Exploration of the associations between dysphagia, liquid intake restrictions, and comorbidities in acute stroke: a retrospective chart review.
Megan E Crawford, Stacey Reynolds, Tyler Corson and 3 others
Liquid intake restrictions in acute stroke tracked with aspiration pneumonia and UTI, but the authors attribute this to acutely ill patients receiving restrictions, not to the restrictions causing infection.
The association is not evidence that thickened liquids or NPO status increases infection risk.
Key findings
1In the logistic regression model, NPO orders were associated with 34.85-fold and thickened liquids with 10.65-fold increased odds of aspiration pneumonia.
2NPO orders were associated with 3.18-fold increased odds of UTI, and female sex with 2.58-fold increased odds.
3Dysphagia was documented in 31.7% of participants (n = 385), but swallow imaging was completed for only 17.6% of the total sample (n = 214).
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What it does not show
Single-center retrospective chart review; all variables depend on what was coded in the medical record, and dysphagia was identified by ICD-10 code rather than by a standardized swallowing assessment. The data did not capture the timing of the dysphagia diagnosis or the liquid restriction order relative to when the infection was documented, so it is impossible to tell whether the restriction came before or after the infection. Liquid restriction data reflect only the most stringent order recorded; it is unknown how many patients on NPO later progressed to thickened liquids. Age above 80 was not available due to an IRB privacy constraint, so the oldest patients could not be analyzed by exact age. The authors note that dysphagia codes may be under-documented because dysphagia is rarely a primary diagnosis, and 11% of patients without a dysphagia code still had liquid restrictions, suggesting some cases were missed. The study cannot establish causality; the authors explicitly state the associations likely reflect that acutely ill patients are both more likely to be restricted and more likely to develop infection.
Declared interests
The authors declared financial support from the National Institute on Aging (R01AG077481) and the Canada Research Chairs Secretariat. No industry sponsor is named, and no company that sells a swallowing product or diet is listed.
The easy way to misread this
Do not read the 34.85-fold association between NPO orders and aspiration pneumonia as proof that the restriction causes the infection. The authors state these associations likely reflect that acutely ill patients are both more likely to be restricted and more likely to develop pneumonia, and the retrospective design cannot separate these two explanations.
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