Intracerebral Hemorrhage and Absence of Pneumonia are Independent Predictors for Nasogastric Tube Removal of Post-Stroke Dysphagia

Sir, Post-stroke dysphagia (PSD), one of the most common complications of stroke, is associated with an increased risk of mortality and morbidity due in part to pneumonia, aspiration, and malnutrition.[1] Although many stroke patients can regain swallowing function spontaneously, 11–50% still have dysphagia at 6 months.[1] Nasogastric tube (NGT) feeding is required to maintain nutrition in chronic dysphagia, but the timing of NGT removal is hard to predict. Lee et al. found that admission Barthel Index, lip closing status, ability to answer simple questions, and functional independence before stroke could predict NGT removal before discharge.[2] However, it did not control the confounding factors, which may affect the stability of the results. In our study, we used propensity score matching (PSM) in SPSS to balance age, gender, and stroke phases. It might be more conducive to obtaining the associating factors on NGT removal and providing the reference for clinical practice. We conducted a retrospective, single-center, case–control study and involved 2091 patients admitted to the Acupuncture Department in First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from Dec 1, 2019, to June 31, 2022. Among the involved patients, we isolated 303 PSD patients with NGT feeding (40 removed during hospitalization). The inclusion criteria were: a. patients satisfying the diagnostic criteria of stroke referring to the guidelines of China;[34] b. age >18 years old; and c. NGT feeding on admission; the exclusion criteria were: a. alternative neurological diagnoses (including traumatic brain injury, intracranial tumors, seizures, and so on); b. incomplete case information; c. times of hospitalization ≥2 (we recorded the most recent one); and d. dysphagia caused by diseases other than stroke. NGT would be removed only when the patients could swallow safely without infectious symptoms and had adequate oral intake. To reduce confounding effects, we used 1:1 PSM in SPSS 26.0 to balance age, gender, and stroke phases. Ultimately, 80 patients were included in the final analysis. Among them, 40 successfully removed NGT during hospitalization, while 40 did not [Figure 1].Figure 1: Detail of recruitment. TUTCM = Tianjin University of Traditional Chinese Medicine, NGT = nasogastric tubeThe baseline characteristics of these two groups were shown in Table 1. After 1:1 PSM, there were no significant differences in age, gender, and stroke phases. Nearly all the included patients were in the subacute phase of stroke, of which only two in the retained group were in the chronic phase of stroke. The total NIHSS score was (median 16.00, interquartile range (IQR) 13.00–20.75) of the retained group, much higher than the removed group (median 12.50, IQR 10.00–16.00). The consciousness score (median 2.50, IQR 1.00–4.00), aphasia score (median 2.50, IQR 2.00–3.00), and dysarthria score (median 2.00, IQR 1.00–2.00) in NIHSS were also higher compared with the removed group. In the univariate analysis [Table 1], intracerebral hemorrhage, pneumonia, and admission NIHSS score (including total, consciousness, aphasia, and dysarthria score) were strongly associated with the removal of NGT (P < 0.05). In the forward stepwise binary logistic regression analysis [Table 2], it showed that patients with intracerebral hemorrhage (OR 3.667, 95%CI 1.211–11.110, P = 0.022) and those with the absence of pneumonia (OR 0.285, 95%CI 0.091–0.890, P = 0.031) were more likely to remove NGT during hospitalization.Table 1: Comparison of baseline characteristics between removed and retained groupsTable 2: Binary logistic regression analysis on factors associated with nasogastric tube (NGT) removal in post-stroke dysphagia (PSD) patientsThis case–control study retrospectively analyzed the predicting factors of NGT removal in PSD patients. We found that intracerebral hemorrhagic stroke and pneumonia were independently associated with the removal of NGT in PSD patients. In our study, the rate of NGT removal during hospitalization was 13.2%, much lower than the previous studies (45–74%).[25] It might be related to the stroke severity of our patients since the NIHSS scores were much higher than in previous studies. In addition, since stroke phases and age have been suggested as the critical risk factors for the recovery of swallowing function,[16] we believe it is necessary to control the confounding effect of these risk factors. In addition, some research has found that NGT insertion did not reduce but increased the risk of pneumonia.[78] Pneumonia was the necessary evaluation index before removing NGT, and patients could remove NGT only when they had no infectious symptoms. This might explain the association between pneumonia and NGT removal in our study. Moreover, our study also found that intracerebral hemorrhage was a predictive factor of NGT removal. A study published in Stroke showed that intracerebral hemorrhagic patients had better functional and neurological recovery than cerebral infarction patients when controlling more powerful prognostic factors.[9] The neurological deficit of intracerebral hemorrhage was caused by bleeding compression, and when the cerebral hematoma subsided, the neurological function would recover to a certain extent. Finally, according to Kumar's study, the admission NIHSS score was related to the stroke severity and had a predictive effect on persistent dysphagia.[10] However, it was not found as an independent factor for NGT removal in our study, which might be related to our small sample size. Our research indicated that additional attention should be paid to stroke subtype and pneumonia in PSD patients with NGT. Patients with intracerebral hemorrhage were more likely to remove NGT before discharge, whereas pneumonia was a risk factor for NGT removal. The strength of our study was that we used PSM to control the confounding effect of the well-recognized risk factors, in order to get more stable predictive factors. Our study also has several limitations: First, due to the retrospective design, we could not obtain other stroke-related factors such as the Barthel Index and the patients' information after discharge. Furthermore, the sample size was small, which could not comprehensively and representative reflect the associating factors of NGT removal in PSD patients. Prospective research should be carried out to further explore the predictors of NGT removal. Financial support and sponsorship The study was funded by National Key R&D Program of China, No. 2018YFC1705000 (Subject No. 4 2018YFC1705004). Conflicts of interest There are no conflicts of interest.