卒中后吞咽障碍贯穿照护连续体：康复、支持性照护与社区随访的全周期框架

文献信息

中文摘要

背景： 卒中后吞咽障碍是卒中常见且具有临床重要后果的并发症，与吸入性肺炎、营养不良、脱水、功能恢复受损、死亡及医疗资源使用增加相关。尽管急性期吞咽障碍筛查和误吸风险管理已日益融入有组织的卒中照护中，但长期再评估、出院过渡、照护者教育、社区随访以及数字化支持的照护连续性仍界定不清。本综述在从超急性期筛查延伸至长期社区照护的全周期临床框架内，综合了卒中后吞咽障碍管理的当前证据。方法：高共识实践包括：经口进食前进行标准化筛查；对高风险患者及时升级至临床吞咽检查和仪器评估；以及就喂养途径、水化、给药、体位、口腔卫生、营养支持和肺部监测尽早做出支持性决策。结果：标准吞咽康复仍是贯穿急性期康复至亚急性期的平台；针对性训练、电刺激或脑刺激、呼吸肌训练和生物反馈是可选的、基于表型的强化模块，而非普遍性治疗。结论：在住院期之外，照护路径应明确吞咽状态、误吸风险、饮食与液体建议、喂养途径、口腔护理指导、警示征象、再评估时机、责任服务、照护者支持及升级规则。姑息治疗支持偏好敏感的预后、症状或喂养决策；社区实施必须解决可及性、照护者能力和失访问题。未来研究应超越孤立的短期吞咽结局，采用具有临床意义的终点评估医院-家庭-社区整合模式，包括肺炎、营养恢复、再入院、死亡、患者报告结局、社会参与和照护者负担。将卒中后吞咽障碍作为跨阶段、跨场所和多学科的卒中照护问题加以管理，可能改善安全性、连续性和长期恢复。

英文摘要

Post-stroke dysphagia is a common and clinically consequential complication of stroke, associated with aspiration pneumonia, malnutrition, dehydration, impaired functional recovery, mortality, and increased healthcare use. Although acute dysphagia screening and aspiration-risk management are increasingly embedded in organised stroke care, long-term reassessment, discharge transition, caregiver education, community follow-up, and digitally supported continuity of care remain less clearly defined. This Review synthesises current evidence on post-stroke dysphagia management within a full-cycle clinical framework extending from hyperacute screening to long-term community care. High-consensus practices include standardised screening before oral intake, timely escalation to clinical swallowing examination and instrumental assessment in high-risk patients, and early supportive decisions regarding feeding route, hydration, medication administration, positioning, oral hygiene, nutrition support, and pulmonary surveillance. Standard swallowing rehabilitation remains the platform from acute rehabilitation through the subacute phase; targeted exercise, electrical or brain stimulation, respiratory muscle training, and biofeedback are optional phenotype-based intensification modules, not universal treatments. Beyond the inpatient episode, care pathways should specify swallowing status, aspiration risk, diet and fluid recommendations, feeding route, oral-care instructions, warning signs, reassessment timing, responsible services, caregiver support, and escalation rules. Palliative care supports preference-sensitive prognosis, symptom, or feeding decisions; community implementation must address access, caregiver capacity, and loss to follow-up. Future research should move beyond isolated short-term swallowing outcomes and evaluate integrated hospital-home-community models using clinically meaningful endpoints, including pneumonia, nutritional recovery, readmission, mortality, patient-reported outcomes, social participation, and caregiver burden. Managing post-stroke dysphagia as a cross-stage, cross-setting, and multidisciplinary stroke-care problem may improve safety, continuity, and long-term recovery.