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Neurogene Dysphagie
Dysphagiekonzept zur Diagnostik und Therapie von Schluckstörungen
Anliegen dieser Arbeiten ist es, ein diagnostisches Stufenkonzept zur Untersuchung der neurogenen oropharyngealen Dysphagie (NOD) zu
etablieren, das vom Schlucktherapeuten bzw. einem Arzt eingesetzt werden kann, um Patienten mit NOD frühzeitig zu identifizieren und eine
entsprechende Therapie zu ermöglichen. Unser Stufenkonzept soll einerseits in der klinischen Versorgung einsetzbar sein, andererseits aber den
wissenschaftlich-fundierten Ansprüchen an eine Schluckuntersuchung auf den verschiedenen diagnostischen Ebenen genügen. Bezüglich des
Schluckscreening durch das Pflegepersonal verweisen wir auf ein modifiziertes Schluckassessment (MSA) für Schlaganfallpatienten nach Perry
Kriterien, das hierfür besonders geeignet erscheint. Die NOD-Kommission der Deutschen Gesellschaft für Neurologie (DGN) und Deutschen
Schlaganfall Gesellschaft (DSG) erarbeitet mit verschiedenen Klinikern und Wissenschaftlern Vorschläge, die nach weiterer Evaluation in das
Dokumentationskonzept Eingang finden können. Das dargestellte Dysphagiekonzept einschließlich einer Computerversion wurde ausführlich
getestet und bestätigt die effektive Durchführbarkeit im Team aus Pflegekräften, Diätassistenten, Schlucktherapeuten und Ärzten.
Die Erfassung der Penetration und Aspiration ist neben weiteren Auffälligkeiten wie Leaking und Retentionen einer der wesentlichen Kriterien für die
Erfassung des Dysphagiegrades mit anschließendem pathophysiologisch-orientierten Vorgehen zur funktionellen, schlucktherapeutischen
Behandlung einschließlich der Indikationsstellung eines invasiven Vorgehens (PEG-Anlage) bzw. enteralen Sondenernährung und/oder
Tracheotomie. Ein standardisiertes Dysphagiekonzept kann dazu beitragen, eine bessere Prognoseeinschätzung vorzunehmen und
Komplikationen wie Aspirationspneumonie und Mangelernährung zu vermeiden. Wir hoffen, dass dieses Konzept eine Hilfestellung für Ärzte,
Schlucktherapeuten, Diätassistenten sowie Pflegekräfte darstellt und damit ein standardisiertes Vorgehen bei Dysphagie in neurologischen Akutund Rehabilitationseinrichtungen ermöglicht.
Dysphagia concept for diagnostic and therapeutic procedures in swallowing disorders
In some patients with dysphagia, the clinical history and clinical swallowing examination are enough for guiding the clinician to decide about
treatment of dysphagia but in others an instrumental examination is necessary. However, the result of the instrumental examination, whether it is
radiology, endoscopy, manometry, electromyography, or any other modality, has always to be compared with the patient´s clinical history.
Videofluoroscopy as well as swallowing endoscopy is often not only necessary in order to establish what kind of swallowing manoeuvres the patient
is able to perform, but also what kind of modification of food and liquid is suitable in a particular patient. Finally many patients, especially elderly, with
neurogenic dysphagia also suffer from concomitant abnormalities like strictures and webs with common oesophageal dysfunction that need to be
ruled out before treatment of the oropharyngeal dysfunction starts.
