Predictive factors for removal of percutaneous endoscopic gastrostomy tube in post-stroke dysphagia

Factors influencing gastrostomy tube removal

BACKGROUND

When commencing enteral feeding, patients and families will want to know the likelihood of returning to an oral diet. There is a paucity of data on the prognosis of patients with gastrostomies. We describe a large dataset of patients, which identifies factors influencing gastrostomy removal and assesses the likelihood of the patient having at home enteral nutrition.

METHODS

Retrospective data was collected on patients from Sheffield Teaching Hospitals who had received a gastrostomy and had outpatient enteral feeding between January 2016 and December 2019. Demographic data, indication and outcomes were analysed.

RESULTS

A total of 451 patients were assessed, median age: 67.7. 183/451(40.6%) gastrostomies were for head and neck cancer, 88/451 (19.5%) for stroke, 28/451 (6.2%) for Motor Neuron Disease, 32/451 (7.1%) for other neurodegenerative causes, 120/451 (26.6%) other. Of the 31.2% who had their gastrostomy removed within 3 years, head and neck cancer was the most common indication (58.3%) followed by stroke (10.2%), Motor Neuron Disease (7.1%) and other neurodegenerative diseases (3.1%). Gastrostomy removal was significantly influenced by age, place of residence, and having head and neck cancer (p < 0.05). There was the greatest likelihood of removal within the first year (24%). 70.5% had enteral feeding at home.

CONCLUSION

This large cohort study demonstrates 31.2% of patients had their gastrostomy removed within 3 years. Head and neck cancer patients, younger age and residing at home can help positively predict removal. Most patients manage their feeding at home rather than a nursing home. This study provides new information on gastrostomy outcomes when counselling patients to provide realistic expectations.

Predicting Failure to Recover Swallowing in Patients with Severe Post-stroke Dysphagia: The DIsPHAGIc Score

In post-stroke dysphagia, early identification of patients at highest risk of failing swallowing recovery (SR) would be useful to decide which of them should undergo percutaneous endoscopic gastrostomy. The studies on this subject were numerous but generally based on small statistical samples. In this retrospective study, 1232 patients with ischemic or hemorrhagic stroke (73.7 ± 13.0 years, 51% men) were assessed: 593 non-dysphagic, 351 partially dysphagic and 288 totally dysphagic. Among the latter, 45.1% could not recover oral intake. A score to assess the risk of failing SR was obtained from the group with total dysphagia, and further 210 patients with total post-stroke dysphagia were utilized for validation. A regular progression of stroke severity markers, complications and mortality was observed from non-dysphagic, to partially dysphagic, up to totally dysphagic patients. Among the latter, seven variables were independently associated with failure of SR, and formed the "DIsPHAGIc score": cerebral lesion Diameter ≥ 6 cm (+ 1), left frontal Ischemia (- 1), Partial anterior circulation syndrome (- 1), Hypoxia (+ 1), Antiplatelet drug (+ 1), GCS verbal reaction < 4 (+ 1), Internal capsule ischemia (- 1). The area under the ROC curve was 0.79 (95% CI 0.74-0.85). For total scores ≥ 2 there was a high risk of failing SR, with specificity 76.9%, sensitivity 72.1% and accuracy 74.7%. The application of the DIsPHAGIc score to the validation sample provided almost identical results. The evolution of post-stroke dysphagia towards irreversibility can be predicted by a simple, reproducible and robust scoring system based on 7 variables commonly available during hospitalization.

Clinical Factors Associated With Successful Gastrostomy Tube Weaning in Patients With Prolonged Dysphagia After Stroke

Objective

To investigate the clinical factors associated with successful gastrostomy tube weaning in patients with prolonged dysphagia after stroke.

Methods

This study involved a retrospective medical chart review of patients diagnosed with prolonged dysphagia after stroke who underwent gastrostomy tube insertion between May 2013 and January 2020. Forty-seven patients were enrolled and consequently divided into gastrostomy tube sustaining and weaning groups. The numbers of patients in the sustaining and weaning groups were 31 and 16, respectively. The patients’ demographic data, Korean version of Mini-Mental State Examination (K-MMSE) score, Korean version of the Modified Barthel Index (K-MBI), Functional Dysphagia Scale (FDS) score, and Penetration-Aspiration Scale (PAS) score were compared between the two groups. A videofluoroscopic swallowing study was performed before making the decision of gastrostomy tube weaning. The clinical factors associated with gastrostomy tube weaning were then investigated.

