Tolerance of Early Diet Textures as Indicators of Recovery from Dysphagia After Stroke

Abstract

We undertook this 12-month retrospective cohort study, of 186 teaching hospital inpatients, to determine how tolerance of differing diet textures after a stroke predicts recovery from dysphagia. Outcome measures were insertion of a percutaneous endoscopic gastrostomy (PEG) tube and/or ability to tolerate a normal diet 28 days after the stroke. Likelihood ratios for needing a PEG were highest for intolerance of pureed food. People who tolerated grade 1 fluids (300-600 cP) or thinner, or who tolerated a modified soft diet or better, 7 days after the stroke did not need a PEG. Half (13/26) the people who could not tolerate grade 3 thickened fluids (10,000-12,000 cP) and 52% (13/25) of people who could not tolerate a puree diet 14 days after the stroke needed a PEG. No one who was intolerant of grade 2 thickened fluids (4000-7000 cP) 7 or 14 days after the stroke could tolerate a normal diet and fluids by day 28. If people were tolerating grade 3 thickened fluids at day 7, the proportion tolerating a normal diet at day 28 was 36%. We present similar data for tolerance of differing fluids and diets at each of the measured time points. We suggest a PEG should be considered in people unable to tolerate grade 3 thickened fluids or a puree diet 14 days after their stroke. However, even in these groups, half will recover sufficiently to manage oral feeding.

Findings of Videofluoroscopic Swallowing Studies AreAssociated with Tube Feeding Dependency at Discharge in StrokePatients with Dysphagia

“…A previous study encountered similar difficulty in predicting tube feeding dependency [18]. Among patients unable to tolerate grade 3 thickened fluids or a puree diet 14 days after their stroke, half recovered sufficiently to manage oral feeding [18]. According to BayesÕ theorem, this relatively low positive predictive value can be attributed to the low prevalence of tube feeding dependency in the study population [29].…”

“…Until further data demonstrate the utility of such an equation, clinicians should be more concerned with the presence or absence of the individual factors of the equation than the equation itself. A previous study encountered similar difficulty in predicting tube feeding dependency [18]. Among patients unable to tolerate grade 3 thickened fluids or a puree diet 14 days after their stroke, half recovered sufficiently to manage oral feeding [18].…”

“…Wojner et al [17] reported that the clinical indicators, including wet voice after swallowing water, hypoglossal nerve dysfunction, high National Institutes of Health Stroke Scale score, and incomplete oral labial closure, were independently associated with tube feeding dependency in acute stroke patients. Wilkinson et al [18] found that intolerance to grade 3 fluid (with thickness equivalent to instant pudding) at day 7 poststroke, or to puree at days 7 or 21, predicted percutaneous endoscopic gastrostomy (PEG) insertion one year after stroke [18]. Notably, previously reported prognostic indicators were all based on clinical findings and bedside swallowing assessments.…”

Functional Dysphagia Therapy and PEG Treatment in a Clinical Geriatric Setting

“…A retrospective cohort study [32] showed that the ability to tolerate oral intake early after stroke is an indicator of improvement of dysphagia. Patients who tolerated thickened liquids and pureed foods 14 days post onset could be fed orally in the course of treatment with a 50% probability.…”

When to PEG?

“…The article by Wilkinson et al in this issue [4], has made good preliminary headway in this direction. The authors conducted a retrospective study to determine the patient variables that lead clinicians to prescribe tube feedings, in particular percutaneous endoscopic gastrostomy (PEG).…”