The aim of the dysphagia concept is to standardize the examination of patients with neurogenic oropharyngeal dysphagia (NOD) to help the nursing
staff, swallowing therapists and doctors for the early identification of NOD and enable them to initiate the appropriate therapeutic measures. On the
one hand, the concept has been designed to be used in the clinical setting, and on the other, to fulfill the scientific requirements for the adequate
diagnosis of swallowing disorders on very different diagnostic levels. With regard to the assessment of swallowing by nursing staff we draw attention
to a modified swallowing assessment (MSA) for stroke patients according to Perry criteria, which seems to be eminently suited to this. The clinical
swallowing examination by swallowing therapists as well as specific technical examinations like the flexible transnasal swallowing endoscopy (FTS)
and the videofluoroscopic swallowing evaluation (VFS) should follow a standardized protocol according to validated criteria. The NOD task force of
the German Stroke Society (DSG) and the German Neurological Society (DGN) collaborates with many clinicians and researchers to present
proposals, which after further investigations might be incorporated continually into the documentation concept. The dysphagia concept is also
available in a computer-version and was thoroughly tested to help the team exsisting of nursing staff, dieticians, swallowing therapists and doctors to
avoid complications like aspiration pneumonia and malnutrition.
Establishing the degree of penetration and aspiration, as well as further symptoms such as leaking and retention is one of the essential criteria in the
assessment of dysphagia with subsequent pathophysiologically-orientated procedures for the functional treatment of the swallowing disorder. This
also includes the diagnostic procedures necessary to decide upon invasive treatment (PEG placement) and tube feeding and/or tracheotomy.
Although there seems to be a growing interest in diagnosis and treatment of patients with dysphagia, there still seems to be a lack of knowledge and
also in fact ignorance to this problem. One reason for this is the misconception that oral and pharyngeal dysfunction cannot be treated properly. In
fact, almost all patients with oral and pharyngeal dysfunction can get help. Treating such dysphagia increases the patient´s quality of life
considerably and should therefore be given priority in the different treatment teams that are now implemented in many institutions. We hope that the
described NOD step-wise concept (NSC) will be of assistance to doctors, swallowing therapists, dieticians and nursing staff, and will be introduced
into acute and rehabilitation facilities as a standardised approach for the diagnosis and treatment of dysphagia.
Literaturstellen:
Ickenstein GW, Kelly PJ, Furie KL, Ambrosi D, Rallis N, Goldstein R, Horick N, Stein J. Predictors of feeding gastrostomy tube removal in stroke
patients with dysphagia. J Stroke & Cerebrovas Dis 2003; 12(4): 169-174
Ickenstein GW, Stein J, Ambrosi D, Goldstein R, Horn M, Bogdahn U. Predictors of survival after severe dysphagic stroke. J Neurology 2005; 252:
1510-1516
Ickenstein GW, Goldstein R, Stein J, Henze T, Bogdahn U. Neuronal regeneration after acute stroke with neurogenic oropharyngeal dysphagia
(NOD): a Kaplan-Meier survival analysis. Neurol Rehabil 2005; 11(5): 270-278
Ickenstein GW, Hofmayer A, Lindner-Pfleghar B, Pluschinski P, Riecker A, Schelling A, Prosiegel M. Standardisation of diagnostic and therapeutic
procedures for neurogenic oropharyngeal dysphagia (NOD). Neurol & Rehabil 2009; 15 (5):290-300
Ickenstein GW, Hofmayer A, Lindner-Pfleghar B, Pluschinski P, Riecker A, Schelling A, Prosiegel M. Manual for the NOD step-wise concept Standardisation of diagnostic and therapeutic procedures for neurogenic oropharyngeal dysphagia (NOD). Neurol & Rehabil 2009; 15 (6): 342-354
Ickenstein GW, Riecker A, Höhlig C, Müller R, Becker U, Reichmann H, Prosiegel M. Pneumonia and in-hospital mortality in the context of
neurogenic oropharyngeal dyspahgia (NOD) in stroke and a new NOD step-wise concept. J Neurology 2010; 257:1492-1501
Ickenstein GW, Höhlig C, Prosiegel M, Koch H, Dziewas R, Bodechtel U, Müller R, Reichmann H, Riecker A. Prediction of outcome in neurogenic
dysphagia within 72 hours of acute stroke. J Stroke Cerebrovasc Dis 2011, PMID 21683618
download pdf 2009
NOD Stufenkonzept
Manual
http://www.helios-kliniken.de/klinik/aue/fachabteilungen/klinik-fuer-neurologie-und-stroke-unit/neurogene-dysphagie.html