Neurology · Medical Literature
Application of gastric tube removal strategy based on the combination of Gugging Swallowing Screen (GUSS) and National Institutes of Health Stroke Scale (NIHSS) scores in patients following acute stroke: A randomized controlled trial.
Abstract
Dysphagia is a common, serious complication in acute stroke patients, often requiring indwelling gastric tubes. Prolonged tube use increases risks of aspiration pneumonia and other adverse events. Current assessment methods often lack the sensitivity needed to guide safe extubation. To investigate the effect of combined Gugging Swallowing Screen (GUSS) and National Institutes of Health Stroke Scale (NIHSS) scores on the gastric tube removal in acute stroke patients. Between November 2021 and November 2022, 110 patients were admitted to our hospital with acute stroke and fitted with an indwelling gastric tube. We collated clinical data, performed the Kubota Water Swallowing Test, and determined the NIHSS and GUSS scores. Patients were then divided randomly into experimental and control groups. In the experimental group, gastric tubes were removed based on an NIHSS score < 15 and a GUSS score ≥ 15, while in the control group, extubation followed the Kubota Water Swallowing Test. Adverse events related to the 2 strategies were analyzed. No significant differences were detected between the 2 groups in terms of baseline clinical characteristics. When compared to the traditional extubation strategy based on the Kubota Water Swallowing Test, the incidence of aspiration pneumonia, indwelling time for the gastric tube, and the secondary indwelling rate associated with the combination of GUSS and NIHSS scores were significantly (P < .05) reduced. Cox and Kaplan-Meier curves demonstrated that the extubation strategy applied in the experimental group significantly (P < .05) reduced the risk of adverse events. An NIHSS score < 15 and a GUSS score ≥ 15 can be used to approve the removal of a gastric tube from acute stroke patients; this represents a reliable and safe strategy that reduces the risk of adverse events.
Clinical relevance
Post-stroke dysphagia affects a substantial proportion of acute stroke patients and frequently necessitates indwelling nasogastric tube (NGT) placement; however, prolonged NGT use is independently associated with aspiration pneumonia, secondary tube re-insertion, and other preventable adverse events. The Kubota Water Swallowing Test—the conventional extubation guide—lacks sufficient sensitivity to reliably identify patients safe for NGT removal, creating a clinically significant gap in evidence-based decision-making. This RCT directly addresses that gap by prospectively evaluating a dual-score extubation protocol (GUSS + NIHSS) in a population where optimizing the timing of NGT removal carries immediate patient safety implications.
Key findings
1. Study population: 110 acute stroke patients with indwelling NGTs enrolled between November 2021 and November 2022 were randomized into an experimental group (GUSS + NIHSS-guided extubation) and a control group (Kubota Water Swallowing Test-guided extubation); baseline clinical characteristics were comparable between groups (p > .05 for all). 2. Extubation threshold: In the experimental group, NGT removal was approved when NIHSS score was < 15 AND GUSS score was ≥ 15, representing a dual-criterion threshold combining neurological severity with bedside swallowing performance. 3. Aspiration pneumonia: The incidence of aspiration pneumonia was significantly lower in the experimental (GUSS + NIHSS) group compared to the control (Kubota) group (p < .05); exact event rates and relative risk reduction were not reported in the abstract. 4. NGT indwelling duration: Total duration of gastric tube placement was significantly shorter in the experimental group versus the control group (p < .05); specific mean durations were not reported in the abstract. 5. Secondary NGT re-insertion rate: The rate of secondary NGT re-indwelling (failed extubation requiring tube replacement) was significantly reduced in the experimental group compared to the control group (p < .05); exact proportions were not provided in the abstract. 6. Adverse event risk over time: Cox proportional hazards analysis and Kaplan-Meier survival curves both demonstrated a statistically significant reduction in the overall risk of adverse events in the experimental group (p < .05); hazard ratios and confidence intervals were not reported in the abstract.
Practice implications
For acute stroke patients requiring NGT feeding, clinicians should consider adopting a dual-threshold extubation protocol—approving NGT removal when the NIHSS score falls below 15 (indicating moderate or less neurological impairment) and the GUSS score is 15 or greater (indicating adequate swallowing function on bedside screening)—in preference to the Kubota Water Swallowing Test alone, as the combined strategy significantly reduces aspiration pneumonia incidence, shortens tube indwelling time, and lowers secondary re-insertion rates. This protocol is particularly relevant for stroke units and neurological wards where timely, structured dysphagia reassessment is feasible, as both the NIHSS and GUSS are standardized, validated, and widely available tools that do not require instrumental swallowing studies. Clinicians should note that this evidence derives from a single-center RCT with a relatively modest sample size (n = 110) and that specific quantitative effect sizes (hazard ratios, confidence intervals, NNT) were not reported in the available abstract, warranting review of the full publication before protocol-level implementation.