非经口进食吞咽障碍脑卒中患者预后的相关因素及预测模型

doi:10.3969/j.issn.1006-9771.2022.04.012

摘要/Abstract

摘要：

目的回顾性分析影响卒中后非经口进食吞咽障碍患者恢复经口进食的因素,并建立预测模型。方法收集2017年4月至2020年11月北京博爱医院听力语言科连续收治的141例脑卒中患者的基本资料、评估及治疗情况,采用单因素分析及Logistic回归建立恢复经口进食进行预后模型,采用Hosmer-Lemeshow(H-L)检验和接受者操作特征(ROC)曲线对模型的拟合度及判别效度进行评价。另选取2020年12月至2021年11月本院脑卒中所致吞咽障碍患者121例为验证组对模型进行验证。结果单因素分析显示,美国国立卫生研究院卒中量表(NIHSS)得分、饮水试验结果、自主咳嗽能力、吞咽后是否呛咳、舌和下颌的运动能力,以及治疗中是否有电刺激与预后相关(H=65.803, χ² > 4.623, P<0.05)。多因素Logistic回归分析显示,NIHSS得分(X₁, OR=0.772, 95%CI 0.64~0.82, P<0.001)、自主咳嗽能力(X₂, OR=5.116, 95%CI 1.28~20.41, P=0.021)和训练方案中是否含电刺激(X₃, OR=94.718, 95%CI 5.65~1589.26, P=0.002)是影响恢复经口进食结局的独立因子,预测模型为 $P = 1 1 + e - (2.368 - 0.325 X 1 + 1.632 X 2 + 4.551 X 3)$ 。模型拟合优度较好(P=0.845);与单项因素相比,模型曲线下面积最大(0.884)。经验证,所建模型的总体准确率91.7%。结论吞咽障碍患者NIHSS得分越低且自主咳嗽能力正常者,吞咽预后更好,而综合康复中加入电刺激治疗可能对患者恢复经口进食更为有利。建立的预测模型有一定的预测效能,可进一步研究。

关键词: 吞咽障碍, 经口进食, 预测模型, Logistic回归

Abstract:

Objective To explore the factors related to the recovery of nil per os (NPO) patients after stroke by retrospective data analysis, and to establish a predictive model.Methods The information of demographics, evaluation and treatment of 141 stroke patients admitted to the Hearing and Language Department in Beijing Bo'ai Hospital from April, 2017 to November, 2020 were selected. The predictive model was established by univariate analysis and Logistic regression. The fitting degree and discriminant validity of the model were evaluated by Hosmer-Lemeshow (H-L) test and receiver operating characteristic (ROC) curve. Other 121 patients with post-stroke dysphagia from December, 2020 to November, 2021 were used as the validation set to verify the model.Results For univariate analysis, National Institute of Health Stroke Scale (NIHSS) score, drinking water test results, autonomous cough ability, cough after swallowing, movement ability of tongue and jaw, and electrical stimulation treatment were significantly associated with the outcome (H=65.803, χ² > 4.623, P<0.05). Multivariate Logistic regression analysis showed that NIHSS score (X₁, OR=0.772, 95%CI 0.64 to 0.82, P<0.001), spontaneous cough ability (X₂, OR=5.116, 95%CI 1.28 to 20.41, P=0.021), and electrical stimulation during treatment (X₃, OR=94.718, 95%CI 5.65 to 1589.26, P=0.002) were independent factors for the outcome of swallowing function. Thus, the predictive model was $P = 1 1 + e - (2.368 - 0.325 X 1 + 1.632 X 2 + 4.551 X 3)$ , which was well fitting (P=0.845), with the largest area under curve (0.884). The overall accuracy of the model in the validation set was 91.7%.Conclusion The patients with dysphagia would like to recover well if he/she was with lower NIHSS scores and normal autonomous cough ability; meanwhile, the addition of electrical stimulation therapy in comprehensive rehabilitation may be helpful. A predictive model has been established, which needs a further research.

Key words: dysphagia, oral feeding, prognostic model, Logistic regression

王博,袁永学,张庆苏. 非经口进食吞咽障碍脑卒中患者预后的相关因素及预测模型[J]. 《中国康复理论与实践》, 2022, 28(4): 453-460.

