Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Individualized prediction of stroke-associated pneumonia for patients with acute ischemic stroke

Background

Stroke-associated pneumonia (SAP) remains a neglected area despite its high morbidity and mortality. We aimed to establish an easy-to-use model for predicting SAP.

Methods

Two hundred seventy-five acute ischemic stroke (AIS) patients were enrolled, and 73 (26.55%) patients were diagnosed with SAP. T-test, Chi-square test and Fisher's exact test were used to investigate the associations of patient characteristics with pneumonia and its severity, and multivariable logistic regression models were used to construct a prediction scale.

Results

Three variables with the most significant associations, including age, NGT placement, and right cerebral hemisphere lesions combined with gender, were used to construct a stroke-associated pneumonia prediction scale with high accuracy (AUC = 0.93). Youden index of our SAP prediction model was 0.77. The sensitivity and specificity of our SAP prediction model were 0.89 and 0.88, respectively.

Conclusion

We identified the best predictive model for SAP in AIS patients. Our study aimed to be as clinically relevant as possible, focusing on features that are routinely available. The contribution of selected variables is visually displayed through SHapley Additive exPlanations (SHAP). Our model can help to distinguish AIS patients of high-risk, provide specific management, reduce healthcare costs and prevent life-threatening complications and even death.

A Novel Machine Learning Model for Predicting Stroke-Associated Pneumonia After Spontaneous Intracerebral Hemorrhage

BACKGROUND

Pneumonia is one of the most common complications after spontaneous intracerebral hemorrhage (sICH), i.e., stroke-associated pneumonia (SAP). Timely identification of targeted patients is beneficial to reduce poor prognosis. So far, there is no consensus on SAP prediction, and application of existing predictors is limited. The aim of this study was to develop a machine learning model to predict SAP after sICH.

METHODS

We retrospectively reviewed 748 patients diagnosed with sICH and collected data from 4 dimensions-demographic features, clinical features, medical history, and laboratory tests. Five machine learning algorithms-logistic regression, gradient boosting decision tree, random forest, extreme gradient boosting, and category boosting-were used to build and validate the predictive model. We also applied recursive feature elimination with cross-validation to obtain the best feature combination for each model. Predictive performance was evaluated by area under the receiver operating characteristic curve.

RESULTS

SAP was diagnosed in 237 patients. The model developed by category boosting yielded the most satisfactory outcomes overall with area under the receiver operating characteristic curves in the training set and test set of 0.8307 and 0.8178, respectively.

CONCLUSIONS

The incidence of SAP after sICH in our center was 31.68%. Machine learning could potentially provide assistance in the prediction of SAP after sICH.

Braden score predicts 30-day mortality risk in patients with ischaemic stroke in the ICU: A retrospective analysis based on the MIMIC-IV database

BACKGROUND

Ischaemic stroke remains a significant global health challenge, associated with high mortality rates. While the Braden Scale is traditionally employed to assess pressure ulcer risk, its potential to predict mortality among the intensive care unit (ICU) patients with ischaemic stroke has not been thoroughly investigated.

AIM/S

This study evaluates the predictive value of the Braden Scale for 30-day mortality among patients with ischaemic stroke admitted to ICU.

STUDY DESIGN

We conducted a retrospective analysis of 4710 adult patients with ischaemic stroke from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The association between the Braden Scale scores and 30-day mortality was assessed using receiver operating characteristic (ROC) curve analysis, Cox regression models and Kaplan-Meier survival estimates.

RESULTS

Patients with Braden Scale scores ≤ 15.5 showed significantly higher 30-day mortality rates (p-value < 0.001; hazard ratio (HR): 2.08, 95% confidence interval (CI): 1.71-2.53). The area under the ROC curve (AUC) was 0.71, demonstrating good predictive performance. Multivariate analysis confirmed the Braden Scale as an independent predictor of mortality, after adjusting for age, gender and comorbidities.

CONCLUSIONS

The Braden Scale effectively identifies high-risk ischaemic stroke patients in ICU settings, endorsing its integration into routine assessments to facilitate early intervention strategies.

RELEVANCE TO CLINICAL PRACTICE

Integrating the Braden Scale into routine ICU evaluations can enhance mortality risk stratification and improve patient care tailoring.

