卒中后吞咽困难的发生机制

卒中是造成吞咽困难的首要病因，吞咽困难是卒中重要的并发症之一，显著影响卒中患者的恢复。了解卒中后吞咽困难的发病机制对于早期识别、采取吞咽策略及康复方法十分重要。文章介绍了吞咽正常生理过程及其中枢及周围神经支配、吞咽困难的临床表现及其病理机制和神经损伤机制。     

卒中后吞咽困难的评估和治疗

卒中后吞咽困难的评估包括床旁评估和仪器评估。前者包括吞咽困难的筛选和困难程度的评定，后者包括X线检查、电生理检查、内镜检查或压力计检查等，各有优缺点，临床上常根据具体情况配合使用。卒中后吞咽困难的治疗已经有很多方法，如代偿策略、直接和间接策略等。但目前仍需继续致力于吞咽困难的研究，以找出较好的筛选方法和科学的评定量表，制定符合本国或本地区情况的治疗指南。     

卒中后吞咽困难的筛查与评估

吞咽困难是卒中常见的严重并发症之一,可导致患者病死率明显增高。其发病率根据卒中发病后评价的时间、诊断方法及标准的不同而不同。卒中后吞咽困难的早期筛查和全面的临床评估主要用于判断吞咽困难的有无及其性质,确定进一步检查的必要性,评测所选治疗手段的有效性以及利用治疗方案的制定。     

卒中后吞咽困难的评估和治疗

卒中后吞咽困难的评估包括床旁评估和仪器评估。前者包括吞咽困难的筛选和困难程度的评定,后者包括X线检查、电生理检查、内镜检查或压力计检查等,各有优缺点,临床上常根据具体情况配合使用。卒中后吞咽困难的治疗已经有很多方法,如代偿策略、直接和间接策略等。但目前仍需继续致力于吞咽困难的研究,以找出较好的筛选方法和科学的评定量表,制定符合本国或本地区情况的治疗指南。     

正规的吞咽困难筛查方案能够预防卒中后肺炎

肺炎是缺血性卒中的一种重要并发症，可使卒中患者的病死率增高3倍。吞咽困难是卒中后肺炎的一个常见原因，一些卒中治疗指南均建议在患者进食前进行吞咽评价。然而，对吞咽困难筛查的强度和哪些患者应进行筛查还不清楚。     

卒中后吞咽困难的发生机制

卒中是造成吞咽困难的首要病因,吞咽困难是卒中重要的并发症之一,显著影响卒中患者的恢复。了解卒中后吞咽困难的发病机制对于早期识别、采取吞咽策略及康复方法十分重要。文章介绍了吞咽正常生理过程及其中枢及周围神经支配、吞咽困难的临床表现及其病理机制和神经损伤机制。     

急性卒中后吞咽困难的评估与神经可塑性

急性卒中后吞咽困难的发生率高达50％,其中部分由单侧大脑半球损害引起。临床上评估吞咽困难的方法主要有床边评估和荧光影像直视检查,后者被认为是金标准。由于存在神经可塑性,90％的卒中后吞咽困难可自行恢复,但吞咽困难最终会影响患者的预后。     

急性卒中后吞咽困难的评估与神经可塑性

急性卒中后吞咽困难的发生率高达50％，其中部分由单侧大脑半球损害引起。临床上评估吞咽困难的方法主要有床边评估和荧光影像直视检查，后者被认为是金标准。由于存在神经可塑性，90％的卒中后吞咽困难可自行恢复，但吞咽困难最终会影响患者的预后。     

急性缺血性卒中后吞咽困难的病理生理学改变与应对措施

吞咽困难是急性缺血性卒中（AIS）的重要并发症。在卒中急性期患者中的发生率为22％～65％，平均约50％，这取决于评价的时间、所采用的诊断方法和患者存在的其他并发症。大多数患者的吞咽困难会在发病后1周至1个月内消失，仅少数持续6个月以上。急性期吞咽困难最令人担忧的后果是发生致命性呼吸道梗阻和吸入性肺炎。尽管呼吸道梗阻经紧急抢救可使患者脱险，但AIS病情会随之加重，并直接影响临床转归。而吸入性肺炎发生后，在增大治疗难度的同时，感染本身也会对AIS患者的临床转归产生十分不利的影响，甚至可增高病死率。此外，持续时间较长的吞咽困难可造成营养不良，不仅会降低AIS生存者的生活质量，而且也不利于康复期神经功能的恢复。因此，必须及时做出正确诊断，并采取有效应对措施。作者就近年来有关AIS后吞咽困难的病理生理学改变和应对措施的研究进展综述如下。     

影响卒中后患者营养不良相关因素的研究

目的 调查社区医院住院的卒中后患者营养不良的检出率以探讨影响恢复期卒中患者营养不良的相关因素.方法 采用横断面研究,以438例社区医院住院的卒中后患者为研究对象,记录营养学评定指标及可能导致营养不良的相关因素.结果 438例卒中后患者营养不良的检出率达52.7%;多因素logistic回归分析显示:卒中次数越多、美国国立卫生研究院卒中评分及Rankin残障量表评分分值越高,检出营养不良的风险越大(趋势检验P<0.0001),营养不良的风险还与卒中后抑郁、家庭照料差、未进行早期康复及大量饮酒史相关.结论 社区医院卒中后患者营养不良检出率高、影响因素多,关注卒中后患者营养状况的可控因素有利于卒中预后.     

