Intensive Care Medicine

, Volume 41, Issue 9, pp 1629–1637 | Cite as

Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial

  • Sonja SuntrupEmail author
  • Thomas Marian
  • Jens Burchard Schröder
  • Inga Suttrup
  • Paul Muhle
  • Stephan Oelenberg
  • Christina Hamacher
  • Jens Minnerup
  • Tobias Warnecke
  • Rainer Dziewas



Treatment of post-stroke dysphagia is notoriously difficult with different neurostimulation strategies having been employed with a variable degree of success. Recently, electrical pharyngeal stimulation (EPS) has been shown to improve swallowing function and in particular decrease airway aspiration in acute stroke. We performed a randomized controlled trial to assess EPS effectiveness on swallowing function in severely dysphagic tracheotomized patients.


All consecutive stroke patients successfully weaned from the respirator but with severe dysphagia precluding decannulation were screened for eligibility. Eligible patients were randomized to receive either EPS (N = 20) or sham stimulation (N = 10) over three consecutive days. Primary endpoint was ability to decannulate the patient. Swallowing function was assessed using fiberoptic endoscopy. Patients having received sham stimulation were offered EPS treatment during unblinded follow-up if required. Investigators were blinded to the patient’s study group allocation.


Both groups were well matched for age, stroke severity, and lesion location. Decannulation after study intervention was possible in 75 % of patients of the treatment group and in 20 % of patients of the sham group (p < 0.01). Secondary outcome parameters did not differ. No adverse events occurred.


In this pilot study, EPS enhanced remission of dysphagia as assessed with fiberoptic endoscopic evaluation of swallowing (FEES), thereby enabling decannulation in 75 % of patients.


Electrical pharyngeal stimulation Stroke Dysphagia Decannulation 


Conflicts of interest

R. Dziewas is a member of the clinical advisory board of Phagenesis Ltd. The other authors declare they have no conflict of interest.

Supplementary material

134_2015_3897_MOESM1_ESM.pdf (143 kb)
Supplementary material 1 (PDF 144 kb)
134_2015_3897_MOESM2_ESM.doc (218 kb)
Supplementary material 2 (DOC 218 kb)


