Factors Associated with Risk of Stroke-Associated Pneumonia in Patients with Dysphagia: A Systematic Review

Sabrina A Eltringham, Karen Kilner, Melanie Gee, Karen Sage, Ben D Bray, Craig J Smith, Sue Pownall, Sabrina A Eltringham, Karen Kilner, Melanie Gee, Karen Sage, Ben D Bray, Craig J Smith, Sue Pownall

Abstract

Dysphagia is associated with increased risk of stroke-associated pneumonia (SAP). However, it is unclear what other factors contribute to that risk or which measures may reduce it. This systematic review aimed to provide evidence on interventions and care processes associated with SAP in patients with dysphagia. Studies were screened for inclusion if they included dysphagia only patients, dysphagia and non-dysphagia patients or unselected patients that included dysphagic patients and evaluated factors associated with a recorded frequency of SAP. Electronic databases were searched from inception to February 2017. Eligible studies were critically appraised. Heterogeneity was evaluated using I2. The primary outcome was SAP. Eleven studies were included. Sample sizes ranged from 60 to 1088 patients. There was heterogeneity in study design. Measures of immunodepression are associated with SAP in dysphagic patients. There is insufficient evidence to justify screening for aerobic Gram-negative bacteria. Prophylactic antibiotics did not prevent SAP and proton pump inhibitors may increase risk. Treatment with metoclopramide may reduce SAP risk. Evidence that nasogastric tube (NGT) placement increases risk of SAP is equivocal. A multidisciplinary team approach and instrumental assessment of swallowing may reduce risk of pneumonia. Patients with impaired mobility were associated with increased risk. Findings should be interpreted with caution given the number of studies, heterogeneity and descriptive analyses. Several medical interventions and care processes, which may reduce risk of SAP in patients with dysphagia, have been identified. Further research is needed to evaluate the role of these interventions and care processes in clinical practice.

Keywords: Deglutition; Deglutition disorders; Dysphagia; Risk factors; Stroke; Stroke-associated pneumonia.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

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Search methodology and outcome

