Abstracts
Objective
To evaluate the risk factors and comorbid conditions associated with the development of pneumonia in patients with acute stroke. To determine the independent predictors of pneumonia.
Method
Retrospective study from July to December 2011. We reviewed all medical charts with diagnosis of stroke.
Results
159 patients (18-90 years) were admitted. Prevalence of pneumonia was 32%. Pneumonia was more frequent in patients with hemorrhagic stroke (OR: 4.36; 95%CI: 1.9-10.01, p < 0.001), higher National Institute of Health Stroke Scale (NIHSS) (p = 0.047) and, lower Glasgow Coma Score (GCS) (p < 0.0001). Patients with pneumonia had longer hospitalization (p < 0.0001). Multivariable logistic regression analysis identified NIHSS as an independent predictor of pneumonia (95%CI: 1.049-1.246, p = 0.002).
Conclusion
Pneumonia was associated with severity and type of stroke and length of hospital stay. The severity of the deficit as evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.
stroke; pneumonia; predictors; length of stay
Objetivo
Avaliar os fatores de risco e as comorbidades associadas ao desenvolvimento de pneumonia em pacientes com acidente vascular cerebral (AVC) agudo. Determinar os preditores independentes de pneumonia.
Método
Estudo retrospectivo, realizado entre julho e dezembro de 2011. Foi revisado todos os prontuários dos pacientes com diagnóstico de AVC.
Resultados
159 pacientes (18-90 anos) foram admitidos. A incidência de pneumonia foi de 32%. A incidência de pneumonia foi maior em pacientes com AVC hemorrágico (OR: 4,36; IC95%: 1,9-10,01, p < 0,001) e em pessoas com escore alto National Institute of Health Stroke Scale (NIHSS) (p = 0,047) e escores mais baixos da Escala de Coma de Glasgow (ECG) (p < 0,0001). Os pacientes com pneumonia tiveram maior tempo de internação (p < 0,0001). A análise de regressão logística identificou apenas o NIHSS como um preditor independente de pneumonia (IC95%: 1,049-1,246, p = 0,002).
Conclusão
O diagnóstico de pneumonia foi associado a tipo e gravidade do AVC e com tempo de hospitalização. A gravidade do déficit, avaliada pela escala NIHSS mostrou ser o único fator de risco independente para pneumonia em pacientes com AVC agudo.
acidente vascular cerebral; pneumonia; preditores; tempo de internação
Despite significant achievements in the acute management and treatment of stroke, it
remains the third leading cause of death in industrialized countries11 Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB
et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of
stroke over the past 50 years. JAMA. 2006;296(24):2939-46.
http://dx.doi.org/10.1001/jama.296.24.2939
https://doi.org/10.1001/jama.296.24.2939...
. The incidence of stroke has decreased
over the past 50 years but the lifetime risk has not declined to the same degree,
perhaps due to improved life expectancy22 Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N
et al. Predictors of early mortality after acute ischaemic stroke. Swiss Med
Wkly. 2010;140(17-8):254-9..
Pneumonia is among the most common medical complications after stroke, with an estimated
incidence ranging from 2.4% to 47%22 Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N
et al. Predictors of early mortality after acute ischaemic stroke. Swiss Med
Wkly. 2010;140(17-8):254-9.,33 Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. et al.
Formal dysphagia screening protocols prevent pneumonia. Stroke.
2005;36(9):1972-6.
http://dx.doi.org/10.1161/01.STR.0000177529.86868.8d
https://doi.org/10.1161/01.STR.000017752...
,44 Hong KS, Kang DW, Koo JS, Yu KH, Han MK, Cho YJ et al. Impact of
neurological and medical complications on 3-month outcomes in acute ischaemic
stroke. Eur J Neurol. 2008;15(12):1324-31.
http://dx.doi.org/10.1111/j.1468-1331.2008.02310.x
https://doi.org/10.1111/j.1468-1331.2008...
,55 Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, Beek D.
Post-stroke infection: a systematic review and meta-analysis. BMC Neurol.
2011;11(1):110. http://dx.doi.org/10.1186/1471-2377-11-110
https://doi.org/10.1186/1471-2377-11-110...
,66 Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of
pneumonia on mortality among patients hospitalized for acute stroke. Neurology.
2003;60(4):620-5.
http://dx.doi.org/10.1212/01.WNL.0000046586.38284.60
https://doi.org/10.1212/01.WNL.000004658...
