|Year : 2019 | Volume
| Issue : 14 | Page : 1-11
An updated Chinese consensus statement on stroke-associated pneumonia 2019
Yong-Jun Wang1, Yu-Guo Chen2, Chuan-Zhu Lv3, Xing-Quan Zhao4, Wei Guo5
1 Emergency Medicine Branch of Chinese Stroke Society
2 Stroke Group, Emergency Medicine Branch of Chinese Medical Association
3 Emergency Medicine Branch of Chinese Geriatric Society
4 Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, China
5 Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences, Hainan Medical University, Haikou, China
|Date of Web Publication||03-Dec-2019|
Emergency Medicine Branch of Chinese Geriatric Society
Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences, Hainan Medical University, Haikou
Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou
Emergency Medicine Branch of Chinese Stroke Society
Stroke Group, Emergency Medicine Branch of Chinese Medical Association
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wang YJ, Chen YG, Lv CZ, Zhao XQ, Guo W. An updated Chinese consensus statement on stroke-associated pneumonia 2019. Asian Pac J Trop Med 2019;12, Suppl S2:1-11
|How to cite this URL:|
Wang YJ, Chen YG, Lv CZ, Zhao XQ, Guo W. An updated Chinese consensus statement on stroke-associated pneumonia 2019. Asian Pac J Trop Med [serial online] 2019 [cited 2023 May 30];12, Suppl S2:1-11. Available from: https://www.apjtm.org/text.asp?2019/12/14/1/271937
The concept of stroke-associated pneumonia (SAP) was first brought out by Hilker in 2003, which is the most important risk factor of mortality after stroke,. SAP causes prolonging hospitalization time and increasing medical expenses, which is a large burden for families and society. Due to the absence of an agreed concept for SAP in China and abroad previously, the variation in diagnostic criteria is considerable. Therefore, in clinical practice, the prevention of SAP may be inadequate, and SAP patients may not be diagnosed timely or receive appropriate anti-infective treatment. The above situation may lead to a poor prognosis in patients. A multidisciplinary expert group composed of specialists in neurology, respiratory, infectious diseases, and intensive care was established in 2009 to discuss and formulate the Chinese consensus of SAP consensus 2010 edition to improve the awareness and standardize the clinical diagnosis and treatment of SAP in China. In recent years, increasing researches on SAP provide more clinical evidence, and the accumulated evidence in the Chinese population is also increasing. Therefore, the specialists in neurology, emergency, respiratory, infectious diseases, intensive care, updated and revised the original consensus together to meet the needs of SAP clinical and prevention work. This version of the consensus is based on the 2010 version; the overall framework and major updates of SAP are determined after several working sessions. This version of the consensus combines the latest research progress and relevant guidelines at home and abroad, and the practical experience and research data on SAP prevention and treatment in China are used as much as possible; it is also revised by extensive solicitation of opinions and repeated discussions. We hope this consensus can provide a reference for the clinical treatment and prevention of SAP [Figure 1].
|Figure 1: Flow chart for prevention, diagnosis, and treatment of stroke-associated pneumonia. SAP: stroke-associated pneumonia; AIS-APS: acute ischemic stroke-associated pneumonia score; ICH-APS: intracerebral hemorrhage-associated pneumonia score.|
Click here to view
| 1. Definition and epidemiology|| |
The consensus published by the Pneumonia in Stroke Consensus Group in 2015 suggests defined SAP as pneumonia occurring within the first seven days after stroke onset in non-ventilated patients without previous pulmonary infection. Pneumonia onset in stroke patients is highly associated with post-stroke body dysfunctions, and inflammation caused by infection is an important factor in exacerbating brain injury after stroke. SAP can also cause other serious complications such as sepsis and gastrointestinal bleeding.
Foreign epidemiological data,,, show that the incidence of SAP is 7% to 38%. Ji et al, found that the incidence of SAP was 11.4% in ischemic stroke patients and 16.9% in hemorrhagic stroke patients, according to the China National Stroke Registry. The research of Xu et al showed that the incidence of SAP was 35.97%, and it is much higher than the incidence of hospital-acquired lower respiratory tract infection (1.76%-1.94%). SAP increases 3-fold in the 30-day mortality in stroke patients, while 1-year and 3-year risk of mortality also increase,.