WANG Bo,YUAN Yongxue,ZHANG Qingsu. Factors related to swallowing recovery for nil per os patients after stroke and prediction model[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(4): 453-460.

图/表 5

表1

表2

表3

表4

表5

参考文献 37

[1]	中国吞咽障碍康复评估与治疗专家共识组. 中国吞咽障碍评估与治疗专家共识(2017年版)第一部分评估篇[J]. 中华物理医学与康复杂志, 2017, 39(12):881-892.
	Expert Consensus Group on Rehabilitation Evaluation and Treatment of Dysphagia in China. Chin J Phys Med Rehabil, 2017, 39(12):881-892.
[2]	SMITHARD D G, O'NEILL P A, ENGLAND R E, et al. The natural history of dysphagia following a stroke[J]. Dysphagia, 1997, 12(4):188-193. doi: 10.1007/PL00009535
[3]	DESAI S V, LAW T J, NEEDHAM D M. Long-term complications of critical care[J]. Crit Care Med, 2011, 39(2):371-379. doi: 10.1097/CCM.0b013e3181fd66e5
[4]	WIRTH R, SMOLINER C, JAGER M, et al. Guideline clinical nutrition in patients with stroke[J]. Exp Transl Stroke Med, 2013, 5(1):14. doi: 10.1186/2040-7378-5-14
[5]	ROFES L, MURIANA D, PALOMERAS E, et al. Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: a cohort study[J]. [ahead of print]. Neurogastroenterol Motil, 2018: e13338. doi: 10.1111/nmo.13338. doi: 10.1111/nmo.13338
[6]	JAMPATHONG N, LAOPAIBOON M, RATTANAKANOKCHAI S, et al. Prognostic models for complete recovery in ischemic stroke: a systematic review and meta-analysis[J]. BMC Neurol, 2018, 18(1):26. doi: 10.1186/s12883-018-1032-5
[7]	WILMSKOETTER J, HERBERT T L, BONILHA H S. Factors associated with gastrostomy tube removal in patients with dysphagia after stroke: a review of the literature[J]. Nutr Clin Pract, 2017, 32(2):166-174. doi: 10.1177/0884533616661012
[8]	GALOVIC M, STAUBER A J, LEISI N, et al. Development and validation of a prognostic model of swallowing recovery and enteral tube feeding after ischemic stroke[J]. JAMA Neurol, 2019, 76(5):561-570. doi: 10.1001/jamaneurol.2018.4858
[9]	DUBIN P H, BOEHME A K, SIEGLER J E, et al. New model for predicting surgical feeding tube placement in patients with an acute stroke event[J]. Stroke, 2013, 44(11):3232-3234. doi: 10.1161/STROKEAHA.113.002402
[10]	KUMAR S, DOUGHTY C, DOROS G, et al. Recovery of swallowing after dysphagic stroke: an analysis of prognostic factors[J]. J Stroke Cerebrovasc Dis, 2014, 23(1):56-62. doi: 10.1016/j.jstrokecerebrovasdis.2012.09.005
[11]	MOON H I, NAM J S, LEEM M J, et al. Periventricular white matter lesions as a prognostic factor of swallowing function in older patients with mild stroke[J]. Dysphagia, 2017, 32(4):480-486. doi: 10.1007/s00455-017-9788-0
[12]	KUMAR S, LANGMORE S, GODDEAU R P, et al. Predictors of percutaneous endoscopic gastrostomy tube placement in patients with severe dysphagia from an acute-subacute hemispheric infarction[J]. J Stroke Cerebrovasc Dis, 2012, 21(2):114-120. doi: 10.1016/j.jstrokecerebrovasdis.2010.05.010
[13]	BROADLEY S, CROSER D, COTTRELL J, et al. Predictors of prolonged dysphagia following acute stroke[J]. J Clin Neurosci, 2003, 10(3):300-305. doi: 10.1016/S0967-5868(03)00022-5
[14]	GALOVIC M, LEISI N, PASTORE-WAPP M, et al. Diverging lesion and connectivity patterns influence early and late swallowing recovery after hemispheric stroke[J]. Hum Brain Mapp, 2017, 38(4):2165-2176. doi: 10.1002/hbm.23511
[15]	GALOVIC M, LEISI N, MULLER M, et al. Lesion location predicts transient and extended risk of aspiration after supratentorial ischemic stroke[J]. Stroke, 2013, 44(10):2760-2767. doi: 10.1161/STROKEAHA.113.001690
[16]	STEINHAGEN V, GROSSMANN A, BENECKE R, et al. Swallowing disturbance pattern relates to brain lesion location in acute stroke patients[J]. Stroke, 2009, 40(5):1903-1906. doi: 10.1161/STROKEAHA.108.535468
[17]	SCHROEDER M F, DANIELS S K, MCCLAIN M, et al. Clinical and cognitive predictors of swallowing recovery in stroke[J]. J Rehabil Res Dev, 2006, 43(3):301-310. doi: 10.1682/JRRD.2004.12.0154
[18]	ICKENSTEIN G W, KELLY P J, FURIE K L, et al. Predictors of feeding gastrostomy tube removal in stroke patients with dysphagia[J]. J Stroke Cerebrovasc Dis, 2003, 12(4):169-174. doi: 10.1016/S1052-3057(03)00077-6
[19]	CHEN W, WANG C, FU F, et al. A model to predict the risk of lymph node metastasis in breast cancer based on clinicopathological characteristics[J]. Cancer Manag Res, 2020, 12:10439-10447. doi: 10.2147/CMAR.S272420