,77 Upadya A, Thorevska N, Sena KN, Manthous C, Amoateng-Adjepong Y.
Predictors and consequences of pneumonia in critically ill patients with stroke.
J Crit Care. 2004;19(1):16-22.
http://dx.doi.org/10.1016/j.jcrc.2004.02.004
https://doi.org/10.1016/j.jcrc.2004.02.0...
.
Katzan et al.66 Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of
pneumonia on mortality among patients hospitalized for acute stroke. Neurology.
2003;60(4):620-5.
http://dx.doi.org/10.1212/01.WNL.0000046586.38284.60
https://doi.org/10.1212/01.WNL.000004658...
showed that pneumonia
has been associated with a relative risk of 3.0 for mortality in a study including
14,293 patients with stroke.
Despite the well-documented association of stroke-associated infections with increased
mortality and worse long-term outcome66 Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of
pneumonia on mortality among patients hospitalized for acute stroke. Neurology.
2003;60(4):620-5.
http://dx.doi.org/10.1212/01.WNL.0000046586.38284.60
https://doi.org/10.1212/01.WNL.000004658...
,
as yet there are only limited data available on independent predictors of pneumonia in
acute stroke patients88 Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre
P et al. Early predictors of death and disability after acute cerebral ischemic
event. Stroke. 1995;26(3):392-8.
http://dx.doi.org/10.1161/01.STR.26.3.392
https://doi.org/10.1161/01.STR.26.3.392...
,99 Czlonkowska A, Ryglewicz D, Lechowicz W. Basic analytical parameters
as the predictive factors for 30-day case fatality rate in stroke. Acta Neurol
Scand. 1997;95(2):121-4.
http://dx.doi.org/10.1111/j.1600-0404.1997.tb00081.x
https://doi.org/10.1111/j.1600-0404.1997...
treated in the emergency unit. The
identification of early predictors is of paramount importance for clinicians, so that
specific therapies and management strategies can be applied to patients at high risk of
dying.
In the present study the objective was to evaluate risk factors and comorbid conditions associated with the diagnosis of pneumonia and to determine the independent predictors of pneumonia in patients with acute stroke.
METHOD
Study population
This is an exploratory, retrospective cohort study. All patients admitted from July to December 2011 with a diagnosis of stroke in an Emergency Unit of an Academic Medical Center were included. Some patients were transferred to the intensive care unit or neurology ward, depending on the severity and availability of the wards. The diagnosis of stroke was based on clinical characteristics and imaging studies. Patients with symptoms that had completely resolved within 24 hours were excluded as well as those with subarachnoid hemorrhage and secondary intracerebral hemorrhage.
The study was approved by the Committee on Ethics of the Faculty of Medical Sciences at the Universidade Estadual de Campinas in accordance with the Regional Health Counsel’s resolution 196/96 (Protocol 1038/2011).
Data collection
We review all the medical charts and extracted information using a structured
questionnaire. The questionnaire included demographics (age, sex, discharge
destination), vascular risk factors (hypertension, diabetes, dyslipidemia,
smoking, alcohol, previous vascular disease, with coronary artery disease and
atrial fibrillation). Stroke severity was assessed on admission using the
National Institute of Health Stroke Scale (NIHSS)1010 Brott T, Adams Jr HP, Olinger CP, Marler JR, Barsan WG, Biller J, et
al. Measurements of acute cerebral infarction: a clinical examination scale.
Stroke. 1989;20(7):864-70.
http://dx.doi.org/10.1161/01.STR.20.7.864
https://doi.org/10.1161/01.STR.20.7.864...
and level of consciousness was assessed using the
Glasgow Coma Score (GCS) scale1111 Teasdale G, Jennett B. Assessment of coma and impaired
consciousness: a practical scale. Lancet. 1974;2(7872):81-4.
http://dx.doi.org/10.1016/S0140-6736(74)91639-0
https://doi.org/10.1016/S0140-6736(74)91...
, type (ischemic vs. hemorrhagic) and
localization of stroke (anterior vs. posterior circulation);
use of thrombolytic therapy; and time use of mechanical ventilation were also
collected.
Pneumonia was diagnosed based on clinical, laboratory and radiological data by the treating physician and registered on the medical chart.