Recommendation: Stroke-associated pneumonia is defined as pneumonia, which occurs within the first seven days after stroke onset in non-ventilated patients without previous pulmonary infection.
| 2. Risk factors and prediction model|| |
SAP risk prediction can help choose interventions to reduce the incidence of high-risk patients. Stroke-induced immunosuppression and dysphagia are major independent risk factors for SAP; other risk factors include but are not limited to age, gender, smoking history, the severity, type and location of stroke, level of consciousness, dysphagia, feeding method, antacid application, admission to intensive care unit (ICU), hypertension, diabetes, history of chronic respiratory disease, history of atrial fibrillation,,. A number of studies have applied multivariate regression models to design various scoring methods to predict SAP risk since 2012,,,,. This Consensus recommends the scoring method based on Chinese population data by Ji et al. to assess the risk of Chinese patients [Table 1],. This prediction model has been validated by related researches,.
Recommendation: It is recommended to apply an AIS-APS, ICH-APS scoring method to assess SAP risk in Chinese stroke patients.
| 3. Pathogenesis|| |
The pathogenesis of SAP is highly related to the body dysfunction caused by stroke, and it is specific comparing with community-acquired pneumonia and hospital-acquired pneumonia. Aspiration caused by the disturbance of consciousness and dysphagia after stroke, as well as stroke-induced immunosuppression, are considered as the most important pathogenesis of SAP. A total of 40%-70% patients will show symptoms such as consciousness decrease, dysphagia, protective reflex decline, lower esophageal sphincter dysfunction, swallow-breathing coordination decline, cough reflex decline; therefore, it is easy to aspirate nasopharynx and oropharynx secretions, and stomach contents into the lungs and cause SAP,. Early identification of dysphagia can provide evidence for decision-making in nutrition management; early swallowing rehabilitation can reduce pulmonary complications.
Impaired cellular immunity function induced by stroke is an important internal mechanism of SAP. Systemic immune responses after acute stroke can prevent further inflammatory stimuli and protect brain tissue, but it also causes immunosuppression and therefore leads to stroke-induced immunosuppression syndrome and infection. Immunoregulatory mediators are released after stroke-induced brain injury, including IL-lß, TNF-α, IL-6, as well as calcitonin gene-related peptide, neuropeptide, vasoactive intestinal peptide, and others. These immunoregulatory mediators act on blood vessels, adrenal glands, and nerve endings and cause the release of norepinephrine, glucocorticoids, acetylcholine from these areas. The above three substances act on receptors on immune cells such as NK cells, Th1, Th2, and macrophages, and down-regulate the immune function of these cells. Therefore, these cells weaken immune function, resulting in systemic immunosuppression and making people prone to infection. In addition, the right cerebral hemisphere is also associated with the activation of T lymphocytes, and the decrease in the number and activation of T lymphocytes increases the probability of infection in patients.
Systemic immune responses after acute stroke can prevent further inflammatory stimuli and protect brain tissue, but cause immunosuppression and cause stroke-induced immunosuppression syndrome and infection.
Bedridden may also lead to SAP. Stroke patients are often bedridden for limb paralysis, and endotracheal secretion is stagnated and accumulated at basis pulmonis, so the bacteria are easy to reproduce, causing SAP.
| 4. Pathogen|| |
Stroke patients may have persistent aspiration due to disturbance of consciousness and abnormal swallowing function; aspirated material includes not only secretions from the oropharynx, but also nasal secretions, food left in the mouth, contents of the gastrointestinal tract, and refluxed digestive fluid. El-Solh et al applied the method of protective bronchoalveolar lavage to study the etiology of aspiration pneumonia. They found the most common pathogens were G-bacilli (49%), anaerobes (16%) and Staphylococcus aureus (12%); the most common anaerobes were Prevotella and Clostridium; 22% were mixed infection, of which 20% were mixed infection of two pathogens, and 2% were mixed infection of three pathogens. Thus, analyzed from this evidence, SAP pathogens are mainly G-bacteria, such as Klebsiella pneumonia, Escherichia More Details coli; mixed infection of various bacteria and anaerobes is common. Besides, pathogens are often changeable during the disease process, and it is difficult to detect pathogens; multi-drug resistant bacteria are prone to occur. There is no large-scale multicenter epidemiological data worldwide currently.
Recommendation: The pathogen SAP is mainly G-bacteria, and mixed infections of various bacteria and anaerobic bacteria are common. Besides, the pathogens during the disease process are often changeable.
| 5. Diagnosis|| |
5.1. Clinical manifestation
Newly emerged pulmonary infection symptoms within the first seven days after stroke onset inpatients without mechanical ventilation: (1) fever, temperature 38 °C; (2) newly emerged or aggravated cough, dyspnea, or shortness of breath; (3) newly emerged purulent sputum, sputum properties changes, or respiratory secretion increases or needs for sputum suction increases within 24 hours; (4) rales or crackles or bronchorespiratory sounds are found during lung auscultation; (5) age≥70 years old, change in consciousness state without other definite causes.
