People with neurogenic dysphagia who have a tracheostomy after stroke
For people with neurogenic dysphagia who have a tracheostomy after stroke, pharyngeal electrical stimulation can be used in the NHS while more evidence is generated. It can only be used with special arrangements for clinical governance, consent, and audit or research.
Clinicians wanting to do pharyngeal electrical stimulation for people with neurogenic dysphagia who have a tracheostomy after stroke should:
Inform the clinical governance leads in their healthcare organisation.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Take account of NICE's advice on shared decision making, including NICE's information for the public.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by healthcare professionals experienced in managing neurogenic dysphagia and with specific training in the procedure. An endoscopic or videofluoroscopic assessment may be used.
The procedure should only be done by healthcare professionals with specific training in the procedure.
People with neurogenic dysphagia after stroke who do not have a tracheostomy, and people with other causes of neurogenic dysphagia
For people with neurogenic dysphagia after stroke who do not have a tracheostomy and people with other causes of neurogenic dysphagia, more research is needed on pharyngeal electrical stimulation.
This procedure should only be done as part of a formal research study and a research ethics committee needs to have approved its use.
More research is needed on:
details of patient selection (including the cause of dysphagia and the timing of the intervention)
effects on length of hospital stay compared with usual care.
Why the committee made these recommendations
There are limited treatment options for neurogenic dysphagia. People with neurogenic dysphagia have an increased risk of getting food, drink or saliva in the lungs, which can cause infection (aspiration pneumonia). People with severe neurogenic dysphagia may need ventilation in an intensive care unit, and a tracheostomy and feeding tubes. There are no safety concerns about pharyngeal electrical stimulation, but the clearest evidence on clinical efficacy is for people with neurogenic dysphagia who have a tracheostomy after a stroke.
Tracheostomy tube removal is an important outcome for people with neurogenic dysphagia after a stroke. Early removal helps with recovery, because having a tracheostomy makes it difficult to take part in other rehabilitation treatments. Tracheostomy removal also allows earlier transfer out of intensive care and may reduce overall length of hospital stay and improve quality of life. Clinical trial and registry evidence shows that pharyngeal electrical stimulation allows the tracheostomy tube to be removed earlier for people with neurogenic dysphagia after stroke. But, evidence on other clinical efficacy outcomes including the degree of aspiration and the severity of dysphagia is unclear, so more evidence is needed. So, for people with neurogenic dysphagia who have a tracheostomy after stroke, this procedure should only be used with special arrangements.
The evidence on clinical efficacy of pharyngeal electrical stimulation for people with neurogenic dysphagia after stroke who do not have a tracheostomy is not clear. Research studies in this group do not show clear evidence that the procedure leads to better clinical outcomes compared with placebo treatments. There is also not enough evidence to show clinical efficacy for people with other causes of neurogenic dysphagia. So, for people with neurogenic dysphagia after stroke who do not have a tracheostomy, and people with other causes of neurogenic dysphagia, this procedure should be used only in research.