Statistical analysis
Categorical variables are expressed as proportions and continuous variables are expressed as mean ± standard deviation (SD) and median (IQR). Univariable analysis comparing demographics, vascular risk factors, stroke severity, level of consciousness, type of stroke, localization, use of thrombolytic and use of mechanical ventilation between patients with and without a diagnosis of pneumonia was performed. Proportions were analyzed with the Fisher’s exact test. Continuous variables were analyzed with the Man-Whitney U test. Variables selected a priori (age, sex, NIHSS, type of stroke) and those with p-value < 0.1 in the bivariate analysis were included in a logistic regression model to assess the independent predictors for a diagnosis of pneumonia. All p-values are double-sided, and the level of statistical significance was set at p < 0.05. All statistical analyses were performed with SPSS 20.0 for Windows.
RESULTS
Study population and stroke characteristics
A total of 159 patients (92 men and 67 women, mean age 63.4 ± 13.4 years) with acute stroke were included. Most patients were discharged home (115, 72.3%), and others died (25, 15.7%) or were transferred to other hospital (19, 11.9%). Ischemic and hemorrhagic stroke were diagnosed in (129, 81.1%) and (30, 18.9%) patients, respectively. Anterior circulation stroke was documented in (132, 83.01%) patients, followed by posterior circulation (27, 16.9%). The location of the lesion was left hemisphere (80, 50.3%) patients; in (64, 40.3%) was right hemisphere and (14, 8.9%) was posterior circulation. Thrombolytic therapy was administered in (29, 18.2%) patients. Pneumonia was diagnosed in (51, 32%) of the patients.
Main outcome measures
Table 1 represents baseline characteristics in patients with and without pneumonia. No significant differences were observed regarding demographic data, site and localization of stroke or use of the thrombolytic therapy. Higher rate of pneumonia was observed among patients with hemorrhagic stroke (odds ratio (OR): 4.36, 95%CI: 1.9-10.0).
Table 2 shows the frequency of pneumonia in stroke patients adjusted by age, NIHSS, Glasgow Coma Score, length of stay in hospital and time use of mechanical ventilation (in days). Pneumonia was most common in those with higher NIHSS (p = 0.047) and lower Glasgow Coma Score (p < 0.0001).
Patients with longer hospital stay more frequently developed pneumonia, the mean hospital stay length was 13.4 days compared with 5.2 days in group without pneumonia (p < 0.0001).
Predictors of stroke-associated pneumonia
In the multivariable analysis the NIHSS was the only factor associated (p = 0.002) with pneumonia (Table 3). Ages, gender, type of stroke were not associated with pneumonia.
DISCUSSION
In this study, pneumonia frequency was higher in patients with hemorrhagic stroke, more common in those with higher NIHSS and lower GCS scores. Patients with longer hospital stay more frequently developed pneumonia. Logistic regression analysis identified only the NIHSS as an independent predictor of pneumonia.
A variety of neurological and medical complications may occur post-stroke, such as
pneumonia, urinary tract infections, malnutrition or volume depletion. Many of those
complications are potentially preventable with the improvement of stroke care. This
is best done in a dedicated stroke unit with experienced staff and early
mobilization1212 Rocco A, Pasquini M, Cecconi E, Sirimarco G, Ricciardi MC, Vicenzini
E et al. Monitoring after the acute stage of stroke: a prospective study.
Stroke. 2007;38(4):1225-8.
http://dx.doi.org/10.1161/01.STR.0000259659.91505.40
https://doi.org/10.1161/01.STR.000025965...
,1313 Weimar C, Ziegler A, Konig IR, Diener HC. Predicting functional
outcome and survival after acute ischemic stroke. J Neurol. 2002; 249(7):888-95.
http://dx.doi.org/10.1007/s00415-002-0755-8
https://doi.org/10.1007/s00415-002-0755-...
,1414 Hacke W, Kaste M, Skyhoj Olsen T, Bogousslavsky J, Orgogozo JM.
Acute treatment of ischemic stroke. Cerebrovasc Dis. 2000;10(Suppl 3):22-33.
http://dx.doi.org/10.1159/000047578
https://doi.org/10.1159/000047578...
. Pneumonia is the leading cause of death in the post-acute
phase of stroke66 Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of
pneumonia on mortality among patients hospitalized for acute stroke. Neurology.
2003;60(4):620-5.
http://dx.doi.org/10.1212/01.WNL.0000046586.38284.60
https://doi.org/10.1212/01.WNL.000004658...
. The majority of
the pneumonias are caused by aspiration but there are other reasons that include
hypostatic pneumonia due to poor caring and immobilization. Frequent changes of the
patient position in bed and pulmonary physical therapy may prevent this type of
infection1414 Hacke W, Kaste M, Skyhoj Olsen T, Bogousslavsky J, Orgogozo JM.