Dysphagia after stroke: research advances in treatment interventions

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Diagnosis and treatment of stroke associated pneumonia: Qualitative exploration of clinicians’ practice

<b>Background:</b> Establishing and implementing a gold standard criteria for diagnosing and treating stroke-associated pneumonia (SAP) would have a significant positive impact on stroke outcomes and antibiotic stewardship. This study aimed to qualitatively explore current diagnostic and treatment practice for SAP among clinicians.<br /> <b>Methods: </b>A qualitative study was employed to conduct semi-structured interviews at the tertiary-care Jordan University Hospital. A purposive sampling technique was employed to recruit the participants, including respiratory consultants (n=3) and residents (n=9) practicing in the internal medicine wards and intensive care unit, where stroke patients are treated. The interviews were audio-recorded, transcribed verbatim, translated, and analyzed thematically using framework analysis.<br /> <b>Results:</b> Clinicians expressed their experiences, which were organized into two themes and eight emerged sub-themes: Terminology and diagnostic approach of SAP involved; no definite terminology, reliance on both clinical evidence and X-ray findings to decide, reliance on clinical evidence alone to suspect SAP and initiate empirical therapy, and SAP overdiagnosis. The treatment strategies include early treatment of SAP, treating SAP the same as CAP/HAP, predominant anaerobes coverage, and SAP overtreatment.<br /> <b>Conclusion:</b><i> </i>Our findings show a wide range of physician-based diagnostic and treatment approaches for SAP, with clinical criteria serving as the main driver for antibiotic initiation. Standard validated algorithmic-based criteria need to be established and implemented.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts' consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose

Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well.

Methods

We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S.

Results

Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se.

Conclusions

The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Tube feeding predictors after ischemic hemispheric stroke during hospitalization

PURPOSE

To verify the factors associated with the need of tube feeding (TF) during patients post-ischemic stroke hospitalization.

METHOD

This is a retrospective study with 70 adult post-ischemic hemispheric stroke adult patients hospitalized in the Neurology department at a tertiary public hospital in Santa Catarina, Brazil. We investigated associations between the need of a feeding tube during hospitalization and the variables age, gender, admission and discharge NIHSS and FOIS, length of hospital stay in days, presence of thrombolytic therapy, extensive stroke, hemisphere affected, prior stroke, pneumonia during hospitalization, presence of signs of laryngeal penetration and laryngotracheal aspiration and dysphagia in the first and last swallowing clinical evaluation.

RESULTS

A total of 33 participants used tube feeding. There was a significant relationship among tube feeding and the following parameters: NIHSS (p value .001), FOIS (p value .001), extensive stroke (p value .034), left hemisphere involvement (p value .035), pneumonia during hospitalization (p value .001), length of hospital stay in days (p value .001), signs of laryngotracheal penetration/aspiration (p value .001) and dysphagia in speech-language assessment (p value .001).

CONCLUSION

Tube feeding during patients hospitalization after ischemic hemispheric stroke was predicted by the severity of stroke and signs of airway permeation.Key pointsSwallowing difficulty is one of the most common post-stroke consequences.There are few studies on the characterization of post-stroke patients with tube feeding.Tube feeding after ischemic stroke predictors were severity of stroke and signs of airway permeation.

Factors associated with length of stay and death in tube-fed patients: A cross-sectional multicentre study

OBJECTIVES

To analyse the factors associated with length of stay (LOS) and death in nasogastric/nasoenteric tube (NG/NET)-fed patients.

DESIGN

A cross-sectional multicentre study.

METHOD

Data collection took place from October 2017-April 2019, and the sample consisted of 365 participants from seven Brazilian hospitals. Demographic, clinical and therapeutic data were collected from the patients' medical records. Data analysis was performed using bivariate and multivariate tests, considering a significance level of p<.05.

RESULTS

Most patients were male, older adults, with high risk of death and highly dependent on nursing care. The LOS was associated with age, patient care complexity and length of NG/NET use. Death was associated with patient age. In the multivariate analysis, patients highly dependent on nursing care, and intensive and semi-intensive care had a greater chance of dying when compared with patients receiving minimal care. Screening for factors affecting LOS and death is important to plan effective nursing care.

Predicting Factors of Functional Outcome in Patients with Acute Ischemic Stroke Admitted to Neuro-Intensive Care Unit-A Prospective Cohort Study

Although thrombectomy is beneficial for most stroke patients with large vessel occlusion (LVO), it has added new issues in acute management due to intensive care support. In this prospective cohort study, we described the patients admitted to our neuro-intensive care unit (NICU) after thrombectomy in order to assess factors linked to functional outcomes. The outcome was independency assessed for stroke patients consecutively admitted to NICU for an ischemic stroke due to LVO of the anterior cerebral circulation that underwent intra-arterial mechanical thrombectomy (IAMT), either in combination with intravenous thrombolysis (IVT) in eligible patients or alone in patients with contraindications for IVT. Overall, 158 patients were enrolled. IVT (odds ratio (OR), 3.78; 95% confidence interval (CI), 1.20–11.90; p = 0.023) and early naso-gastric tube removal (OR, 3.32; 95% CI, 1.04–10.59 p = 0.042) were associated with good outcomes, whereas a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.72 for each point of increase; 95% CI, 0.61–0.85; p < 0.001) was a predictor of poor outcomes at 3 months. Older age (OR, 0.95 for each year of increase; 95% CI, 0.92–0.99; p = 0.020) and hemorrhagic transformation (OR, 0.31; 95% CI, 0.11–0.84; p = 0.022) were predictors of poor outcomes after IAMT, whereas a modified Treatment in Cerebral Infarction (mTICI) score of 2b/3 was a predictor of good outcomes (OR, 7.86; 95% CI, 1.65–37.39; p = 0.010) at 6 months. Our results show that acute stroke patients with LVO who require NICU management soon after IAMT may show specific clinical factors influencing short- and long-term neurologic independency.

