Development and Validation of a Prognostic Model of Swallowing Recovery and Enteral Tube Feeding After Ischemic Stroke.

Galovic, Marian; Stauber, Anne Julia; Leisi, Natascha; Krammer, Werner; Brugger, Florian; Vehoff, Jochen; Balcerak, Philipp; Müller, Anna; Müller, Marlise; Rosenfeld, Jochen; Polymeris, Alexandros; Thilemann, Sebastian; De Marchis, Gian Marco; Niemann, Thorsten; Leifke, Maren; Lyrer, Philippe; Saladin, Petra; Kahles, Timo; Nedeltchev, Krassen; Sarikaya, Hakan

Key Points: Question: Can a prognostic model predict swallowing recovery and inform the need for enteral tube feeding after dysphagic ischemic stroke? Findings: In this single-center derivation and multicenter validation study of 279 adults with severe dysphagia, a scoring system based on 5 factors (age, stroke severity on admission, stroke location, initial risk of aspiration, and initial impairment of oral intake) predicted the recovery of functional oral intake 7 (an indication for nasogastric tube feeding) and 30 days (an indication for percutaneous endoscopic gastronomy feeding) after stroke. Meaning: The Predictive Swallowing Score, available as the "PRESS calc" smartphone application, provided accurate predictions and could be used to guide decisions about enteral tube feeding. Importance: Predicting the duration of poststroke dysphagia is important to guide therapeutic decisions. Guidelines recommend nasogastric tube (NGT) feeding if swallowing impairment persists for 7 days or longer and percutaneous endoscopic gastrostomy (PEG) placement if dysphagia does not recover within 30 days, but, to our knowledge, a systematic prediction method does not exist. Objective: To develop and validate a prognostic model predicting swallowing recovery and the need for enteral tube feeding. Design, Setting, and Participants: We enrolled participants with consecutive admissions for acute ischemic stroke and initially severe dysphagia in a prospective single-center derivation (2011-2014) and a multicenter validation (July 2015-March 2018) cohort study in 5 tertiary stroke referral centers in Switzerland. Exposures: Severely impaired oral intake at admission (Functional Oral Intake Scale score <5). Main Outcomes and Measures: Recovery of oral intake (primary end point, Functional Oral Intake Scale ≥5) or return to prestroke diet (secondary end point) measured 7 (indication for NGT feeding) and 30 (indication for PEG feeding) days after stroke. Results: In total, 279 participants (131 women [47.0%]; median age, 77 years [interquartile range, 67-84 years]) were enrolled (153 [54.8%] in the derivation study; 126 [45.2%] in the validation cohort). Overall, 64% (95% CI, 59-71) participants failed to recover functional oral intake within 7 days and 30% (95% CI, 24-37) within 30 days. Prolonged swallowing recovery was independently associated with poor outcomes after stroke. The final prognostic model, the Predictive Swallowing Score, included 5 variables: age, stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake. Predictive Swallowing Score prediction estimates ranged from 5% (score, 0) to 96% (score, 10) for a persistent impairment of oral intake on day 7 and from 2% to 62% on day 30. Model performance in the validation cohort showed a discrimination (C statistic) of 0.84 (95% CI, 0.76-0.91; P <.001) for predicting the recovery of oral intake on day 7 and 0.77 (95% CI, 0.67-0.87; P <.001) on day 30, and a discrimination for a return to prestroke diet of 0.94 (day 7; 95% CI, 0.87-1.00; P <.001) and 0.71 (day 30; 95% CI, 0.61-0.82; P <.001). Calibration plots showed high agreement between the predicted and observed outcomes. Conclusions and Relevance: The Predictive Swallowing Score, available as a smartphone application, is an easily applied prognostic instrument that reliably predicts swallowing recovery. It will support decision making for NGT or PEG insertion after ischemic stroke and is a step toward personalized medicine. This validation study describes the development of a prognostic model to predict swallowing recovery and guide the decision for enteral tube feeding in people with dysphagia after ischemic stroke.

JAMA Neurology, 2019, Vol 76, Issue 5, p561

2168-6149

Academic Journal

10.1001/jamaneurol.2018.4858