Interventions for dysphagia in acute stroke

 

Abstract

Background

It is unclear how dysphagic patients should be fed and treated after acute stroke.

Objectives

To assess the effect of different management strategies for dysphagic stroke patients, in particular how and when to feed, whether to supplement nutritional intake, and how and whether to treat dysphagia.

Search methods

We searched the Cochrane Stroke Group trials register, MEDLINE, EMBASE, ISI, and existing review articles. We contacted researchers in the field and equipment manufacturers. Date of the most recent searches: March 1999.

Selection criteria

Unconfounded truly or quasi randomised controlled trials in dysphagic patients with acute/subacute (within three months) stroke.

Data collection and analysis

Three reviewers independently applied the trial inclusion criteria. Two reviewers assessed trial quality and extracted the data.

Main results

Percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) feeding: two trials (49 patients) suggest that PEG reduces end-of-trial case fatality (Peto odds ratio (OR) 0.28, 95% confidence interval (CI) 0.09 to 0.89) and treatment failures (OR 0.10, 95% CI 0.02 to 0.52), and improves nutritional status, assessed as weight (weighted mean difference (WMD) +4.1 kg, 95% CI -4.3 to +12.5), mid-arm circumference (WMD +2.2 cm, 95% CI -0.5 to +4.9) or serum albumin (WMD +7.0 g/l, 95% CI +4.9 to +9.1) as compared with NGT feeding; two larger studies are ongoing. Timing of feeding: no completed trials; one large study is ongoing. Swallowing therapy for dysphagia: two trials (85 patients) suggest that formal swallowing therapy does not significantly reduce end-of-trial dysphagia rates (OR 0.55, 95% CI 0.18 to 1.66). Drug therapy for dysphagia: one trial (17 patients); nifedipine did not alter end-of-trial case fatality or the frequency of dysphagia. Nutritional supplementation: one trial (42 patients) found a non-significant trend to a lower case fatality, and significantly increased energy and protein intake; one large trial is ongoing and data is awaited from two other studies. Fluid supplementation: one trial (20 patients) found that supplementation did not alter the time to resolution of dysphagia.

Authors' conclusions

Too few studies have been performed, and these have involved too few patients. PEG feeding may improve outcome and nutrition as compared with NGT feeding. Further research is required to assess how and when patients are fed, and the effect of swallowing or drug therapy on dysphagia.

 

Plain language summary

Interventions for dysphagia in acute stroke

Difficulties in swallowing occur in up to half of people experiencing a non-fatal stroke. Although some spontaneously recover this function in the first two weeks, many continue to have problems that interfere with physical function, nutrition, recovery and quality of life. Because of the inability to swallow safely, fluid can also get into the airways causing chest infections and pneumonia. People can be fed through a tube, inserted either up the nose and into the stomach (nasogastric tube) or through the skin of the abdomen into the stomach (percutaneous endoscopic gastrostomy). Nasogastric tubes are easy to insert but many people find them uncomfortable and pull them out. Two controlled trials (49 patients) looked at the effectiveness of the two types of feeding tubes. The tube through the abdomen was associated with fewer deaths and treatment failures. This tube does require an operation and may be associated with chest infections and infection around the insertion site but does not irritate the patient. From two trials (85 patients), formal swallowing therapy did not significantly reduce dysphagia compared with standard treatment and in 17 patients the drug nifedipine was ineffective.

 

摘要

背景

急性中風期吞嚥困難的處理

急性中風期吞嚥困難的病人該如何餵食和治療,目前並不清楚

目標

這篇回顧的目標在於評估不同處理方法對於中風後吞嚥困難病人的效果,特別是該如何及何時餵食,是否加入營養品補充及如何及是否去治療吞嚥困難

搜尋策略

我們搜尋了Cochrane Stroke Group trials register, Medline, Embase, ISI,及現有的回顧性文章. 也聯絡了這方面領域的研究者及設備製造者. 目前最近期的搜尋是在1999年3月.

選擇標準

臨床試驗為急性及亞急性(3個月內)中風且有吞嚥困難者,且研究為無受干擾,真正的試驗或是接近真正的隨機對照性試驗.

資料收集與分析

3位回顧者獨立地使用試驗收錄標準來選取試驗.2位回顧者評估試驗品質及摘錄數據

主要結論

經皮內視鏡胃造口術比上鼻胃管灌食:2個包含49人的試驗顯示,經皮內視鏡胃造口術降低了試驗終了致死率(Peto Odds Ratio, OR 0.28, 95% CI 0.09 to 0.89)和治療失敗率(OR 0.10, 95% CI 0.02 to 0.52),也改善了以體重(加權平均數,+4.1 kg, 95% CI −4.3 to +12.5),和上臂中點環圍(加權平均數,+2.2 cm, 95% CI −0.5 to +4.9)或是血中白蛋白值(加權平均數,+ 7.0 g/l, 95% CI +4.9 to +9.1)來評估的營養狀況,且有2個大型試驗是正在進行. 灌食的時機:並無已完成的試驗,但有1個大型試驗是正在進行. 吞嚥訓練治療:2個包含85人的試驗顯示正規的吞嚥訓練無法有效降低試驗終了吞嚥困難率(OR 0.55, 95% CI 0.18 to 1.66). 藥物治療:1個包含17人的試驗顯示nifedipine無法改善試驗終了致死率或吞嚥困難的頻率. 營養補充:1個包含42人的試驗顯示有非有意義地降低死亡率的趨勢和有意義地增加能量和蛋白質的攝取;有1個試驗是正在進行,且有其他2個試驗正在整理數據中. 液體補充:1個包含20人的試驗顯示無法改變吞嚥困難恢復的時間.

作者結論

研究數目太少且收錄的病人數也不足. 相較於鼻胃管灌食,經皮內視鏡胃造口術灌食可能可以改善結果和營養狀況. 之後的研究希望能進一步評估如何及何時要灌食,及吞嚥訓練和藥物治療的效果.

翻譯人

本摘要由奇美醫院何乘彰翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

針對中風後病人的吞嚥困難治療和餵食方法:在非致死性中風後有約一半的病人會發生吞嚥困難. 部份病人在前兩星期會自動地改善,但很多人會持續並影響身體功能,營養,復原和生活品質. 因為無法安全地吞入,液體會嗆入氣管並造成肺部感染和肺炎. 病人通常會被置入鼻胃管或是經皮內視鏡胃造口術來餵食. 鼻胃管放置容易但很多人覺得不舒服而把它拔掉.2個包含49人的對照試驗比較這2種餵食管的功效. 經腹部的餵食管有較少的死亡和治療失敗但需要手術並可能會引發肺部感染和植入處的感染,但不會刺激病人. 從2個共85人的試驗,正規的吞嚥訓練和標準治療相比,並不能在統計學上有意義地減少吞嚥困難,而17個使用nifedipine的病人顯示無效.