Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Abstract

Objective: To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients.Methods: This study analyzed prespecified outcomes of PSP at 14 days and mortality and function measured by the modified Rankin Scale at 90 days in 1,217 nil-by-mouth stroke patients at #48 hours of symptom onset in a multicenter randomized controlled trial of preventive antibiotics between April 21, 2008, and May 17, 2014. Generalized mixed models adjusted for age, comorbidities, stroke type and severity, and quality of care were used. No patients were lost to follow-up at 14 days, and 36 (3%) were lost at 90 days. Conclusions: Early NGT does not increase PSP incidence, mortality, or poor functional outcomes and can be used safely in acute stroke patients. Neurology ® 2016;87:1352-1359 GLOSSARY CI 5 confidence interval; mRS 5 modified Rankin Scale; NGT 5 nasogastric tube; NIHSS 5 NIH Stroke Scale; OR 5 odds ratio; PSP 5 poststroke pneumonia; STROKE-INF 5 Prophylactic antibiotics for reducing pneumonia in acute stroke patients with dysphagia study. ResultsPoststroke pneumonia (PSP) is associated with a third of early deaths and a fifth of poor outcomes in stroke.1,2 Dysphagia is present in 51% to 78% of stroke patients and is often managed with nasogastric tubes (NGTs) for nutrition and hydration.3 Dysphagia increases the risk of PSP from 2% to 8% to 16% to 19%, 4,5 which may be increased further to 33% to 70% by NGT placement.6-8 Because supportive pharmacological or antimicrobial interventions do not appear to prevent PSP, it remains a major clinical challenge in nil-by-mouth patients, even on stroke units. [9][10][11] Evidence that NGT placement increases PSP incidence remains equivocal; observational studies suggesting this association are limited by heterogeneity in patients, settings, and diagnostic criteria for PSP. [6][7][8] It is possible that PSP and higher mortality are influenced by stroke severity rather than by NGT placement.12,13 Although preventive antibiotics did not reduce PSP in unselected stroke patients, 10,11 they may be effective in patients with NGT who have greater gastric reflux and aspiration caused by NGT-induced pharyngeal and lower esophageal sphincter dysfunction.

Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review

“…Eleven studies of 10 ischemic and hemorrhagic stroke patient cohorts were included (Table 1). Kalra et al [31] and Kalra et al [32] used the same RCT data. Study designs included RCTs (30%) [15,[31][32][33], prospective (20%) [13,34] and retrospective (40%) [35][36][37][38] observational studies and one quasi-experimental design [39].…”

“…Kalra et al [31] and Kalra et al [32] used the same RCT data. Study designs included RCTs (30%) [15,[31][32][33], prospective (20%) [13,34] and retrospective (40%) [35][36][37][38] observational studies and one quasi-experimental design [39]. Europe hosted 55% of studies [15,[31][32][33][34]37], Australia 27% [13,36,38] and Japan 18% [35,39].…”

“…Potential sources of selection bias in the cluster RCT studies [31,32] included where patients at increased risk of SAP might have been preferentially recruited into the intervention group. A limitation of the Kalra et al [31] study was that data were derived from an RCT and a prospective cohort data structure was assumed, which may have resulted in selection bias. A possible source of performance bias was participants and researchers being aware of allocation treatment.…”

“…One study made a diagnosis based on the British Thoracic Society recommendations [15]. The STROKE-INF trial data set used blinded application of CDC criteria and physician-diagnosed pneumonia [31,32]. Four used a combination of clinical symptoms, radiologic findings on X-ray and laboratory results and combined antibiotics [13,15,33,37].…”

Variation in Dysphagia Assessment and Management in Acute Stroke: An Interview Study

“…There is emerging evidence for the use of preventative measures such as screening for stroke-induced immunosuppression and dysphagia, for identifying patients at high risk for SAP [15]. Further studies are needed to test this and screening for oral aerobic Gram-negative bacteria [16] as well as the need to evaluate if treatment with proton pump inhibitors [17] and nasogastric tubes (NGT) [18][19][20] are associated with SAP in patients with dysphagia.…”