[20]	杜丽洁, 姜增誉, 王娇, 等. Rosenbek渗透/误吸量表在脑卒中误吸筛查中的应用[J]. 中西医结合心脑血管病杂志, 2015, 13(10):1225-1226.
	DU L J, JIANG Z Y, WANG J, et al. Application of the Rosenbek penetration/aspiration scale in stroke aspiration screening[J]. Chin J Integr Med Cardio/Cerebrov Dis, 2015, 13(10):1225-1226.
[21]	LEE W H, LIM M H, SEO H G, et al. Development of a novel prognostic model to predict 6-month swallowing recovery after ischemic stroke[J]. Stroke, 2020, 51(2):440-448. doi: 10.1161/STROKEAHA.119.027439
[22]	ROST N S, BOTTLE A, LEE J M, et al. Stroke severity is a crucial predictor of outcome: an international prospective validation study[J]. J Am Heart Assoc, 2016, 5(1):e002433.
[23]	窦祖林. 吞咽障碍评估与治疗[M]. 2版. 北京: 人民卫生出版社, 2017.
	DOU Z L. Evaluation and Treatment of Dysphagia[M]. 2nd ed. Beijing: People's Medical Publishing House, 2017.
[24]	COSTA M M. Videofluoroscopy: the gold standard exam for studying swallowing and its dysfunction[J]. Arq Gastroenterol, 2010, 47(4):327-328. doi: 10.1590/S0004-28032010000400001
[25]	中国吞咽障碍康复评估与治疗专家共识组. 中国吞咽障碍评估与治疗专家共识(2017年版)第二部分治疗与康复管理篇[J]. 中华物理医学与康复杂志, 2018, 40(1):1-10.
	Expert consensus group on rehabilitation evaluation and treatment of dysphagia in China[J]. Chin J Phys Med Rehabil, 2018, 40(1):1-10.
[26]	廖耀华, 伍琼文. 脑卒中后吞咽功能障碍患者继发吸入性肺炎的独立危险因素分析[J]. 中国医药科学, 2019, 9(14):172-174, 233.
	LIAO Y H, WU Q W. Analysis on independent risk factors for secondary aspiration pneumonia in patients with swallowing dysfunction after stroke[J]. Chin Med Pharm, 2019, 9(14):172-174, 233.
[27]	BROGAN E, LANGDON C, BROOKES K, et al. Dysphagia and factors associated with respiratory infections in the first week post stroke[J]. Neuroepidemiology, 2014, 43(2):140-144. doi: 10.1159/000366423
[28]	沈文燕. 舒适护理对吞咽障碍鼻饲患者负性情绪和应激反应的影响[J]. 系统医学, 2019, 4(22):178-180.
	SHEN W Y. Effect of comfortable nursing on negative emotion and stress response in patients with swallowing nasal feeding[J]. System Med, 2019, 4(22):178-180.
[29]	GÜLEÇ A, ALBAYRAK I, ERDUR Ö, et al. Effect of swallowing rehabilitation using traditional therapy, kinesiology taping and neuromuscular electrical stimulation on dysphagia in post-stroke patients: a randomized clinical trial[J]. Clin Neurol Neurosurg, 2021, 211:107020.
[30]	冯海容. 口鼻腔护理对留置胃管患者舒适度、疼痛程度的影响[J]. 广州医科大学学报, 2016, 44(3):132-133.
	FENG H R. Effect of oral and nasal nursing on comfort and pain of patients with indwelling gastric tube[J]. Acad J Guangzhou Med Univ, 2016, 44(3):132-133.
[31]	王晨, 钟鸣. 脑血管病患者吸入性肺炎的危险因素和预防研究进展[J]. 临床内科杂志, 2021, 38(6):367-369.
	WANG C, ZHONG M. Research progress on risk factors and prevention of aspiration pneumonia in patients with cerebrovascular disease[J]. J Clin Intern Med, 2021, 38(6):367-369.
[32]	LIN L C, WANG S C, CHEN S H, et al. Efficacy of swallowing training for residents following stroke[J]. J Adv Nurs, 2003, 44(5):469-478. doi: 10.1046/j.0309-2402.2003.02830.x
[33]	MARTINDALE N, STEPHENSON J, POWNALL S. Neuromuscular electrical stimulation plus rehabilitative exercise as a treatment for dysphagia in stroke and non-stroke patients in an nhs setting: feasibility and outcomes[J]. Geriatrics (Basel), 2019, 4(4):53.
[34]	EVERTON L F, BENFIELD J K, MICHOU E, et al. Effects of pharyngeal electrical stimulation on swallow timings, clearance and safety in post-stroke dysphagia: analysis from the swallowing treatment using electrical pharyngeal stimulation (STEPS) trial[J]. Stroke Res Treat, 2021, 2021:5520657.
[35]	MENG P, ZHANG S, WANG Q, et al. The effect of surface neuromuscular electrical stimulation on patients with post-stroke dysphagia[J]. J Back Musculoskelet Rehabil, 2018, 31(2):363-370. doi: 10.3233/BMR-170788
[36]	张怒文, 张杏容, 倪莉, 等. 经皮电刺激联合球囊扩张术对颅脑损伤后吞咽障碍患者的康复效果观察[J]. 中外医学研究, 2021, 19(27):17-20.
	ZHANG N W, ZHANG X R, NI L, et al. Rehabilitation effect of percutaneous electrical stimulation combined with balloon dilatation on patients with dysphagia after traumatic brain injury[J]. Chin Foreign Med Res, 2021, 19(27):17-20.
[37]	吴扬, 蒋丽红. 神经肌肉电刺激联合康复护理对脑梗死吞咽功能障碍患者康复效果的影响[J]. 医疗装备, 2021, 34(18):142-144.
	WU Y, JIANG L H. Rehabilitation effect of neuromuscular electrical stimulation combined with the nursing on patients with dysphagia after cerebral infarction[J]. Med Equip, 2021, 34(18):142-144.

