Dysphagia after acute stroke is common, with a reported incidence as high as 50%. Such an inability to swallow compromises both nutrition and hydration and may cause serious complications, including aspiration pneumonia and dehydration.
To overcome this problem, it is often necessary to feed patients using a nasogastric tube. After a stroke, it can often be difficult or even impossible to place such nasogastric tubes.
Patient cooperation may be severely impaired due to reduced awareness, aphasia, lingual incoordination, and buccofacial apraxia.
In a letter to The Lancet, doctors from the Department of Neurology at the Universitätsklinikum Münster, in Münster, Germany, describe a technique they have developed for the placing of nasogastric tubes, which relies on the swallowing reflex of the patient and thus is independent of the patient's ability to swallow.
The method uses a thin catheter inserted through the nostril, with the nasogastric tube placed in a similar position in the other nostril.
The swallowing reflex is then induced by bolus injection of 0.5 ml of distilled water through the thin catheter. If unsuccessful, a further injection of double or quadruple this volume is used.
At the onset of swallowing, as judged by visual observation of the characteristic laryngeal movement, the nasogastric tube is gently moved forward.
The research group evaluated the efficacy of their new technique by standardizing and documenting its use during a 4-month period in a stroke unit.
In all patients, severity of stroke was measured using the National Institutes of Health stroke scale, while swallowing was assessed with a 50 ml water-swallowing test.
Coughing during or for 1 minute after completion of the test or the presence of a post-swallow wet-hoarse voice quality was scored as abnormal.
The study group comprised patients for whom neither an experienced nurse nor the treating physician had succeeded in placing a nasogastric tube using the conventional approach.
At least 4 attempts and the use of known facilitating measures (such as increasing the rigidity of the tube by refrigeration and tilting the patient's head forward) were required before the application of the new method was allowed.
| New technique - uses swallowing reflex of the patient |
A total of 20 placements were included in the study period, with 7 patients studied twice and 2 patients studied 3 times.
In these patients the conventional approach repeatedly resulted in tracheal positioning of the tube or its coiling in the mouth. By using the swallowing reflex the tube was successfully placed at the first or second attempt in 19 of 20 trials.
The only failure occurred in a patient with a left middle-cerebral artery infarction in whom the swallowing reflex could not be provoked.
No serious complications or respiratory distress were noted, and the procedure was well tolerated by all patients.
Dr Rainer Dziewas, one of the co-authors of the report, said that the study confirms that the placing of nasogastric tubes by inducing the swallowing reflex is a useful alternative if the conventional method fails.
He added, "the new method is much less distressing for the patients than direct placement of the nasogastric tube" but cautioned, "the procedure may not work in patients who have had a brainstem infarction because they are prone to lack a sufficient swallowing reflex."