Results

There were significant differences in age; history of aspiration pneumonia; K-MMSE, FDS, and PAS scores; and K-MBI between the groups. In the multiple logistic regression analysis, the FDS (odds ratio [OR]=0.791; 95% confidence interval [CI], 0.634–0.987) and PAS scores (OR=0.205; 95% CI, 0.059–0.718) were associated with successful gastrostomy tube weaning. In the receiver operating characteristic curve analysis, the FDS and PAS were useful screening tools for successful weaning, with areas under the curve of 0.911 and 0.918, respectively.

Conclusion

In patients with prolonged dysphagia, the FDS and PAS scores are the only factors associated with successful gastrostomy tube weaning. An evaluation of the swallowing function is necessary before deciding to initiate gastrostomy tube weaning.

Effect of dysphagia rehabilitation in patients receiving enteral nutrition at home nursing care: A retrospective cohort study

Objective

We considered the effect of dysphagia rehabilitation and investigated parameters associated with the resumption of oral intake in the elderly patients receiving home nursing care who were not eating by mouth.

Methods

The participants were 116 patients aged ≥65 years (66 men and 50 women, mean age 79.7 ± 8.9 years) who were receiving home nursing care and not eating by mouth because of dysphagia. All patients underwent dysphagia rehabilitation for 6 months with the objective of resuming oral intake. After 6 months of dysphagia rehabilitation, the patients’ eating status was assessed using the Functional Oral Intake Scale (FOIS) and the associations of the post‐intervention FOIS score with age, history of pneumonia, duration of enteral nutrition, body mass index (BMI), alertness, physical function (ability to walk) and swallowing function at the initial examination.

Results

Functional Oral Intake Scale scores increased significantly after 6 months rather than those at the initial evaluation (P < .001). Eighty patients (69.0%) resumed oral intake (FOIS score ≥2), thirty patients (25.9%) of whom became capable of daily oral intake (FOIS score ≥3). Swallowing function was associated with the resumption of oral intake. In addition, physical function before dysphagia rehabilitation was an important factor to resume daily oral intake.

Conclusions

The results of the present study suggest that the resumption of oral intake by patients receiving enteral nutrition requires improvement in swallowing function. In addition, anyone who cannot walk may not recover daily oral intake.

Predictors and associating factors of nasogastric tube removal: Clinical and brain imaging data analysis in post-stroke dysphagia

BACKGROUND/PURPOSE

Post-stroke dysphagia is a frequent complication. Although most patients with dysphagia recover after the acute phase, some patients require long-term enteral feeding, either through a nasogastric (NG) or gastrostomy tube; the effectiveness of using either tube is still under debate. This study elucidated the natural course of NG tube installation and removal and examined the predictors and associating factors based on clinical and brain imaging data.

METHODS

This retrospective cohort study with medical record reviews recruited patients received NG tube installation after their acute stroke events between January 1, 2016, and December 31, 2016. Inclusion criteria were subjects above 20 years of age and with a diagnosis of a newly onset stroke except SAH whose comprehensive clinical and imaging data were available. Survival analysis was performed for the right-censored data because some patients were lost to follow-up after discharge or transferal.

RESULTS

In total we recruited 135 patients. Among these patients, the timing of their NG tube removal reached a plateau at 12-16 weeks after stroke. The modified Rankin score on discharge, representing the overall subacute disease status, was the most significant factor. Other clinical variables could be divided into 2 categories: baseline patient characteristics and stroke event severity. Moreover, semi-quantitative brain imaging scores corresponding to the aforementioned 3 categories were correlated significantly.

CONCLUSION

In Taiwan, the NG tube removal rate reached a plateau at around 12-16 weeks after stroke onset. Variables related to long-term NG tube use were divided into baseline characteristics of patient and stroke event severity.

Predictors of Oral Feeding Resumption after Stroke in a Rehabilitation Hospital: A Retrospective Study

BACKGROUND

Dysphagia is common after stroke, requiring exclusive enteral feeding in 20% of patients. Recovery of oral feeding is associated with increased quality of life, better functional outcomes, and decreased mortality rates. However, evidence is heterogeneous and not conclusive on which factors are predictive of oral feeding recovery for stroke patients in rehabilitation units.

AIM

To investigate predictors of complete oral feeding recovery.

DESIGN

Retrospective study.

SETTING

Intensive inpatient rehabilitation hospital.

POPULATION

Poststroke dysphagic individuals with enteral feeding.