Acute treatment of ischemic stroke. Cerebrovasc Dis. 2000;10(Suppl 3):22-33.
http://dx.doi.org/10.1159/000047578
https://doi.org/10.1159/000047578...
. Thus, a better
understanding of the risk factors and comorbid conditions may guide the
implementation of strategies in organized stroke care provision1515 Saposnik G, Fang J, O’Donnell M, Hachinski V, Kapral MK, Hill MD.
Escalating levels of access to in-hospital care and stroke mortality. Stroke.
2008;39(9):2522-30.
http://dx.doi.org/10.1161/STROKEAHA.107.507145
https://doi.org/10.1161/STROKEAHA.107.50...
.
Chen et al.1616 Chen CM, Hsu HC, Tsai WS, Chang CH, Chen KH, Hong CZ. Infections in
acute older stroke inpatients undergoing rehabilitation. Am J Phys Med Rehabil.
2012;91(3):211-9.
http://dx.doi.org/10.1097/PHM.0b013e31824661a9
https://doi.org/10.1097/PHM.0b013e318246...
referred that
ischemic stroke could be a predictor for the lower occurrence of general infections
in all stroke patients, based on findings showing that hemorrhagic stroke patients
showed a higher frequency of general infections. Our cohort showed the relationship
between pneumonia and hemorrhagic stroke, probably because these patients had more
complications during the hospitalization and more deaths than ischemic group.
Some studies have demonstrated that complications such as stroke progression or
pneumonia adversely affect clinical outcome66 Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of
pneumonia on mortality among patients hospitalized for acute stroke. Neurology.
2003;60(4):620-5.
http://dx.doi.org/10.1212/01.WNL.0000046586.38284.60
https://doi.org/10.1212/01.WNL.000004658...
,1717 Birschel P, Ellul J, Barer D. Progressing stroke: towards an
internationally agreed definition. Cerebrovasc Dis. 2004;17(2-3):242-52.
http://dx.doi.org/10.1159/000076161
https://doi.org/10.1159/000076161...
. Increase risk of poor outcome in patients with
pneumonia, if unadjusted, reflects not only the effect of pneumonia but the effect
of other factors predisposing them to pneumonia, such as initial stroke severity or
neurological complications. Ifejika-Jones et al.1818 Ifejika-Jones NL, Harun N, Peng H, Elizabeth A, Grotta JC, Francisco
GE. The interaction of aspiration pneumonia with demographic and cerebrovascular
disease risk factors is predictive of discharge level of care in acute stroke
patient. Am J Phys Med Rehabil. 2012;91(2):141-7.
http://dx.doi.org/10.1097/PHM.0b013e31823caa8d
https://doi.org/10.1097/PHM.0b013e31823c...
showed the correlation between aspiration pneumonia
and NIHSS, where they were more likely to require continued postacute stroke care
because the lower functional status. In the actual study, it was found the relation
among pneumonia and NIHSS and GCS severity. In this case, inpatients in the acute
phase are more likely to develop pneumonia when they have worse consciousness level
and neurological deficits. Patients with the greatest degree of impairment
experienced complications most frequently.
There was a relationship between pneumonia and hospitalization time, as expected and
previously shown by Chen et al.1616 Chen CM, Hsu HC, Tsai WS, Chang CH, Chen KH, Hong CZ. Infections in
acute older stroke inpatients undergoing rehabilitation. Am J Phys Med Rehabil.
2012;91(3):211-9.
http://dx.doi.org/10.1097/PHM.0b013e31824661a9
https://doi.org/10.1097/PHM.0b013e318246...
.
Kwan and Hand1919 Kwan J, Hand P. Infection after acute stroke is associated with poor
short-term outcome. Acta Neurol Scand. 2007;115(5):331-8.
http://dx.doi.org/10.1111/j.1600-0404.2006.00783.x
https://doi.org/10.1111/j.1600-0404.2006...
reported that
post-stroke infection could prolong the length of stay of patients, in the acute
stroke stage. The length of stay in hospital has been influenced by the hospitals’
characteristics and the organization of services within the hospital. We can’t
assert that the incidence of pneumonia might be the cause of the increase in length
of stay in the emergency unit. However, the pneumonia group remained more time
hospitalized, with an average of 13 days in the hospital compared to 5 days in the
group without pneumonia. Moreover, the highest length of stay in hospital will
influence the total financial costs. The marginal cost of pneumonia is up to three
times higher than the group without pneumonia2020 Wilson RD. Mortality and cost of pneumonia after stroke for
different risk groups. J Stroke Cerebrovasc Dis. 2012;21(1):61-7.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2010.05.002
https://doi.org/10.1016/j.jstrokecerebro...