5.2. Laboratory and imaging inspection
Peripheral blood leukocytes≥10 000×109/L or≤4 000×109/L, with or without left shift; imaging result shows newly emerged or progressing infiltrating shadow, and chest CT can be performed if necessary. Zhang et al found leukocyte count and C-reactive protein (CRP) of SAP patients are significantly higher than patients without SAP, and the rising of CRP independently is associated with poor outcomes, as well as the increased mortality and infection risk. Procalcitonin is a better predictor for infection compared with CRP. A higher procalcitonin level indicates a more serious bacterial infection and a higher possibility of bacterial infection and sepsis.
5.3. Pathogen examinations
Collect qualified lower respiratory secretions (neutrophils count >25/low-power field, epithelial cell count <10/low-power field, or ratio of the above two >2.5:1), protected specimen brush, bronchoalveolar lavage fluid, or aseptic body fluid (blood or pleural effusion) before applying anti-infective drugs, and send for pathogenic microorganism examination. Among the above sampling method, sputum expectoration is more acceptable for patients and their families, as this sampling method is noninvasive; therefore, it is more common in clinical application. Before sputum samples collection, patients need to remove dentures, dental trays, etc., and clean oral cavity; patients need to cough deeply and expectorate, and it is better to have medical staff guidance during this sample collecting process. Patients who cannot expectorate spontaneous need claps on their backs to expel sputum. Sputum samples were sent for examination once a day, and sputum smear and culture were conducted for 2-3 consecutive days; laboratory treatment needs to be done within 1-2 hours after sample collection. Blood culture is an essential method for diagnosing bloodstream infections. Blood samples should be collected 2-3 sets each time for adult patients, and each set should be collected from different puncture sites. Blood samples collected from the same puncture site are usually injected into aerobic and anaerobic culture flasks, respectively, and the blood volume per bottle is 8-10 mL to increase the positive rate. For complication with pleural effusion, it is feasible to send pleural cavity puncture to routine and biochemical examinations, smear (such as Gram staining, acid-fast staining), culture, and other tests.
If necessary, blood samples should be sent to detect antibodies or nucleic acid of atypical pathogens (mycoplasma, chlamydia, and legionella); the definite diagnosis can be made if the serum IgM antibody is positive or the titer of serum specific IgG antibody in acute and recovery period rises four-fold or higher. Respiratory secretions (nose/throat swabs) should be sent for corresponding viral antigens or nucleic acid detection or virus culture, when during the epidemic of respiratory viruses and with epidemiological exposure history.
Recommendation: It is recommended to conduct pathogen examinations proactively to optimize SAP anti-infective treatment strategies.
5.4. Diagnostic criteria
The SAP diagnostic criteria referred to the improved criteria by the Centers for Disease Control and Prevention are as follows:
At least meet one of the following criteria: (1) Fever without other clear cause (body temperature≥38 C); (2) Leukopenia (≤4 000×109/L) or leukocytosis (≥10 000×109/L); (3) Age≥70 years old, change in consciousness state without other clear cause;
And at least meet two of the following criteria: (1) Newly emerged purulent sputum properties changes or respiratory secretion increases or needs for sputum suction increases within 24 hours; (2) Newly emerged or aggravated cough, dyspnea, or shortness of breath (respiratory rate > 25 times/minute); (3) Find rales or crackles or bronchorespiratory sounds during lung auscultation; (4) Impaired gas exchange (such as hypoxemia (PaO2/FiO2≤300), increase in oxygen demand;
Chest imaging meet one of the following criteria: Newly emerged or progressing infiltrating shadow, solid shadow or ground glass shadow (For patients without underlying cardiopulmonary disease), a chest imaging test with any of the above imaging features is acceptable.
5.5. SAP severity assessment
The assessment on the severity of SAP is important for choosing antibiotic sempirically and treatment sites, as well as determining prognosis. CURB-65 (C: confusion, U: uremia, R: respiratory rate, B: blood pressure) and pneumonia severity index (PSI) can be applied to assessment [Table 2].
|Table 2: Scoring systems of stroke-associated pneumonia severity assessment.|
Click here to view
Recommendation: The combined application of CURB-65 and PSI is recommended to assess disease severity to guide further treatment of the patient.
5.6. Differential diagnosis
Hospital-acquired pneumonia (HAP): The patient does not have pre-existing infection nor in the incubation period of infection at the admission, but the parenchymal inflammation in pulmonary initiated by bacteria, fungi, mycoplasma, viruses, protozoa, or other pathogens occurs after 48 hours since admission. There are some overlap or intersection between HAP and SAP to some extent, but the patient group of HAP is more extensive than SAP, and SAP refers to pneumonia in patients after stroke, regardless of whether they are admitted to the hospital or not. For hospitalized SAP patients, their disease onset time is earlier (can be within 48 hours after admission), and their time window for disease onset is shorter (only within 7 days after stroke onset).