Dysphagia in psychiatric patients: Clinical and videofluoroscopic study

Deaths due to airway obstruction are more common in psychiatric inpatients than in the normal population. A dysphagia program was started in a 400 bed Massachusetts psychiatric hospital after 4 patients in 1 year died from asphyxia. In the year after the program was started, there were no deaths; however, 28 patients experienced 32 choking incidents. The 28 patients received clinical evaluations by speech pathologists, neurologists, psychiatrists, and internists. Of the incidents, 55% required use of the Heimlich maneuver to open the airway. Choking incidents could be classified into five types based on results of clinical examination: bradykinetic, dyskinetic, fast eating syndrome, paralytic, and medical. Twenty-one of the 28 patients were studied by videofluoroscopy and 86% of the videos were abnormal, showing aspiration in eight, webs in five, and delay in the oral phase in five. Patients with bradykinetic dysphagia (secondary to neuroleptic-induced extra-pyramidal syndrome [EPS]) and paralytic dysphagia appeared to experience a more severe from of choking.     

Dysphagia in postpolio patients: A videofluorographic follow-up study

In patients with a history of acute paralytic poliomyelitis (APP), late progressive muscle weakness may arise, known as the progressive postpoliomyelitis muscular atrophy (PPMA). In 43 patients with PPMA, 8 were evaluated for recent or late progressive dysphagia. The mean interval between APP and onset of swallow symptoms was 27.1 years (range 23–45); the mean age of the patients was 45.4 years (range 35–52). Initial videofluorography showed signs of slight-to-moderate oropharyngeal dysfunction in 6 patients (delayed swallow reflex, diminished peristalsis of constrictor pharyngeus muscle, diminished laryngeal elevation, retention of bolus). In 2 patients, no abnormalities were found. Seven patients were rexamined after 12–36 months (mean 18). All reported subjective progression of symptoms. Videofluorography showed minor changes in 1 patient and unaltered findings in 6. No signs of aspiration were found either clinically or by video. We conclude that patients with PPMA complaining of late dysphagia do not show a significant loss in oropharyngeal function on 1–3 years follow-up.     

Dysphagia in aging

Dysphagia is a common problem in older patients and is becoming a larger health care problem as the populations of the United States and other developed countries rapidly age. Changes in physiology with aging are seen in the upper esophageal sphincter and pharyngeal region in both symptomatic and asymptomatic older individuals. Age related changes in the esophageal body and lower esophageal sphincter are more difficult to identify, while esophageal sensation certainly is blunted with age. Stroke, Parkinson's disease, amyotrophic lateral sclerosis, Zenker's diverticula, and several other motility and structural disorders may cause oropharyngeal dysphagia in an older patient. Esophageal dysphagia can also be caused by both disorders of motility (achalasia, diffuse esophageal spasm, scleroderma and others) and structure (malignancy, strictures, rings, external compression, and others). Many of these disorders have an increased prevalence in older patients and should be sought with an appropriate diagnostic evaluation in older patients. The treatment of dysphagia in older patients is similar to that in younger patients, but more invasive therapies such as surgery may not be possible in some older patients making less aggressive medical and endoscopic therapy more attractive.     

Dysphagia

Opinion statement Dysphagia is a common complaint that always warrants investigation. The patient’s history and preliminary testing can help differentiate between the two types of dysphagia: oropharyngeal or esophageal. Specific treatments for either of these types of dysphagia depend on the underlying etiology. Oropharyngeal dysphagia is often associated with a neuromuscular disorder and is treated with swallowing rehabilitation. Esophageal dysphagia is usually due to an anatomic defect or a motility disorder. Anatomic defects can often be corrected with endoscopic or surgical procedures. Motility disorders often benefit from pharmacologic treatment. Achalasia may be corrected with an endoscopic procedure with pneumatic dilation or, more recently, with injection of botulinum toxin.     

吞咽困难

1引言 吞咽困难(dysphagia)是个希腊词,其意思是进食功能紊乱.典型的吞咽困难指吞咽过程中断造成的进食困难.由于有引起吸人性肺炎、营养不良、脱水、体质量下降和气道阻塞等危险,吞咽困难对人的健康是一种严重威胁.在神经系统和非神经系统疾病患者中,多种病因可引起吞咽困难.