. The pneumonia and stay in intensive care unit are
independent predictors of acute treatment costs in Brazil hospitals2121 Christensen MC, Valiente R, Silva GS, Lee WC, Dutcher S, Rocha MSG
et al. Acute treatment costs of stroke in Brazil. Neuroepidemiology.
2009;32(2):142-9. http://dx.doi.org/10.1159/000184747
https://doi.org/10.1159/000184747...
.
Stroke severity on admission is a well-known predictor of mortality88 Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre
P et al. Early predictors of death and disability after acute cerebral ischemic
event. Stroke. 1995;26(3):392-8.
http://dx.doi.org/10.1161/01.STR.26.3.392
https://doi.org/10.1161/01.STR.26.3.392...
,99 Czlonkowska A, Ryglewicz D, Lechowicz W. Basic analytical parameters
as the predictive factors for 30-day case fatality rate in stroke. Acta Neurol
Scand. 1997;95(2):121-4.
http://dx.doi.org/10.1111/j.1600-0404.1997.tb00081.x
https://doi.org/10.1111/j.1600-0404.1997...
, but not as a predictor of pneumonia. Ruijun et
al.2222 Ji R, Shen H, Yuesong P, Wang P, Liu G, Wang Y et al. Novel risk
score to predict pneumonia after acute ischemic stroke. Stroke.
2013;44(5):1303-9. showed that age, atrial
fibrillation, congestive heart failure, chronic obstructive pulmonary disease and
current smoking, prestroke dependence, dysphagia, admission NIHSS and GCS scores,
stroke subtype and blood glucose were independent predictors of pneumonia in
ischemic stroke. Finlayson et al.2323 Finlayson O, Kapral M, Hall R, Asllani E, Selchen D, Saposnik G et
al. Risk factors, inpatient care, and outcomes of pneumonia after ischemic
stroke. Neurology. 2011;77(14):1338-45. indicated that male sex, nonlacunar ischemic stroke, and
preadmission dependency were predictors too.
Our study evaluated the predictors of pneumonia in ischemic and hemorrhagic acute
stroke. After the adjustment for possible confounders, the NIHSS score was only an
independent predictor of pneumonia, despite the small sample size and the reduced
collection time of only 5 months. This predictor can help in the recognition of
neurological impairment, including motor, sensory deficit, and aphasias.
Furthermore, aspiration is frequently found in patients with reduced consciousness,
impaired gag reflexes or swallowing disturbances22 Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N
et al. Predictors of early mortality after acute ischaemic stroke. Swiss Med
Wkly. 2010;140(17-8):254-9.44 Hong KS, Kang DW, Koo JS, Yu KH, Han MK, Cho YJ et al. Impact of
neurological and medical complications on 3-month outcomes in acute ischaemic
stroke. Eur J Neurol. 2008;15(12):1324-31.
http://dx.doi.org/10.1111/j.1468-1331.2008.02310.x
https://doi.org/10.1111/j.1468-1331.2008...
. The
use of NIHSS scale could help alert the physicians to prevent pneumonia in those
with increased suspicious.
Thus, it is possible an early intervention, adopting measures such as early
mobilization, evaluation of swallowing and respiratory function in patients with
suspect or confirmed pneumonia2525 Kasuya Y, Hargett JL, Lenhardt R, Heine MF, Doufas AG, Remmel KS et
al. Ventilator-associated pneumonia in critically ill stroke patients:
frequency, risk factors, and outcomes. J Crit Care. 2011;26(3):273-9.
http://dx.doi.org/10.1016/j.jcrc.2010.09.006
https://doi.org/10.1016/j.jcrc.2010.09.0...
,2626 Adams Jr HP, Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A et al.
Guidelines for the early management of adults with ischemic stroke: a guideline
from the American Heart Association / American Stroke Association Stroke
Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care
Outcomes in Research Interdisciplinary Working Groups: the American Academy of
Neurology affirms the value of this guideline as an educational tool for
neurologists. Stroke. 2007;38(5):1655-711.
http://dx.doi.org/10.1161/STROKEAHA.107.181486
https://doi.org/10.1161/STROKEAHA.107.18...