Community-acquired pneumonia: Inflammation of infectious pulmonary parenchyma (including the alveolar wall, i.e., pulmonary interstitium in a broad sense) occurs outside the hospital, including pneumonia which is caused by pathogens with a definite incubation period and onset within the average incubation period (within 48 hours) after admission. SAP refers to pneumonia in patients after stroke, but it is not associated with whether these patients are hospitalized. Some community-acquired pneumonia patients combined with acute stroke should be differentiated with SAP; their pathogenic characteristics may be quite different.
Ventilator-associated pneumonia: Pneumonia occurred after 48 hours of mechanical ventilation with endotracheal intubation or tracheotomy or within 48 hours of artificial airway removal. In cases of pulmonary infection after mechanical ventilated stroke patients, diagnosis and treatment should be carried out according to ventilator-associated pneumonia-related principles.
Chemical pneumonitis: Chemically toxic pneumonitis caused by inhalation of chemical irritant gases, liquids, or organic dust. Inhalation of large amounts of gastric contents can lead to chemical pneumonitis, but only when inhaling large quantities of substances with low pH value (pH< 2.5). The disease is characterized by sudden onset of dyspnea, hypoxemia, tachycardia, auscultation of extensive wheezing, and popping sounds in both lungs. Airway secretions ofchemical pneumonitis patients are often thin, and infection-related laboratory tests and pathogen tests are negative.
| 6. Treatment and management|| |
6.1. General treatment
- Treatment of primary disease: Corresponding treatment for stroke, including treatment such as thrombolysis for ischemic stroke, hematoma clearance and intracranial pressure reduction for hemorrhagic stroke.
- Diluting sputum and sputum drainage: Apply expectorants such as ambroxol hydrochloride, acetylcysteine, and carbocisteine, to dilute sputum.
- Oral management: Strengthening oral care and comprehensive management (using normal saline, chlorhexidine or povidone-iodine mouthwash to wash or/and brush teeth, tongue surface, and other parts in oral cavity) can reduce the conditionally pathogenic bacteria in the oropharynx, avoid their displacement and translocation, and reduce or prevent the risk of lung infection.
- Oxygen therapy and respiratory support: Monitoring the patients’ blood oxygen saturation or blood gas analysis dynamically; blood oxygen saturation should be maintained at 94%, and the oxygen partial pressure should be maintained above 70 mmHg. Continues nasal catheter oxygen or high-flow nasal cannula oxygen therapy can be given when hypoxemia occurs. If conventional oxygen therapy is ineffective, give mechanical ventilation in case of severe hypoxemia or respiratory failure (partial oxygen pressure 60 mmHg). Note: stroke with consciousness disturbance is a contraindication of noninvasive mechanical ventilation.
- Symptomatic treatment: When body temperature is above 38.5 °C, give antipyretic or physical cooling and liquid supplement, relieve cough and asthma, as well as other symptomatic treatments.
Recommendation: Treat primary disease actively; strengthen oral care and comprehensive management in order to reduce or prevent the risk of lung infection.
6.2. Early nutrition support therapy
Give digestible and nutritious food or nutrient solution within 24 to 48 hours after disease onset to maintain water-electrolyte balance. Try to take food orally. If the patient is unable to take food by mouth, it is recommended to use continuous enteral nutrition, and it is more beneficial for patients in severe status to use this sequential treatment from initial enteral administration of short peptide preparation to whole protein preparation. If there is any contraindication of oral feeding or enteral nutrition, it is necessary to start parenteral nutrition within 3–7 days; If the patient can tolerate enteral nutrition, intravenous nutrition will not be applied. The energy supply for non-bedridden patients with mild symptoms is 25–35 kcal/kg/d, and that of patients with severe symptoms in the acute stress periodis 20-25 kcal/kg/d. For the patients without complications, the protein intake should be at least 1 g/kg/d; the fat intake should not exceed 35% of the total energy intake, and preparation rich in polyun saturated fatty acids should be applied. Dietary fiber intake should be as close as possible to 25–30 g/d. In order to avoid overfeeding, it is not recommended to give the total nutrition goal too early; the nutrition standard can reach total nutrition goal within 3-7 days.
Recommendation: Try to give food orally within 24–48 hours after stroke onset; If the patient is unable to take food by mouth, continuous enteral nutrition is recommended; If the patient can tolerate enteral nutrition, intravenous nutrition will not be applied.
