Lien vers les tableaux de données probantes et la liste des références (en Anglais)
The use of a standardized program for bedside screening is now included in most clinical guidelines. Its implementation has long been thought to decrease the incidence of dysphagia-related pneumonia. Bedside screening may include components related to a patient’s level of consciousness, an evaluation of the patient’s oral motor function and oral sensation, as well as the presence of a cough. It may also include trials of small sips of water, whereby a “wet” or hoarse voice are suggestive of an abnormal swallow. A recent systematic review (Smith et al. 2018) included the results from 3 RCTs comparing dysphagia screening protocols or quality improvement interventions designed to improve screening rates versus no screening, alternative screening, usual care. The percentage of patients who received dysphagia screening and developed pneumonia was not significantly lower, compared with patients in a control group, in any of the trials. The authors highlight the lack of evidence from RCTs and state that “no conclusions can be drawn about the clinical effectiveness of dysphagia screening protocols.”
While texture-modified diets, the use of restorative swallowing therapy, and compensatory techniques, are the most commonly used treatments for the management of dysphagia in patients who are still safe to continue oral intake, there is little direct evidence of their benefit. The effectiveness of a variety of treatments for dysphagia and nutritional management was evaluated in a Cochrane review (Bath et al. 2018). Dysphagia treatments examined included acupuncture, behavioural interventions, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation. Overall, there was no reduction in the odds of death or disability or case fatality at the end of the trial associated with dysphagia therapies. While swallowing therapy significantly reduced the proportion of participants with dysphagia at the end of the trial, reduced the risk of chest infections or pneumonia, and was associated with a mean reduction in hospital length of stay or almost 3 days, the authors cautioned that further high-quality trials are required before clinical decisions can be made about what treatments are effective. Neuromuscular electrical stimulation using devices such as VitalStim have been shown to be an effective intervention for restoring swallowing function in trials including persons with stroke-associated dysphagia (Park et al. 2016, Terre & Mearin 2015). While this treatment is popular in the United States and other countries, it is not widely used in Canada. Carnaby-Mann & Crary et al. (2007) conducted a systematic review, which included the results from 7 studies of patients with oropharyngeal dysphagia secondary to stroke, cancer or other disease. A medium-sized treatment effect was reported for the outcome of change in swallowing score (SMD=0.66, 95% CI 0.47 to 0.85, p<0.001). Pharyngeal electrical stimulation is a novel new treatment that is not used routinely in clinical practice. While demonstrated to be safe, its effectiveness remains unproven (Bath et al. 2016).
For patients who cannot obtain nutrient and fluid needs orally, enteral nutrition may be required. Results from the largest trial of its kind indicates that there is little difference between routes of feeding when choosing between enteral feeding approaches. The FOOD trial (Dennis et al. 2005) also addressed the issues of timing of initiation of enteral feeding. The FOOD trial included 1,210 patients admitted within 7 days of stroke from 47 hospitals in 11 countries. In one arm of the trial, patients were randomized to receive either a percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) feeding tube within 3 days of enrolment into the study. PEG feeding was associated with a non-significant absolute increase in risk of death of 1.0% (–10.0 to 11.9, p=0.9) and a borderline increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05) at 6 months. In the second part of the trial patients were randomized to receive feeds as early as possible or to avoid feeding for 7 days. Early tube feeding was associated with non-significant absolute reductions in the risk of death or poor outcome (1.2%, 95% CI -4.2 to 6.6, p=0.7) and death (15.8%, 95% CI -0.8 to 12.5, p=0.09) at 6 months. A Cochrane review (Gomes et al. 2015) comparing NG and PED feeding tubes also reported few differences between feeding tube types. PEG tubes were associated with significantly reduced odds of treatment failures (blocked tubes or disruptions in feeding schedule), but there was no significant difference between groups in in mortality, aspiration-related pneumonia or adverse events.
Oral supplementation can be used for patients who are not able to consume sufficient energy and protein to maintain body weight, or for those with premorbid malnutrition. The results from the FOOD trial (Dennis et al. 2005) indicate that while routine supplementation with an additional 540 Kcal/day for all patients, regardless of premorbid nutritional status, does not help to improve global outcomes. In this trial, 4,023 patients were randomized to receive or not receive an oral nutritional supplement in addition to a regular hospital diet, provided for the duration of their entire hospital stay. At 6-month follow-up, there was no significant difference between groups on the primary outcome, death or poor outcome (OR=1.03, 95% CI 0.91 to 1.17, p>0.05). The FOOD trial results would be compatible with a 1% to 2% absolute benefit or harm from oral supplements. Oral supplementation was not associated with a reduction in the odds of case fatality, death or dependency, the need for institutionalization, or mean LOS in a Cochrane review (Geeganage et al. 2012). However, oral supplementation was associated with a reduction in the odds of pressure sores (OR=0.56, 95% CI 0.32 to 0.96, p=0.034) and an increase in daily mean energy and protein intake.