Prediction of Pneumonia in Acute Stroke Patients Using Tongue Pressure Measurements

Abstract

Swallowing dysfunction caused by stroke is a risk factor for aspiration pneumonia. Tongue pressure measurement is a simple and noninvasive method for evaluating swallowing dysfunction. We have hypothesized that low tongue pressure may be able to predict pneumonia occurrence in acute stroke patients. Tongue pressure was measured using balloon-type equipment in 220 acute stroke patients. The modified Mann Assessment of Swallowing Ability (MASA) score was evaluated independently on the same day. Tongue pressure was measured every week thereafter. An improvement in tongue pressure was observed within the first 2 weeks. Receiver operating curve analysis was performed to determine the ability of tongue pressure to predict modified MASA score <95, which suggests swallowing dysfunction. The optimal cutoff for tongue pressure was 21.6 kPa (χ2 = 45.82, p<0.001, sensitivity 95.9%, specificity 91.8%, area under the curve = 0.97). The tongue pressure was significantly lower in patients with pneumonia than in those without pneumonia. Using a Cox proportional hazard model for pneumonia onset with a cutoff tongue pressure value of 21.6 kPa and adjustment for age, sex, and National Institutes of Health Stroke Scale score at admission, the tongue pressure had additional predictive power for pneumonia onset (hazard ratio, 7.95; 95% confidence interval, 2.09 to 52.11; p = 0.0013). In the group with low tongue pressure, 27 of 95 patients showed improvement of tongue pressure within 2 weeks. Pneumonia occurred frequently in patients without improvement of tongue pressure, but not in patients with improvement (31/68 and 2/27, p<0.001). Tongue pressure is a sensitive indicator for predicting pneumonia occurrence in acute stroke patients.

Fatores associados à pressão de língua em pacientes pós-acidente vascular cerebral

“…Studies with post-stroke patients (6,18,19) also found that the mean and maximum tongue pressure was significantly lower in the dysphagia group. Thus, the decrease in tongue pressure observed in some cases of stroke was basically associated with the presence of dysphagia.…”

“…In addition, it is a resource that can be used at the bedside and can predict the occurrence of pneumonia if the pressure is below 21.6 kPa (6) . Therefore, the analysis of the pressure of the tongue should be an aspect valuable and approached therapeutically during rehabilitation from dysphagia, in addition to other alterations found.…”

“…Although these are not variables addressed in the literature, they should not be disregarded in future research and investigations, since the present study was the only one found with an evaluation of the patients in the first days after the stroke. Tongue pressure may increase significantly after two weeks from the event (6) . Thus, it is important to monitor the tongue pressure gain over time, since patients who do not show an increase in tongue pressure, even with therapy, are at higher risk of developing pneumonia (6) .…”

“…Clinical speech pathology practice in hospitals shows that there is a high prevalence of dysphagia in post-stroke patients (2) , a fact supported by the literature (3) . Dysphagia indicates a decline in the swallowing function, and its estimated prevalence can vary from 42% to 76% in patients with acute stroke (4,5,6) . The presence of dysphagia is associated with an increased risk of pulmonary complications from aspiration of saliva and/or food, malnutrition, dehydration, pneumonia, prolonged hospitalization, and death (7) .…”

“…Abnormal tongue function may also favor the presence of oral residue, prolonged oral transit time (3) , difficulty in bolus formation, and premature loss of food (10) . There is evidence that the greatest degree of tongue strength impairment occurs in patients with oropharyngeal dysphagia, compared with those with adequate swallowing (6,8,11) . However, there are few studies investigating patients after stroke, and there are no publications with data from the Brazilian population.…”