Recommendation: If there is any contraindication of oral feeding or enteral nutrition, it is necessary to start parenteral nutrition within 3-7 days.
6.3. Anti-infective treatment
The principle of anti-infective treatment in SAP is the combination of empirical treatment and targeted anti-infective treatment. The initial empirical treatment should be timely and sufficient. At the same time, the pathogen examination should be highly valued, to obtain early and accurate evidence for targeted anti-infective treatment and optimizing the anti-infective treatment plan.
Empirical anti-infective treatment should be initiated within 6 hours of the pneumonia occurrence, or as soon as possible; otherwise, it will increase the mortality and prolong the hospitalization time of patients. Intravenous preparation is recommended for the initial empirical anti-infective treatment. During this period, the medication should be adjusted in time on the basis of therapeutic response and etiology information. According to the CURB-65 or PSI scale, a combination of ß-lactamswith ß-lactamase inhibitor (for instance, amoxicillin/clavulanate, piperacillin/tazobactam, cefoperazone/ sulbactam), cephamycins (for instance, cefoxitin, cefmetazole) and oxacephems (latamoxef or flomoxef) are preferred for patients with mild to moderate SAP. The course of treatment is 5–7 days generally. For patients who are assessed as severe SAP by CURB-65 or PSI scale, medications such as ertapenem, meropenem, imipenem, and biapenem are preferred; the avenge course of treatment is 7–10 days.
According to the risk factors assessment of drug-resistant bacteria or microbial culture, if the pathogen was assessed or confirmed to be methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter, or carbapenem-resistant Enterobacter (CRE), the course of treatment should be prolonged to 10 to 21 days. Vancomycin, norvancomycin, linezolid, orteicoplanin can be used in MRSA infection. Anti-Pseudomonas carbapenems (such as piperacillin/tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, imipenem, meropenem) are recommended for the treatment of Pseudomonas aeruginosa infection, and combination of quinolones (ciprofloxacin, levofloxacin, for instance) or aminoglycosides are recommended if necessary. The drug resistance rate of Acinetobacter is generally high, so sulbactam preparations (such as cefoperazone/sulbactam, ampicillin/sulbactam), carbapenems, tigecycline, or polymyxins can be applied for treatment or even the combination treatment with the medications mentioned above. Ceftazidime/avibactam, polymyxin, or tigecycline can beapplied in CRE infected patients. Combination therapy can be considered when mixed anaerobic infections; and nitroimidazoles (such as levornidazole, metronidazole, tinidazole) are preferred for the treatment of anaerobic bacteria.
If the pathogen examinations confirm atypical pathogens (Mycoplasma, Chlamydia, or Legionella) infections in SAP patients, they can be treated with quinolones (such as levofloxacin and moxifloxacin), macrolides (such as azithromycin) or tetracycline antibiotics (such as doxycycline and minocycline). It should be noted that quinolones have central nervous system side effects, especially in patients with severe strokes, lesions adjacent to the cortex, or previous epilepsy history. More detail of the above content is shown in [Table 3], [Table 4].
|Table 3: Recommended empirical anti-infective treatment for stroke-associated pneumonia.|
Click here to view
Efficacy evaluation and adjustment of the empirical anti-infective treatment plan: the therapeutic effect of the anti-infective treatment can be evaluated by leukocyte count, body temperature, blood oxygen saturation, and other indicators, and comprehensive analysis of above indicators can be used to guide clinical medication. Chest imaging often lags behind the improvement of clinical indicators. With effective treatment, SAP patients usually have significant clinical improvement within 48–72 hours, and the anti-infective treatment plan can be adjusted at this time. If the etiological examinations have been carried out, narrow-spectrum anti-infective drugs should be applied according to the etiological examination results, especially for the patients who initially used carbapenem broad-spectrum antibiotics. If the pathogen has been examined, a narrow-spectrum anti-infective treatment should be used after 72 hours according to the results of the pathogen examination, especially for patients who initially used broad-spectrum carbapenem antibiotics.
Recommendation: Initialize anti-infection therapy as soon as possible once the SAP diagnosis is established.
| 7. Prevention|| |
For stroke patients who are estimated as high-risk and extremely high-risk by AIS-APS and ICH-APS predictive model, to strengthen SAP prevention is essential. Preventive measures include but are not limited to: In order to prevent cross-infection, medical staff should preform standardize hand washing before and after contact with patients, wear gloves and masks, wear isolation gowns if necessary, place patients with special infections in isolation rooms. This consensus emphasizes the following aspects considering the specific characteristics of SAP:
7.1. Semi-recumbent position
Research focusing on ICU patients with mechanical ventilation found that to elevate head-of-bed for 30° to 45° reduces the incidence of aspiration comparing with patients in the prone position. Therefore, the semi-recumbent position (elevating head-of-bed for 30° to 45°) is preferred in stroke patients when without contraindications, such as pelvic and spinal diseases.