References

    1. Kishore KA, Vail A, Chamorro A, Garau J, Hopkins JS, Di Napoli M, et al. How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke. 2015;46(5):1202–1209. doi: 10.1161/STROKEAHA.114.007843.
    1. Westendorp WF, Nederkoorn PJ, Vermeij J, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurology. 2011;11(1):110. doi: 10.1186/1471-2377-11-110.
    1. Finlayson O, Kapral M, Selchen D, Saposnik G, Hall R, Asllani E. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology. 2011;77(14):1338–1345. doi: 10.1212/WNL.0b013e31823152b1.
    1. Ali AN, Howe J, Majid A, Redgrave J, Pownall S, Abdelhafiz AH. The economic cost of stroke-associated pneumonia in a UK setting. Top Stroke Rehabil. 2018;25(3):214–223. doi: 10.1080/10749357.2017.1398482.
    1. Hannawi Y, Hannawi B, Rao CPV, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis. 2013;35(5):430–443. doi: 10.1159/000350199.
    1. Emsley HC, Hopkins SJ. Acute ischaemic stroke and infection: Recent and emerging concepts. Lancet Neurol. 2008;7(4):341–353. doi: 10.1016/S1474-4422(08)70061-9.
    1. Dirnagl U, Klehmet J, Braun JS, Harms H, Meisel C, Ziemssen T, et al. Stroke-induced immunodepression experimental evidence and clinical relevance. Stroke. 2007;38:770–773. doi: 10.1161/01.STR.0000251441.89665.bc.
    1. Prass K, Meisel C, Hoflich C, Braun J, Halle E, Wolf T, et al. Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1-like immunostimulation. J Exp Med. 2003;198:725–736. doi: 10.1084/jem.20021098.
    1. Winek K, Dames C, Krasteva-Christ G, Kummer W, Meisel C, Meisel A (unpublished) in Meisel, A. Post-stroke pneumonia. ESOC 2018. In: 4th European stroke organisation conference, 16–18 May 2018, Gothenburg, Sweden. 2018
    1. Brogan E, Langdon C, Brookes K, Budgeon C, Blacker D. Dysphagia and factors associated with respiratory infections in the first week post stroke. Neuroepidemiology. 2014;43(2):140–144. doi: 10.1159/000366423.
    1. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756. doi: 10.1161/01.STR.0000190056.76543.eb.
    1. Eltringham S, Kilner K, Gee M, Sage K, Bray B, Pownall S, Smith C. Impact of dysphagia assessment and management on risk of stroke-associated pneumonia: a systematic review. Cerebrovasc Dis. 2018;46(3–4):99–107. doi: 10.1159/000492730.
    1. Langdon PC, Lee AH, Binns CW. High incidence of respiratory infections in ‘nil by mouth’ tube-fed acute ischemic stroke patients. Neuroepidemiology. 2009;32(2):107–113. doi: 10.1159/000177036.
    1. Lyons M, Smith C, Boaden E, Brady M, Brocklehurst P, Dickinson H. Oral care after stroke: where are we now? Eur Stroke J. 2018;3(4):347–354. doi: 10.1177/2396987318775206.
    1. Warusevitane A, Karunatilake D, Sim J, Lally F, Roffe C. Safety and effect of metoclopramide to prevent pneumonia in patients with stroke fed via nasogastric tubes trial. Stroke. 2015;46(2):454–460. doi: 10.1161/STROKEAHA.114.006639.
    1. Langmore S, Terpenning M, Schork A, Chen Y, Murray J, Lopatin D, Loesche W. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998;13:69–81. doi: 10.1007/PL00009559.
    1. Benfield J, Michou E. Dysphagia screening and assessment in the stroke unit. Br J Neurosci Nurs. 2016;12:S24–S28. doi: 10.12968/bjnn.2016.12.Sup2.S24.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097.
    1. Centre for Reviews and Dissemination. Systematic reviews: guidance for undertaking reviews in healthcare. . Accessed 14 Oct 2017
    1. Booth A. Unpacking your literature search toolbox: on search styles and tactics. Health Inf Libr J. 2008;25(4):313–317. doi: 10.1111/j.1471-1842.2008.00825.x.
    1. Intercollegiate Stroke Working Party. National clinical guideline for stroke, 5th ed. London: Royal College of Physicians; 2016. . Accessed 27 June 2017.
    1. Smith JC, Kishore KA, Vail A, Chamorro A, Garau J, Hopkins JS, et al. Diagnosis of stroke-associated pneumonia: recommendations from the pneumonia in stroke consensus group. Stroke. 2015;46(8):2335–2340. doi: 10.1161/STROKEAHA.115.009617.
    1. Caldeira D, Alarcão J, Vaz-Carneiro A, Costa J. Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis. BMJ. 2012;345(7868):e4260. doi: 10.1136/bmj.e4260.
    1. Beavan J. Update on management options for dysphagia after acute stroke. Br J Neurosci Nurs. 2015;11(Suppl 2):10–19. doi: 10.12968/bjnn.2015.11.Sup2.10.
    1. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke. Evidence Tables. London: Royal College of Physicians . Accessed 18 Oct 2017.