  1. 1.
    Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R (2005) Dysphagia after stroke—incidence, diagnosis, and pulmonary complications. Stroke 36:2756–2763CrossRefPubMedGoogle Scholar
  2. 2.
    Hoffmann S, Malzahn U, Harms H, Koennecke HC, Berger K, Kalic M, Walter G, Meisel A, Heuschmann P (2012) Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke. Stroke 43:2617–2623CrossRefPubMedGoogle Scholar
  3. 3.
    Hannawi Y, Hannawi B, Rao CP, Suarez JI, Bershad EM (2013) Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis 35:430–443CrossRefPubMedGoogle Scholar
  4. 4.
    Carnaby G, Hankey GJ, Pizzi J (2006) Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 5:31–37CrossRefPubMedGoogle Scholar
  5. 5.
    Wirth R, Smoliner C, Jager M, Warnecke T, Leischker AH, Dziewas R (2013) Guideline clinical nutrition in patients with stroke. Exp Transl Stroke Med 5:14PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Speyer R, Baijens L, Heijnen M, Zwijnenberg I (2010) Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review. Dysphagia 25:40–65PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Shigematsu T, Fujishima I, Ohno K (2013) Transcranial direct current stimulation improves swallowing function in stroke patients. Neurorehabil Neural Repair 27:363–369CrossRefPubMedGoogle Scholar
  8. 8.
    Kumar S, Wagner CW, Frayne C, Zhu L, Selim M, Feng W, Schlaug G (2011) Noninvasive brain stimulation may improve stroke-related dysphagia: a pilot study. Stroke 42:1035–1040PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Park JW, Oh JC, Lee JW, Yeo JS, Ryu KH (2013) The effect of 5 Hz high-frequency rTMS over contralesional pharyngeal motor cortex in post-stroke oropharyngeal dysphagia: a randomized controlled study. Neurogastroenterol Motil 25:324–e250PubMedGoogle Scholar
  10. 10.
    Khedr EM, Abo-Elfetoh N, Rothwell JC (2009) Treatment of post-stroke dysphagia with repetitive transcranial magnetic stimulation. Acta Neurol Scand 119:155–161CrossRefPubMedGoogle Scholar
  11. 11.
    Jayasekeran V, Singh S, Tyrell P, Michou E, Jefferson S, Mistry S, Gamble E, Rothwell J, Thompson D, Hamdy S (2010) Adjunctive functional pharyngeal electrical stimulation reverses swallowing disability after brain lesions. Gastroenterology 138:1737–1746CrossRefPubMedGoogle Scholar
  12. 12.
    Warnecke T, Suntrup S, Teismann I, Hamacher C, Oelenberg S, Dziewas R (2013) Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med 41:1728–1732CrossRefPubMedGoogle Scholar
  13. 13.
    Fraser C, Power M, Hamdy S, Rothwell J, Hobday D, Hollander I, Tyrell P, Hobson A, Williams S, Thompson D (2002) Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury. Neuron 34:831–840CrossRefPubMedGoogle Scholar
  14. 14.
    Crary MA, Mann GD, Groher ME (2005) Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil 86:1516–1520CrossRefPubMedGoogle Scholar
  15. 15.
    Bosel J (2014) Tracheostomy in stroke patients. Curr Treat Options Neurol 16:274CrossRefPubMedGoogle Scholar
  16. 16.
    Pelosi P, Ferguson ND, Frutos-Vivar F, Anzueto A, Putensen C, Raymondos K, Apezteguia C, Desmery P, Hurtado J, Abroug F, Elizalde J, Tomicic V, Cakar N, Gonzalez M, Arabi Y, Moreno R, Esteban A (2011) Management and outcome of mechanically ventilated neurologic patients. Crit Care Med 39:1482–1492CrossRefPubMedGoogle Scholar
  17. 17.
    Kurtz P, Fitts V, Sumer Z, Jalon H, Cooke J, Kvetan V, Mayer SA (2011) How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? Neurocrit Care 15:477–480CrossRefPubMedGoogle Scholar
  18. 18.
    Durbin CG Jr (2010) Tracheostomy: why, when, and how? Respir Care 55:1056–1068PubMedGoogle Scholar
  19. 19.
    Rabinstein AA, Wijdicks EF (2004) Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis 18:325–331CrossRefPubMedGoogle Scholar
  20. 20.
    Choate K, Barbetti J, Currey J (2009) Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care 22:8–15CrossRefPubMedGoogle Scholar
  21. 21.
    Leung R, MacGregor L, Campbell D, Berkowitz RG (2003) Decannulation and survival following tracheostomy in an intensive care unit. Ann Otol Rhinol Laryngol 112:853–858CrossRefPubMedGoogle Scholar
  22. 22.
    Heffner JE, Miller KS, Sahn SA (1986) Tracheostomy in the intensive care unit. Part 2: complications. Chest 90:430–436CrossRefPubMedGoogle Scholar
  23. 23.
    Epstein SK (2005) Late complications of tracheostomy. Respir Care 50:542–549PubMedGoogle Scholar
  24. 24.
    Martinez GH, Fernandez R, Casado MS, Cuena R, Lopez-Reina P, Zamora S, Luzon E (2009) Tracheostomy tube in place at intensive care unit discharge is associated with increased ward mortality. Respir Care 54:1644–1652PubMedGoogle Scholar
  25. 25.
    Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF (2007) Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med 35:132–138CrossRefPubMedGoogle Scholar
  26. 26.
    Tolep K, Getch CL, Criner GJ (1996) Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest 109:167–172CrossRefPubMedGoogle Scholar
  27. 27.
    Romero CM, Marambio A, Larrondo J, Walker K, Lira MT, Tobar E, Cornejo R, Ruiz M (2010) Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy. Chest 137:1278–1282CrossRefPubMedGoogle Scholar
  28. 28.
    Sharma OP, Oswanski MF, Singer D, Buckley B, Courtright B, Raj SS, Waite PJ, Tatchell T, Gandaio A (2007) Swallowing disorders in trauma patients: impact of tracheostomy. Am Surg 73:1117–1121PubMedGoogle Scholar
  29. 29.
    Hafner G, Neuhuber A, Hirtenfelder S, Schmedler B, Eckel HE (2008) Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. Eur Arch Otorhinolaryngol 265:441–446PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.
    Macht M, Wimbish T, Bodine C, Moss M (2013) ICU-acquired swallowing disorders. Crit Care Med 41:2396–2405CrossRefPubMedGoogle Scholar
  31. 31.
    Hamdy S, Rothwell JC, Aziz Q, Singh KD, Thompson DG (1998) Long-term reorganization of human motor cortex driven by short-term sensory stimulation. Nat Neurosci 1:64–68CrossRefPubMedGoogle Scholar
  32. 32.
    Fraser C, Rothwell J, Power M, Hobson A, Thompson D, Hamdy S (2003) Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia. Am J Physiol Gastrointest Liver Physiol 285:G137–G144CrossRefPubMedGoogle Scholar
  33. 33.
    Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, Hess D (2008) Determinants of tracheostomy decannulation: an international survey. Crit Care 12:R26PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Santus P, Gramegna A, Radovanovic D, Raccanelli R, Valenti V, Rabbiosi D, Vitacca M, Nava S (2014) A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score. BMC Pulm Med 14:201PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Garrubba M, Turner T, Grieveson C (2009) Multidisciplinary care for tracheostomy patients: a systematic review. Crit Care 13:R177PubMedCentralCrossRefPubMedGoogle Scholar
  36. 36.
    Tobin AE, Santamaria JD (2008) An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care 12:R48PubMedCentralCrossRefPubMedGoogle Scholar
  37. 37.
    Cetto R, Arora A, Hettige R, Nel M, Benjamin L, Gomez CM, Oldfield WL, Narula AA (2011) Improving tracheostomy care: a prospective study of the multidisciplinary approach. Clin Otolaryngol 36:482–488CrossRefPubMedGoogle Scholar
  38. 38.
    Speed L, Harding KE (2013) Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care 28:216 e211–210CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Sonja Suntrup
    • 1
    Email author
  • Thomas Marian
    • 1
  • Jens Burchard Schröder
    • 1
  • Inga Suttrup
    • 1
  • Paul Muhle
    • 1
  • Stephan Oelenberg
    • 1
  • Christina Hamacher
    • 1
  • Jens Minnerup
    • 1
  • Tobias Warnecke
    • 1
  • Rainer Dziewas
    • 1
  1. 1.Department of NeurologyUniversity Hospital MünsterMünsterGermany

Personalised recommendations