7.2. Swallowing function assessment and training
Hinchey et al conducted a study on 2 532 patients with acute ischemic stroke, and they found that screening and training swallowing function reduced the incidence of pneumonia significantly (P<0.01). Early assessment, screening, and rehabilitation of swallowing function after acute stroke can help reduce pneumonia.
7.3. Airway management
In terms of nursing, it is necessary to turn over, clap back, change position (postural drainage of sputum), and perform suctioning regularly. Mechanical and physical methods such as the simulated cough machine can be selected to promote the discharge of respiratory tract secretions. In patients with severe hypoxemia (partial pressure of oxygen≤60 mmHg) caused by sputum deposition, and can’t be improved by oxygen inhalation through nasal catheter or mask, artificial airways can be placed in patients who need sputum drainage. Patients who are assessed as able to improve within 1–2 weeks can receive oral or nasal intubation; otherwise, they are given a tracheotomy (a sputum suction tube can be applied to suction the distal airway secretion, which is more conducive to sputum removal). Patients with sputum deposition or aspiration can be conducted suction by bronchoscope; the frequency of operation is adjusted according to the individual sputum volume of each patient, from once a day initially to once every other day or once a week as the sputum decreases. Argyle nasopharyngeal airway should be applied to keep the airway unobstructed in patients with upper airway obstruction caused by tongue falling backward and short neck with obesity. High-flow nasal cannula oxygen therapy has gradually become an important means of oxygen therapy and airway management because of its high flow of inhaled gas, good humidification, and a certain level of positive end-expiratory pressure. It can be applied actively.
7.4. Feeding management
- It is recommended to provide soft and thick food (such as rice paste, yogurt) for patients who take food orally, instead of viscous or thin liquid. Try to keep the chin down and the head to one side when eating; patients are encouraged swallowing a small amount of food each time, swallowing multiple times and coughing after each swallowing.
- Confirming the position of feeding tube before feeding: Misplacement of the feeding tube, such as placement in the esophagus or misplacement into the bronchus, is one of the serious complications of feeding and can lead to pneumonia. X-ray examination is the gold standard to confirm the position of the feeding tube. In patients with coma, sedation, or weakness or disappeared cough reflexes, to conduct an X-ray examination before the first time of feeding is important. In the case of aspiration or suspected feeding tube displacement during feeding, the position of the feeding tube should be verified by X-ray examination again.
- Post-pyloric feeding: In patients with pyloric obstruction, gastroparesis, esophageal reflux, or aspiration, using post-pyloric feeding may reduce the incidence of pneumonia.
- It is recommended to provide nutritional support through percutaneous endoscopic gastrostomy or duodenostomy for those whose swallowing function isn’t expected to recover within a long time (> 2–3 weeks).
7.5. Application of medications
- Reduce the use of glucocorticoids, proton pump inhibitors, H2-receptor blockers, sedatives, and muscle relaxants.
- Avoid prophylactic use of anti-infective medications: It is not recommended to apply anti-infective medications to prevent stroke-associated pneumonia in every country currently.
- In Asian stroke patients, the use of an angiotensin-converting enzyme inhibitor (captopril) to control blood pressure can reduce the risk of aspiration pneumonia. It may work by increasing the substance Plevel, promoting cough, and improving swallowing reflex.
Recommendation: Elevating head-of-bed for 30° to 45° is an effective measure to prevent SAP.
Recommendation: Early assessment and training of swallowing function in stroke patients can reduce the incidence of SAP.
Recommendation: In patients with pyloric obstruction, gastroparesis, esophageal reflux or aspiration, the use of post-pyloric feeding can reduce the incidence of pneumonia.