METHODS

Retrospective chart review of demographic, clinical, rehabilitation, and swallowing factors. Univariate analysis and multivariate regression analysis were used to compare variables between the oral feeding recovery group and the enteral feeding group at discharge.

RESULTS

One hundred thirty-nine patients were included in the analysis. A total of 61.9% of the sample population resumed complete oral intake at discharge. There were statistically significant differences between the 2 groups in Functional Independence Measure cognitive score, clinical swallow evaluation, and instrumental swallow evaluation at admittance, and dysphagia rehabilitation. Multiple logistic regression analysis identified the absence of aspiration signs with liquids associated with a higher probability of the resumption of complete oral feeding (odds ratio [OR] 3.57; 95% confidence interval [CI] 1.07-11.89). Age between 73 and 79 years (OR .96; 95% CI .01-.58), the presence of aspiration and/or penetration (OR .22; 95% CI .07-.72), and the presence of residue (OR .14; 95%CI .04-.43) during fiberoptic endoscopic evaluation of swallowing presented lower probability of returning to complete oral feeding.

CONCLUSION

Several demographic and swallowing characteristics predicted oral feeding recovery. Absence of dysphagia signs documented on fiberoptic endoscopic evaluation of swallowing was the strongest predictor of complete oral feeding resumption.

Factors Predicting Recovery of Oral Intake in Stroke Survivors with Dysphagia in a Convalescent Rehabilitation Ward

BACKGROUND

Percutaneous endoscopic gastrostomy may be performed in dysphagic stroke patients. However, some patients regain complete oral intake without gastrostomy. This study aimed to investigate the predictive factors of intake, thereby determining gastrostomy indications.

METHOD

Stroke survivors admitted to our convalescent rehabilitation ward who underwent gastrostomy or nasogastric tube placement from 2009 to 2015 were divided into 2 groups based on intake status at discharge. Demographic data and Functional Independence Measure (FIM), Dysphagia Severity Scale (DSS), National Institutes of Health Stroke Scale, and Glasgow Coma Scale (GCS) scores on admission were compared between groups. We evaluated the factors predicting intake using a stepwise logistic regression analysis.

RESULTS

Thirty-four patients recovered intake, whereas 38 achieved incomplete intake. Mean age was lower, mean body mass index (BMI) was higher, and mean time from stroke onset to admission was shorter in the complete intake group. The complete intake group had less impairment in terms of GCS, FIM, and DSS scores. In the stepwise logistic regression analysis, BMI, FIM-cognitive score, and DSS score were significant independent factors predicting intake. The formula of BMI × .26 + FIM cognitive score × .19 + DSS score × 1.60 predicted recovery of complete intake with a sensitivity of 88.2% and a specificity of 84.2%.

CONCLUSIONS

Stroke survivors with dysphagia with a high BMI and FIM-cognitive and DSS scores tended to recover oral intake.

Critical care in acute ischemic stroke

Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.

Age, Body Mass Index, and White Blood Cell Count Predict the Resumption of Oral Intake in Subacute Stroke Patients

OBJECTIVE

To identify the predictors for the resumption of oral feeding at discharge among tube feeding-dependent stroke patients admitted to rehabilitation wards.

MATERIALS AND METHODS

This study was a retrospective analysis of 107 stroke patients (mean age, 72.1 years) dependent on tube feeds at admission to a rehabilitation ward. Data analyzed included demographic information, severity of impairments, functional independence, body mass index, nutritional and inflammatory laboratory markers at admission, and videofluoroscopic examination findings, if conducted. The variables were compared between the groups with and without resumption of oral intake. The predictive factors for resumption of oral intake were analyzed by using a stepwise multiple logistic regression model.

RESULTS

At discharge, 69.2% (74 of 107) of the patients resumed oral intake. There were significant differences in age, the Functional Independence Measure, body mass index, serum albumin, C-reactive protein, white blood cell count, and duration of stroke onset at admission between the 2 groups. Multiple logistic regression analysis identified age (odds ratio [OR] .55; 95% confidence interval [CI] .31-.95), body mass index (OR 1.34; 95% CI 1.12-1.60), and white blood cell count (OR .76; 95% CI .60-.97) as significant predictors for the resumption of oral intake in these patients.

CONCLUSION

Older age, lower body mass index, and higher white blood cell count were significant independent negative predictors for the resumption of oral feeding among stroke patients dependent on tube feeding at admission to rehabilitation wards.

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients' demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima's classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02-1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04-3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01-1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03-0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08-1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r ² = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.