Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit

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Abstract

Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18–1.00; p = 0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU.

Introduction

Medical complications are frequently seen in acute stroke patients, and may increase mortality and length of hospital stay in the acute and subacute stroke phases [1]. Pneumonia is a common and important complication of stroke, affecting up to one third of patients [2], [3], [4]. Pneumonia has a great impact on the prognosis of stroke patients, and accounts for about 30% or a 3-fold increase in 30-day mortality [3]. Risk factors associated with post-stroke pneumonia include older age, poor oral hygiene, decreased level of consciousness, severity of post-stroke disability, brainstem stroke, and impaired swallowing function [2], [5], [6], [7]. There is a significant increased risk of stroke-associated pneumonia (SAP) in stroke patients with dysphagia, and an even greater risk in patients with aspiration [8]. Early identification of dysphagia by screening in acute stroke patients has been shown to reduce the incidence of SAP [9], and systematic use of dysphagia screening can decrease SAP significantly and improve outcome [10], [11].

Methods for detecting dysphagia include non-instrumental bedside screening, and instrumental methods such as videofluoroscopic study of swallowing (VFSS) and fiberoptic endoscopic examination of swallowing (FEES). VFSS is regarded as the gold standard for evaluation of swallowing function, but is limited by impracticability in acute stroke [12], [13]. FEES requires special equipment and a skilled operator, and cannot be used to evaluate the oral phase and esophageal phase during swallowing [13]. Although the detection sensitivity of bedside screening is not as good as that of instrumental methods, bedside screening is easy, noninvasive, repeatable, and can be incorporated into daily clinical practice [5], [14], [15]. Bedside screening of dysphagia has been shown to effectively reduce pneumonia incidence rates, and dysphagia screening has gradually been incorporated into the guidelines for the care of acute stroke patients [9], [16].

Acute stroke patients who require critical care have higher rates of SAP [6], [17], [18], since these patients have conditions that are related to more severe neurological deficits including dysphagia [19]. Knowing how to reduce SAP in acute stroke patients under critical care is crucial. To our knowledge, there have not been any reports evaluating routine bedside swallowing screening for decreasing SAP in acute stroke patients requiring critical care. The aim of this study was to assess effectiveness of bedside swallowing screening for prevention of SAP in acute stroke patients admitted to the intensive care unit (ICU).

Section snippets

Patients

About 1200 acute stroke patients are treated annually at the National Taiwan University Hospital (NTUH), and about 350 patients are cared for in the stroke ICU. The stroke ICU has 12 beds, and mainly serves acute stroke patients requiring intensive care and monitoring [20]. The criteria for admission to the stroke ICU include severe stroke (National Institutes of Health Stroke Scale [NIHSS] score > 10), ischemic stroke with the patient receiving thrombolytic therapy, acute stage of hemorrhagic

Results

After excluding 44 patients (pre-screen, 21 and post-screen, 23) who received endotracheal intubation on the first day of ICU admission and 7 patients (pre-screen, 5 and post-screen, 2) with TIA, 74 and 102 patients were included in the pre-screen and post-screen groups, respectively. The demographic data are shown in Table 1. The post-screen group was significantly older than the pre-screen group (pre-screen, 64.4 ± 13.3 years versus post-screen, 69.9 ± 13.7 years; p = 0.01); there was no significant

Discussion

This study showed that SAP in patients with acute stroke who were admitted to the stroke ICU was associated with a higher NIHSS score, older age, and nasogastric tube placement. This is the first study to demonstrate that dysphagia screening might prevent pneumonia in patients with acute stroke admitted to the ICU. However, the results indicated that dysphagia screening does not reduce in-hospital mortality.

We found that older stroke patients had a higher risk of pneumonia, which is consistent

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