变量	赋值方式
NIHSS得分	计量资料
饮水试验	正常=1;可疑=2;异常=3
吞咽后呛咳	否=0;是=1
自主咳嗽	无=0;有=1
舌运动	正常=0;异常=1
下颌运动	正常=0;异常=1
综合训练含电刺激	否=0;是=1
预后良好	否=0;是=1

项目	回归系数	标准误	Wald值	P值	OR值	95%CI
NIHSS得分	-0.325	0.061	28.088	< 0.001	0.722	0.64~0.82
自主咳嗽	1.632	0.706	5.348	0.021	5.116	1.28~20.41
电刺激	4.551	1.439	10.004	0.002	94.718	5.65~1589.26
常数	2.368	1.504	2.479	0.115	10.675

指标	AUC	标准误	临界值	P值	95%CI
预测模型	0.884	0.033	0.5	< 0.001	0.819~0.948
NIHSS得分	0.091	0.024	16.5	< 0.001	0.044~0.138
自主咳嗽	0.616	0.049	0.5	0.020	0.520~0.712
电刺激	0.720	0.042	0.5	< 0.001	0.638~0.803

实际预后(n)	模型预测预后(n)		合计
实际预后(n)	不良(< 0.5)	良好(≥ 0.5)	合计
不良	67	4	71
良好	6	44	50
合计	73	48	121