Risk prediction models for enteral nutrition-related aspiration in critically ill patients: A systematic review

Abstract

BACKGROUND

Aspiration is a common and serious complication in critically ill patients receiving enteral nutrition, leading to increased morbidity and mortality. Accurate risk prediction is crucial for timely prevention and management; however, the quality and predictive performance of existing prediction models remain uncertain and require systematic evaluation.

AIM

To systematically identify, appraise, and synthesize evidence on the development, validation, and performance of published risk prediction models for enteral nutrition-related aspiration in critically ill adults.

METHODS

A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, Cochrane Library, CINAHL, CNKI, Wanfang Data, VIP, and CBM databases from inception to June 2025. Eligible studies included those reporting the development, validation, or impact assessment of multivariate models for predicting aspiration risk in critically ill adults receiving enteral nutrition. Two reviewers independently extracted data and assessed the risk of bias and applicability using the Prediction model Risk of Bias Assessment Tool.

RESULTS

Twelve studies (all from China) reporting 18 prediction models were included. Common predictors were age, Glasgow Coma Scale, mechanical ventilation, and gastric residual volume. Areas under the curve ranged from 0.771 to 0.995 in derivation cohorts, with sensitivity ranging from 0.776 to 0.952 and specificity from 0.695 to 0.952. However, only four models underwent external validation. Prediction model Risk of Bias Assessment Tool assessment rated 10 studies (83.3%) as high risk of bias, primarily due to inadequate sample size, improper handling of missing data, and lack of external validation.

CONCLUSION

Existing aspiration prediction models demonstrate good discrimination but have a high risk of bias and limited external validation. Rigorous validation in diverse populations is urgently needed.

Keywords: Critical illness; Enteral nutrition; Respiratory aspiration; Risk prediction models; Systematic review; Risk factors

Core Tip: This systematic review is the first to comprehensively evaluate risk prediction models for enteral nutrition-related aspiration in critically ill adults. We identified 18 models from 12 studies, with age, Glasgow Coma Scale score, and mechanical ventilation being the most common predictors. Although most models showed acceptable discrimination, the overall risk of bias was high, primarily due to inadequate methodological conduct in the analysis domain of the Prediction model Risk of Bias Assessment Tool. Rigorous external validation and adherence to standardized reporting guidelines are urgently needed before these models can be safely implemented in clinical practice.