient is put on an intravenous infusion of saline for hydration until their ability to swallow safely can be evaluated by a speech-language pathologist or a similarly trained professional.