List of Authors
Qi Bi, Beijing Anzhen Hospital, Capital Medical University
Yu-Guo Chen, Qilu Hospital of Shandong University
Xu-Yan Chen, Beijing Tsinghua Changgung Hospital
Xiao-Fan Chu, Shenzhen People’s Hospital
Bang-Han Ding, Guangdong Provincial Hospital of Chinese Medicine
Ze-Yu Ding, Beijing Tiantan Hospital, Capital Medical University
Qiang Dong, Huashan Hospital, Fudan University
Bang-Jiang Fang, Longhua Hospital Shanghai University of Traditional Chinese Medicine
Jian-Hui Fu, Huashan Hospital, Fudan University
Yang-Tai Guan, Changhai Hospital
Shu-Bin Guo, Beijing Chaoyang Hospital, Capital Medical University
Wei Guo, Beijing Tiantan Hospital, Capital Medical University
Xiao-Jun He, Chinese Journal of Emergency Medicine
Bo Hu, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
Wen-Li Hu, Beijing Chaoyang Hospital, Capital Medical University
Yi Huang, Changhai Hospital
Rui-Jun Ji, Beijing Tiantan Hospital, Capital Medical University
Hai Kang, Yantai Yuhuangding Hospital
Tan-Shi Li, Chinese People’s Liberation Army General Hospital
Li Dou, Beijing Emergency Medical Centre
Shu-Juan Li, Beijing Chaoyang Hospital, Capital Medical University
Yong Li, Cangzhou Central Hospital
Yu-Sheng Li, The First Affiliated Hospital of Zhengzhou University
Cheng Liang, Lanzhou University Second Hospital
Hui-Hui Liu, The Second Affiliated Hospital of Soochow University
Shuang Liu, Peking University International Hospital
Zhi Liu, The First Hospital of China Medical University
Lin Lu, Shandong Provincal Hospital
Chuan-Zhu Lv, Hainan Medical University
Lian-Sheng Ma, First Hospital of Shanxi Medical University
Yue-Feng Ma, The Second Affiliated Hospital of Zhejiang University School of Medicine
Qiao Pei, Chinese Journal of Critical Care Medicine
Peng Peng, The First hospital of XinJiang Medical University
Zhi-Gang Shan, Beijing Royal Integrative Medicine Hospital
Ning Shen, Peking University Third Hospital
Guang-Zhi Shi, Beijing Tiantan Hospital, Capital Medical University
Ji-Xue Shi, The Second Affiliated Hospital of Shandong First Medical University
Hai-Qing Song, Xuanwu Hospital ,Capital Medical University
Zhou-Ping Tang, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology
Yong-Jun Wang, Beijing Tiantan Hospital, Capital Medical University
Guo-Feng Wu, The Affiliated Hospital of Guizhou Medical University
Feng Xu, Qilu Hospital of Shandong University
Jun Xu, Peking Union Medical College Hospital
Tie Xu, The Affiliated Hospital of Xuzhou Medical University
Li-Shan Yang, General Hospital of Ningxia Medical University
Qing-Wu Yang, Daping Hospital
Zhong-Hua Yang, Beijing Tiantan Hospital, Capital Medical University
Tao Yu, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
Hong-Ke Zeng, Guangdong Provincial People’s Hospital and Guangdong Academy of Medical Sciences
Hong Zhan, The First Affiliated Hospital of Sun Yat sen University
Bo Zhang, Air Force General Hospital, PLA
Guo-Qiang Zhang, China-Japan Friendship Hospital
Jie Zhang, Beijing Tiantan Hospital, Capital Medical University
Jin-Jun Zhang, Beijing Emergency Medical Centre
Rui Zhang, The Affiliated Hospital of Qingdao University
Yue-Wei Zhang, Beijing Tiantan Hospital, Capital Medical University
Yun-Zhou Zhang, Xuanwu Hospital,Capital Medical University
Min Zhao, Shengjing Hospital of China Medical University
Xing-Quan Zhao, Beijing Tiantan Hospital, Capital Medical University
Bo Zheng, Peking University First Hospital
Hua-Dong Zhu, Peking Union Medical College Hospital
Chang-Ju Zhu, The First Affiliated Hospital of Zhengzhou University
Conflicts of interest statement
The authors declare that there are no conflicts of interest.
| References|| |
Li J, Zhang P, Wu S, Wang Y, Zhou J, Yi X, et al. Stroke-related complications in large hemisphere infarction: incidence and influence on unfavorable outcome. Ther Adv Neurol Disord
de Montmollin E, Ruckly S, Schwebel C, Philippart F, Adrie C, Mariotte E, et al. Pneumonia in acute ischemic stroke patients requiring invasive ventilation: Impact on short and long-term outcomes. J Infect
Wilson RD. Mortality and cost of pneumonia after stroke for different risk groups. J Stroke Cerebrovasc Dis
Kishore AK, Vail A, Chamorro A, Garau J, Hopkins SJ, Di Napoli M, et al. How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke
Chinese Consensus Group of Stroke-Associated Pneumonia. A Chinese consensus of stroke-associated pneumonia. Chin J Int Med
Ji R, Shen H, Pan Y, Wang P, Liu G, Wang Y, et al. Novel risk score to predict pneumonia after acute ischemic stroke. Stroke
Ji R, Wang D, Shen H, Pan Y, Liu G, Wang P, et al. Interrelationship among common medical complications after acute stroke: pneumonia plays an important role. Stroke
Smith CJ, Bray BD, Hoffman A, Meisel A, Heuschmann PU, Wolfe CD, et al. Can a novel clinical risk score improve pneumonia prediction in acute stroke care? A UK multicenter cohort study. J Am Heart Assoc
Teh WH, Smith CJ, Barlas RS, Wood AD, Bettencourt-Silva JH, Clark AB, et al. Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome. Acta Neurol Scand
Yu YJ, Weng WC, Su FC, Peng TI, Chien YY, Wu CL, et al. Association between pneumonia in acute stroke stage and 3-year mortality in patients with acute first-ever ischemic stroke. J Clin Neurosci
Ji R, Shen H, Pan Y, Du W, Wang P, Liu G, et al. Risk score to predict hospital-acquired pneumonia after spontaneous intracerebral hemorrhage. Stroke
2014; 45(9): 2620-2628.
