脳卒中の嚥下と栄養介入：コクラン

急性期、回復期の脳卒中に対する嚥下と栄養サポート介入のコクランレビューを紹介します。

Chamila Geeganage, Jessica Beavan, Sharon Ellender, Philip MW Bath. Interventions for dysphagia and nutritional support in acute and subacute stroke. The Cochrane Library DOI: 10.1002/14651858.CD000323.pub2

リサーチクエスチョンは以下の通りです。

P：急性期、回復期（発症6か月以内）の脳卒中患者に
I：嚥下障害に対する介入や栄養サポートを行うと
C：行わない場合と比較して
O：生命予後や機能予後が改善する
D：系統的レビュー

結果ですが、全般的にエビデンスは不十分です。行動介入（嚥下リハ）と鍼治療は、嚥下障害を少なくしました。咽頭電気刺激は、咽頭通過時間を短縮しました。経鼻経管よりPEGのほうが治療の失敗や消化管出血が少なく、十分な栄養投与が可能でアルブミン値が高値でした。栄養療法で褥瘡が減少し、エネルギー・蛋白摂取量が増えました。

以上より、経口摂取が可能な急性期脳卒中患者に、エネルギー・蛋白を追加投与する必要はなさそうです。ただし、低栄養の場合には、褥瘡減少に有効かもしれません。長期間の経管栄養を要する場合には、経鼻経管よりPEGが適当です。

脳卒中の嚥下リハと栄養管理が重要なことは間違いありませんが、コクランレビューとなるとエビデンスが乏しいのが現状でした。それでも低栄養患者の場合に栄養介入したほうが褥瘡減少に有効というのは意味があります。回復期脳卒中患者に対するリハ栄養の介入試験で、生命予後や機能予後が改善することを検証したいですね。

Abstract

Background

Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome.

Objectives

To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke.

Search methods

We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers.

Selection criteria

Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment.

Data collection and analysis

Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial.

Main results

We included 33 studies involving 6779 participants.

Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I² = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I² = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I² = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I² = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I² = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I² = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I² = 92%).

Authors' conclusions

There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.