Oral Health, Oral Microbiota, and Incidence of Stroke-Associated Pneumonia-A Prospective Observational Study

Stroke-associated pneumonia is a major cause for poor outcomes in the post-acute phase after stroke. Several studies have suggested potential links between neglected oral health and pneumonia. Therefore, the aim of this prospective observational study was to investigate oral health and microbiota and incidence of pneumonia in patients consecutively admitted to a stroke unit with stroke-like symptoms. This study involved three investigation timepoints. The baseline investigation (within 24 h of admission) involved collection of demographic, neurological, and immunological data; dental examinations; and microbiological sampling (saliva and subgingival plaque). Further investigation timepoints at 48 or 120 h after baseline included collection of immunological data and microbiological sampling. Microbiological samples were analyzed by culture technique and by 16S rRNA amplicon sequencing. From the 99 patients included in this study, 57 were diagnosed with stroke and 42 were so-called stroke mimics. From 57 stroke patients, 8 (14%) developed pneumonia. Stroke-associated pneumonia was significantly associated with higher age, dysphagia, greater stroke severity, embolectomy, nasogastric tubes, and higher baseline C-reactive protein (CRP). There were trends toward higher incidence of pneumonia in patients with more missing teeth and worse oral hygiene. Microbiological analyses showed no relevant differences regarding microbial composition between the groups. However, there was a significant ecological shift over time in the pneumonia patients, probably due to antibiotic treatment. This prospective observational study investigating associations between neglected oral health and incidence of SAP encourages investigations in larger patient cohorts and implementation of oral hygiene programs in stroke units that may help reducing the incidence of stroke-associated pneumonia.

Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study

(1) Background: Patients with dysphagia are at increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed. The aim of this study is to explore staff opinions about current practice of dysphagia screening, assessment and clinical management in acute phase stroke. (2) Methods: Fifteen interviews were conducted in five English National Health Service hospitals. Hospitals were selected based on size and performance against national targets for dysphagia screening and assessment, and prevalence of stroke-associated pneumonia. Participants were purposefully recruited to reflect a range of healthcare professions. Data were analysed using a six-stage thematic process. (3) Results: Three meta themes were identified: delays in care, lack of standardisation and variability in resources. Patient, staff, and service factors that contribute to delays in dysphagia screening, assessment by a speech and language therapist, and delays in nasogastric tube feeding were identified. These included admission route, perceived lack of ownership for screening patients, prioritisation of assessments and staff resources. There was a lack of standardisation of dysphagia screening protocols and oral care. There was variability in staff competences and resources to assess patients, types of medical interventions, and care processes. (4) Conclusion: There is a lack of standardisation in the way patients are assessed for dysphagia and variation in practice relating to staff competences, resources and care processes between hospitals. A range of patient, staff and service factors have the potential to impact on stroke patients being assessed within the recommended national guidelines.

Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review

Dysphagia is associated with increased risk of stroke-associated pneumonia (SAP). However, it is unclear what other factors contribute to that risk or which measures may reduce it. This systematic review aimed to provide evidence on interventions and care processes associated with SAP in patients with dysphagia. Studies were screened for inclusion if they included dysphagia only patients, dysphagia and non-dysphagia patients or unselected patients that included dysphagic patients and evaluated factors associated with a recorded frequency of SAP. Electronic databases were searched from inception to February 2017. Eligible studies were critically appraised. Heterogeneity was evaluated using I². The primary outcome was SAP. Eleven studies were included. Sample sizes ranged from 60 to 1088 patients. There was heterogeneity in study design. Measures of immunodepression are associated with SAP in dysphagic patients. There is insufficient evidence to justify screening for aerobic Gram-negative bacteria. Prophylactic antibiotics did not prevent SAP and proton pump inhibitors may increase risk. Treatment with metoclopramide may reduce SAP risk. Evidence that nasogastric tube (NGT) placement increases risk of SAP is equivocal. A multidisciplinary team approach and instrumental assessment of swallowing may reduce risk of pneumonia. Patients with impaired mobility were associated with increased risk. Findings should be interpreted with caution given the number of studies, heterogeneity and descriptive analyses. Several medical interventions and care processes, which may reduce risk of SAP in patients with dysphagia, have been identified. Further research is needed to evaluate the role of these interventions and care processes in clinical practice.