Wei Xu, HP Li. Risk factors analysis in stroke patients with lower respiratory tract infection. Chin J Stroke
Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology
Zapata-Arriaza E, Moniche F, Blanca PG, Bustamante A, Escudero-Martinez I, Ucles O, et al. External validation of the ISAN, A2DS2, and AIS-APS scores for predicting stroke-associated pneumonia. J Stroke Cerebrovasc Dis
Hoffmann S, Harms H, Ulm L, Nabavi DG, Mackert BM, Schmehl I, et al. Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia - The PREDICT study. J Cereb Blood Flow Metab
Sui R, Zhang L. Risk factors of stroke-associated pneumonia in Chinese patients. Neurol Res
Eltringham SA, Kilner K, Gee M, Sage K, Bray BD, Smith CJ, et al. Factors associated with risk of stroke-associated pneumonia in patients with dysphagia: A systematic review. Dysphagia
Hoffmann S, Malzahn U, Harms H, Koennecke HC, Berger K, Kalic M, et al. Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke. Stroke
Harms H, Grittner U, Droge H, Meisel A. Predicting post-stroke pneumonia: the PANTHERIS score. Acta Neurol Scand
Zhang R, Ji R, Pan Y, Jiang Y, Liu G, Wang Y, et al. External validation of the prestroke independence, sex, age, National Institutes of Health Stroke Scale Score for Predicting Pneumonia After Stroke Using Data From the China National Stroke Registry. J Stroke Cerebrovasc Dis
Hannawi Y, Hannawi B, Rao CP, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis
Ouyang M, Boaden E, Arima H, Lavados PM, Billot L, Hackett ML, et al. Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study. Int J Stroke
Pacheco-Castilho AC, Vanin GM, Dantas RO, Pontes-Neto OM, Martino R. Dysphagia and associated pneumonia in stroke patients from Brazil: A systematic review. Dysphagia
Eltringham SA, Kilner K, Gee M, Sage K, Bray BD, Pownall S, et al. Impact of dysphagia assessment and management on risk of stroke-associated pneumonia: A systematic review. Cerebrovasc Dis
Shim R, Wong CH. Ischemia, immunosuppression and infection--Tackling the predicaments of post-Stroke complications. Int J Mol Sci
El-Solh AA, Pietrantoni C, Bhat A, Aquilina AT, Okada M, Grover V, et al. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med
Zhang X, Wang F, Zhang Y, Ge Z. Risk factors for developing pneumonia in patients with diabetes mellitus following acute ischaemic stroke. J Int Med Res
Liu D, Su LX, Guan W, Xiao K, Xie LX. Prognostic value of procalcitonin in pneumonia: A systematic review and meta-analysis. Respirology
Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control
Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr
2019; 38(1): 48-79.
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med
Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH. Tracheobronchial aspiration of gastric contents in critically ill tubefed patients: frequency, outcomes, and risk factors. Crit Care Med
Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke
Matthay MA. Saving lives with high-flow nasal oxygen. N Engl J Med
Lyons M, Smith C, Boaden E, Brady MC, Brocklehurst P, Dickinson H, et al. Oral care after stroke: Where are we now? Eur Stroke J
Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. JPEN J Parenter Enteral Nutr
(6 Suppl): S51-S55.
Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev
Song TJ, Kim J. Risk of post-stroke pneumonia with proton pump inhibitors, H2 receptor antagonists and mucoprotective agents: A retrospective nationwide cohort study. PLoS One
Shinohara Y, Origasa H. Post-stroke pneumonia prevention by angiotensin-converting enzyme inhibitors: results of a meta-analysis of five studies in Asians. Adv Ther
[Table 1], [Table 2], [Table 3], [Table 4]