    1. Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions, Version 5.1.0. The Cochrane Collaboration; 2011. . Updated March 2011.
    1. Critical Appraisal Skills Programme (CASP). CASP checklists. . Accessed 18 Oct 2017.
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560. doi: 10.1136/bmj.327.7414.557.
    1. Review Manager (RevMan). [Computer program], version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014.
    1. Neyeloff JL, Fuchs SC, Moreira LB. Meta-analyses and forest plots using a Microsoft excel spreadsheet: step-by-step guide focusing on descriptive data analysis. BMC Res Notes. 2012;5:52. doi: 10.1186/1756-0500-5-52.
    1. Kalra L, Irshad S, Hodsoll J, Smithard D, Manawadu D. Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients. Neurology. 2016;87(13):1352–1359. doi: 10.1212/WNL.0000000000003151.
    1. Kalra L, Irshad S, Hodsoll J, Simpson M, Gulliford M, Smithard D, et al. Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial. Lancet. 2015;386(10006):1835–1844. doi: 10.1016/S0140-6736(15)00126-9.
    1. Gosney M, Martin MV, Wright AE. The role of selective decontamination of the digestive tract in acute stroke. Age Ageing. 2006;35(1):42–47. doi: 10.1093/ageing/afj019.
    1. Hoffmann S, Harms H, Ulm L, Nabavi DG, Mackert B, Schmehl I, et al. Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia—the PREDICT study. J Cereb Blood Flow Metab. 2016;37(12):3671–3682. doi: 10.1177/0271678X16671964.
    1. Arai N, Nakamura A, Tabuse M, Miyazaki H, Nakamizo T, Ihara H, et al. Histamine H2-blocker and proton pump inhibitor use and the risk of pneumonia in acute stroke: a retrospective analysis on susceptible patients. PLoS ONE. 2017;12(1):e0169300. doi: 10.1371/journal.pone.0169300.
    1. Brogan E, Brookes K, Langdon C, Budgeon C, Blacker D. Can’t swallow, can’t transfer, can’t toilet: factors predicting infections in the first week post stroke. J Clin Neurosci. 2015;22(1):92–97. doi: 10.1016/j.jocn.2014.05.035.
    1. Gandolfi M, Smania N, Bisoffi G, Squaquara T, Zuccher P, Mazzucco S. Improving post-stroke dysphagia outcomes through a standardized and multidisciplinary protocol: an exploratory cohort study. Dysphagia. 2014;29(6):704–712. doi: 10.1007/s00455-014-9565-2.
    1. Schwarz M, Coccetti A, Murdoch A, Cardell E. The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: a retrospective cohort study. J Clin Nurs. 2018;27(1–2):e235–e241. doi: 10.1111/jocn.13922.
    1. Aoki S, Hosomi N, Hirayama J, Nakamori M, Yoshikawa M, Nezu T, et al. The multidisciplinary swallowing team approach decreases pneumonia onset in acute stroke patients. PLoS ONE. 2016;11(5):e0154608. doi: 10.1371/journal.pone.0154608.
    1. 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. 2008;36(5):309–332. doi: 10.1016/j.ajic.2008.03.002.
    1. Vermeij JD, Westendorp WF, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in people with acute stroke. Cochrane Database Syst Rev. 2018; Issue 1. Art. No.:CD008530. 10.1002/14651858.CD008530.pub3.
    1. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute stroke. A randomised, open, phase III, clinical trial with blinded outcome assessment Study Protocol. .
    1. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2015;36(9):1972–1976. doi: 10.1161/01.STR.0000177529.86868.8d.
    1. Palli C, Fandler S, Doppelhofer K, Niederkorn K, Enzinger C, Vetta C, et al. Early dysphagia screening by trained nurses reduces pneumonia rate in stroke patients. Stroke. 2017;48(9):2583–2585. doi: 10.1161/STROKEAHA.117.018157.
    1. Perry L, McLaren SM. An evaluation of implementation of evidence-based guidelines for dysphagia screening and assessment following acute stroke: phase 2 of an evidence-based practice project. J Clin Excellence. 2000;2(3):147–156.
    1. Odderson IR, Keaton JC, McKenna BS. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil. 1995;76(12):1130–1133. doi: 10.1016/S0003-9993(95)80121-9.
    1. Odderson IR, McKenna BS. A model for management of patients with stroke during the acute phase: outcome and economic implications. Stroke. 1993;24(12):1823–1827. doi: 10.1161/01.STR.24.12.1823.
    1. Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, et al. Cluster-randomized, crossover trial of head positioning in acute stroke. N Engl J Med. 2017;376(25):2437–2447. doi: 10.1056/NEJMoa1615715.

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