. Prevention and early rehabilitation may decrease the risk
of complications, reducing mortality and improving prognosis after acute ischemic
stroke2727 Bae HJ, Yoon DS, Lee J, Kim BK, Koo JS, Kwon O et al. In-hospital
medical complications and long-term mortality after ischemic stroke. Stroke.
2005;36(11):2441-5.
http://dx.doi.org/10.1161/01.STR.0000185721.73445.fd
https://doi.org/10.1161/01.STR.000018572...
,2828 Foley N, Salter K, Teasell R. Specialized stroke services: a
meta-analysis comparing three models of care. Cerebrovasc Dis.
2007;23(2-3):194-202. http://dx.doi.org/10.1159/000097641
https://doi.org/10.1159/000097641...
.
Our study further provides the differential to assess the impact of pneumonia, on the clinical outcome, after stroke, in emergency unit. We believe that the high incidence of pneumonia in this study could happen because of the lack of a specialized and trained stroke unit, where there are joint interventions of the multidisciplinary team.
All the patients should be treated in a stroke unit incorporating rehabilitation,
with regular supervise about neurological status, vital functions and adequate
ventilation1414 Hacke W, Kaste M, Skyhoj Olsen T, Bogousslavsky J, Orgogozo JM.
Acute treatment of ischemic stroke. Cerebrovasc Dis. 2000;10(Suppl 3):22-33.
http://dx.doi.org/10.1159/000047578
https://doi.org/10.1159/000047578...
. The Brazilian
Stroke Society proposed recently a classification of referral centers for diagnosis
and treatment of acute stroke, including a multidisciplinary team qualified for care
and management of high-complexity stroke patients3030 Martins SCO, Freitas GR, Pontes Neto OM, Pieri A, Moro CH, Jesus PA
et al. Guidelines for acute ischemic stroke treatment: part II: stroke
treatment. Arq Neuropsiquiatr. 2012;70(11):885-93.
http://dx.doi.org/10.1590/S0004-282X2012001100012
https://doi.org/10.1590/S0004-282X201200...
. Stroke unit care can act better than general ward in
intervention and maintenance of physiological homeostasis, more attention to
preventive measures, selective use of antipyretics, antibiotic medication and
insulin, better training and greater dedication of professional staff, and emphasis
on patient and family education and involvement in care3131 Langhorne P, Tong BLP, Stott DJ, Indredavik B. Association between
physiological homeostasis and early recovery after stroke. Stroke.
2000;31(10):2518-9.
http://dx.doi.org/10.1161/01.STR.31.10.2517-f
https://doi.org/10.1161/01.STR.31.10.251...
.
Our study has the limitation of being in single-center in hospital-based study, wherever the patients with acute stroke included in the present study are not representative of the entire population. We didn’t include data on some other variables that might have influence on the development of pneumonia, with pre-stroke antibiotic treatment, specific anti-inflammatory and/or immunomodulatory therapy before the index stroke. Furthermore, we didn’t collected modifiable risk factors for pneumonia, e.g. subglotic aspiration, oral hygiene, raised head of bed and presence of dysphagia. Other limitations are related to a retrospective design of our study. Thus, we were not able to determine the precise date of the diagnosis of pneumonia, being possible that some assessments (e,g., time of mechanical ventilation) may have taken place before pneumonia and we could not provide data on positive cultures or timing of pneumonia after hospital admission by the lack of additional data from medical chart.
In conclusion, pneumonia was related to the severity and type of stroke and length of stay in hospital. The severity of the neurological deficit evaluated by the NIHSS was shown to be the only independent risk factor for pneumonia in acute stroke patients.
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-
1Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA. 2006;296(24):2939-46. http://dx.doi.org/10.1001/jama.296.24.2939
» https://doi.org/10.1001/jama.296.24.2939 -
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-
3Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. et al. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972-6. http://dx.doi.org/10.1161/01.STR.0000177529.86868.8d
» https://doi.org/10.1161/01.STR.0000177529.86868.8d -
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» https://doi.org/10.1111/j.1468-1331.2008.02310.x -
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Support: Fabrício Lima and Mariana Bahia are recipient of FAPESP scholarship. This study is part of the CEPID-Brainn funded by FAPESP 2013/07559-3.
Publication Dates
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Publication in this collection
May 2015
History
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Received
27 Sept 2014 -
Reviewed
28 Dec 2014 -
Accepted
16 Jan 2015