1.1. Patients with acute stroke should be screened for swallowing before being given any oral intake (fluid, food and medication) (Heart and Stroke Foundation, 2025; Stroke Foundation, 2025; NICE, 2023)
1.2. Swallowing screening is a minimally invasive procedure that enables quick determination of:
– the likelihood that dysphagia exists,
– whether the patient requires referral for further swallowing assessment, and
– whether the patient requires referral for nutritional or hydrational support.
(American Speech-Language-Hearing Association, 2025)
1.3. Swallowing screening should be conducted by trained health professionals using a validated screening tool (Heart and Stroke Foundation, 2025; Stroke Foundation, 2025; NICE, 2023)
1.4. Swallowing screening should also be conducted for patients with chronic stroke (postdischarge from acute care). Swallowing difficulties should be suspected if the patient reports any symptoms as follows:
– recurrent chest infection or low-grade fever
– persistent weight loss,
– coughing before/during/after swallowing,
– change in voice quality (wet or gurgling voice),
– drooling,
– complaint of difficulty when swallowing,
– prolonged mealtimes, and
– sensation of food being stuck in the throat.
(Aziz et. al, 2017)
1.5. A water test may be used to screen the swallow function. Presence of cough and wet voice are typically the common predictors for risk of aspiration. Examples of swallowing screening test are available in Appendix 1.
1.6. The sensitivity of swallowing screening may be increased by incorporating nonswallowing information which are demographic information, medical history, functional assessment and oral motor assessment (Daniels, Anderson & Wilson, 2012; Malaysian Clinical Practice Guidelines for Management of Ischemic Stroke (Malaysian Stroke Guidelines), 2020)
1.7. Patients who failed swallowing screening should be referred to a speech-language therapist for a clinical swallowing assessment (Heart and Stroke Foundation, 2025; Stroke Foundation, 2025).
1.8. Until a safe swallowing method is established, a non-oral route should be considered (Stroke Foundation, 2025).
1.9. A nasogastric tube could be used if enteral feeding is indicated. Furthermore, the use of PEG could be considered if prolonged enteral feeding is required (Malaysian Stroke Guideline, 2020; Heart and Stroke Foundation, 2025; NICE, 2023).
2.1. Instrumental assessments (Video Fluoroscopy for Swallowing (VFSS) and/or Fiberoptic Endoscopic Examination for Swallowing (FEES)) are recommended to be performed on patients with high risk for oropharyngeal dysphagia or poor airway protection, based on results from the bedside swallowing assessment, to examine the nature of swallowing difficulties and inform the swallowing rehabilitation/management (Heart and Stroke Foundation, 2025; NICE, 2023).
3.1. Management of dysphagia may include rehabilitation/restorative approach and/or compensatory techniques, and ongoing monitoring and reassessment to ensure the efficiency and safety of the oropharyngeal swallow (Heart and Stroke Foundation, 2025).
3.2. Adjunct modalities (acupuncture, non-invasive brain stimulation, pharyngeal electrical stimulation and surface neuromuscular electrical stimulation) should only be used together with the rehabilitative approach, taking into consideration the current evidence and competencies required (Stroke Foundation, 2025).
3.3. Patients should receive an individualized management plan, that includes therapy for dysphagia, dietary needs and nutritional plan (Heart and Stroke Foundation, 2025). The plan may involve various professionals such as dietitians, speech-language therapists and occupational therapists.
3.4. Whenever possible, patients should be encouraged to self-feed to lower their risk of aspiration pneumonia (Heart and Stroke Foundation, 2025).
3.5. Patients with dysphagia on texture-modified diets and/or fluids should be monitored for their tolerance and sufficiency of oral intake regularly to ensure their nutrition and hydration needs are met (Stroke Foundation, 2025).
3.6. All staff and caregivers involved in feeding patients should receive appropriate training in feeding and swallowing techniques (Heart and Stroke Foundation, 2025).
3.7. Patients, families and caregivers should be educated about swallowing, prevention of aspiration, and feeding recommendations (Heart and Stroke Foundation, 2025), and the potential of dysphagia on their quality of life (Al Rjoob et al., 2022)