Effect of an indwelling nasogastric tube on swallowing function in elderly post-stroke dysphagia patients with long-term nasal feeding

BACKGROUND

In clinical practice, a large number of post-stroke survivors require nasogastric tube (NGT) placement and nasal feeding for a relatively long period. However, its impact on the swallowing function remains largely unknown. This study examines the impact of prolonged placement of an NGT on the swallowing function of elderly post-stroke patients.

METHODS

The participants of this study were 30 elderly post-stroke patients who had been using an NGT for more than 2 months. A videofluoroscopic swallowing study (VFSS) was performed before and 5 h after removal of the NGT. The following parameters were analyzed and compared, the functional dysphagia scale (FDS), residue in the valleculae, residue in the pyriform sinuses, and the penetration-aspiration scale (PAS). In addition, prior to the VFSS, the pharynx and larynx were examined using a fiberoptic laryngoscope.

RESULTS

Significant differences were observed between the total scores of the FDS, pharyngeal transit times (PTTs), the residue in the valleculae, and the residue in the pyriform sinuses before and after the NGT removal, suggesting an improved swallowing function following the removal of the NGT. A significantly lower penetration-aspiration degree was found after removing the NGT compared with that before its removal. In addition, examinations using the fiberoptic laryngoscope showed that laryngopharyngeal edema was present in three quarters of the patients.

CONCLUSIONS

Our results demonstrate that prolonged placement of the NGT had a negative impact on the swallowing function of elderly post-stroke dysphagia patients, mainly on the pharyngeal phase.

Elevated C-reactive protein increases diagnostic accuracy of algorithm-defined stroke-associated pneumonia in afebrile patients

BACKGROUND AND AIM

Pyrexia-dependent clinical algorithms may under or overdiagnose stroke-associated pneumonia. This study investigates whether inclusion of elevated C-reactive protein as a criterion improves diagnosis.

METHODS

The contribution of C-reactive protein  ≥30 mg/l as an additional criterion to a Centers for Disease Control and Prevention-based algorithm incorporating pyrexia with chest signs and leukocytosis and/or chest infiltrates to diagnose stroke-associated pneumonia was assessed in 1088 acute stroke patients from 37 UK stroke units. The sensitivity, specificity, and positive predictive value of different approaches were assessed using adjudicated stroke-associated pneumonia as the reference standard.

RESULTS

Adding elevated C-reactive protein to all algorithm criteria did not increase diagnostic accuracy compared with the algorithm alone against adjudicated stroke-associated pneumonia (sensitivity 0.74 (95% CI 0.65-0.81) versus 0.72 (95% CI 0.64-0.80), specificity 0.97 (95% CI 0.96-0.98) for both; kappa 0.70 (95% CI 0.63-0.77) for both). In afebrile patients (n = 965), elevated C-reactive protein with chest and laboratory findings had sensitivity of 0.84 (95% CI 0.67-0.93), specificity of 0.99 (95% CI 0.98-1.00), and kappa 0.80 (95% CI 0.70-0.90). The modified algorithm of pyrexia or elevated C-reactive protein and chest signs with infiltrates or leukocytosis had sensitivity of 0.94 (95% CI 0.87-0.97), specificity of 0.96 (95% CI 0.94-0.97), and kappa of 0.88 (95% CI 0.84-0.93) against adjudicated stroke-associated pneumonia.

CONCLUSIONS

An algorithm consisting of pyrexia or C-reactive protein ≥30 mg/l, positive chest signs, leukocytosis, and/or chest infiltrates has high accuracy and can be used to standardize stroke-associated pneumonia diagnosis in clinical or research settings.

TRIAL REGISTRATION

http://www.isrctn.com/ISRCTN37118456.

Dysphagia Management and Stroke Units

Dysphagia is one of the many complications of stroke. It is common and is an independent marker of outcome. Dysphagia management is important. Although the speech and language pathologist is the key worker in dysphagia management, they are supported by all members of the multi-disciplinary team. Stroke patients should be screened on admission for the presence of dysphagia and assessed by the speech and language therapist (or appropriate professional), where indicated investigation should be undertaken to understand the swallowing physiology and to guide treatment. Management, at present, is based around texture modification of food/liquids and swallowing manoeuvres. Rehabilitation of swallowing remains in its infancy, but there is a lot of promising research with neurostimulation, medication and devices to strengthen muscles involved in swallowing.