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Observational Study
. 2019 May 1;76(5):561-570.
doi: 10.1001/jamaneurol.2018.4858.

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

Marian Galovic  1   2   3 , Anne Julia Stauber  1 , Natascha Leisi  4 , Werner Krammer  1 , Florian Brugger  1 , Jochen Vehoff  1 , Philipp Balcerak  1 , Anna Müller  1 , Marlise Müller  4 , Jochen Rosenfeld  4 , Alexandros Polymeris  5 , Sebastian Thilemann  5 , Gian Marco De Marchis  5 , Thorsten Niemann  5 , Maren Leifke  5 , Philippe Lyrer  5 , Petra Saladin  6 , Timo Kahles  6 , Krassen Nedeltchev  6   7 , Hakan Sarikaya  7 , Simon Jung  7 , Urs Fischer  7 , Concetta Manno  8 , Carlo W Cereda  8 , Josemir W Sander  2   3   9 , Barbara Tettenborn  1 , Bruno J Weder  1   10 , Sandro J Stoeckli  4 , Marcel Arnold  7 , Georg Kägi  1
Affiliations
Observational Study

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

Marian Galovic et al. JAMA Neurol. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Brugger reported grants from Baasch-Medicus-Stipend, Merz Pharma Switzerland, and Clinical Trials Unit of Kantonsspital St. Gallen outside the submitted work and Zambon Pharma (speakers honorarium), Kantonsspital St Gallen and Spital Grabs (employment), University College London Hospitals (previous employment), and Südwestdeutscher Verlag für Hochschulschriften (royalties). Dr Vehoff reported personal fees from Almiral, Roche, and Teva outside the submitted work. Dr Fischer reported grants from Medtronic and consulting fees from Medtronic and Stryker outside the submitted work. Dr Sander reported grants from UCB and personal fees from UCB and Janssen outside the submitted work. Dr Tettenborn reported grants from SNF and Biogen and personal fees from Novartis and Sanofi outside the submitted work. Dr Arnold reported grants and personal fees from Nestle Health Science during the conduct of the study and personal fees from Amgen, Bayer, Boehringer Ingelheim, Medtronic, Covidien, Bayer, BMS, Pfizer, and Daichy Sankyo outside the submitted work. Dr Kägi reports serving on the scientific advisory board for Bayer and Boehringer Ingelheim and receiving speaking honoraria from Zambon outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Kaplan-Meier Estimates of Time to Recovery of Oral Intake
A, Plot of the overall clinical course of swallowing recovery (95% confidence intervals are shaded in red). B-F, Kaplan-Meier estimates for individual predictors in the Predictive Swallowing Score (PRESS) model. Separate lines are displayed for each cutoff used in PRESS. FOIS indicates Functional Oral Intake Scale; NIHSS, National Institutes of Health Stroke Scale.
Figure 2.
Figure 2.. Calculation of the Predictive Swallowing Score
FOIS indicates Functional Oral Intake Scale; NIHSS, National Institutes of Health Stroke Scale.
Figure 3.
Figure 3.. Prediction Estimates of Swallowing Recovery According to Predictive Swallowing Score (PRESS) Values
A and B, Risk estimates for impaired oral intake 7 days (indication for nasogastric tube feeding) and 30 days (indication for percutaneous endoscopic gastronomy feeding) after stroke. C and D, Risk estimates for a failed return to a prestroke diet. Horizontal lines are 95% confidence intervals.
Figure 4.
Figure 4.. Predictive Swallowing Score (PRESS) Smartphone Graphic App
A free smartphone and tablet app called “PRESS calc” is available to facilitate bedside examinations and prediction. It is available on Apple iOS (http://itunes.apple.com/us/app/press-calc/id1401176212) and Google Android (https://play.google.com/store/apps/details?id=ch.kssg.press).
See this image and copyright information in PMC

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