Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia – The PREDICT study

Höffmann, Sarah; Harms, Hendrik; Ulm, Lena; Nabavi, Darius G.; Mackert, Bruno-Marcel; Schmehl, Ingo; Jungehülsing, Gerhard Jan; Montaner, Joan; Bustamante, Alejandro; Hermans, Marcella; Hamilton, Frank A.; Göhler, Jos; Malzahn, Uwe; Malsch, Carolin; Heuschmann, Peter U.; Meisel, Christian; Meisel, Andreas

doi:10.1177/0271678x16671964

Cited by 161 publications

(209 citation statements)

References 42 publications

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“…Accordingly, we observed a clearly higher pneumonia proportion in dysphagic patients compared to those with normal swallowing function. This is in line with the range of 13–33% reported for dysphagic stroke patients in the literature [1, 26, 28]. The vast majority of our patients were treated on SUs.…”

Section: Discussionsupporting

confidence: 90%

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The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

et al. 2018

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Background: Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. Methods: In this prospective register-based study (“Stroke Register of Northwestern Germany”), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. Results: Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2–5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0–3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0–3.2], p < 0.001). The order of magnitude of these end points did not change over time. Conclusion: Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.

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Section: Discussionsupporting

confidence: 90%

“…Dysphagia is known to be an independent predictor of post-stroke pneumonia, in addition to poor oral health and stroke-induced immune suppression [26-28]. Accordingly, we observed a clearly higher pneumonia proportion in dysphagic patients compared to those with normal swallowing function.…”

Section: Discussionsupporting

confidence: 47%

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

et al. 2018

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“…27 Clinically, reduction of HLA-DR expression in monocytes is a prognostic marker of strokeinduced immune suppression and SAP. 2,28,29 Interestingly, we found that ischemic stroke increases the expression of the monocyte chemoattractant CCL2 in the lungs, yet monocyte infiltration into the lungs was not observed. Conversely, following ischemic stroke, we observed a massive infiltration of monocytes into the brain, which may account for temporal peripheral immune exhaustion following ischemic stroke.…”

Section: Discussionmentioning

confidence: 69%

Ischemic stroke alters immune cell niche and chemokine profile in mice independent of spontaneous bacterial infection

Farris

Monaghan

Zheng

et al. 2019

Immunity Inflam & Disease

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Introduction Stroke‐associated pneumonia (SAP) is a major cause of mortality in patients who have suffered from severe ischemic stroke. Although multifactorial in nature, stroke‐induced immunosuppression plays a key role in the development of SAP. Previous studies using a murine model of transient middle cerebral artery occlusion (tMCAO) have shown that focal ischemic stroke induction results in functional defects of lymphocytes in the spleen, thymus, and peripheral blood, leading to spontaneous bacterial infection in the lungs without inoculation. However, how ischemic stroke alters immune cell niche and the expression of cytokines and chemokines in the lungs has not been fully characterized. Methods Ischemic stroke was induced in mice by tMCAO. Immune cell profiles in the brain and the lungs at 24‐ and 72‐hour time points were compared by flow cytometric analysis. Cytokine and chemokine expression in the lungs were determined by multiplex bead arrays. Tissue damage and bacterial burden in the lungs following tMCAO were evaluated. Results Ischemic stroke increases the percentage of alveolar macrophages, neutrophils, and CD11b+ dendritic cells, but reduces the percentage of CD4+ T cells, CD8+ T cells, B cells, natural killer cells, and eosinophils in the lungs. The alteration of immune cell niche in the lungs coincides with a significant reduction in the levels of multiple chemokines in the lungs, including CCL3, CCL4, CCL5, CCL17, CCL20, CCL22, CXCL5, CXCL9, and CXCL10. Spontaneous bacterial infection and tissue damage following tMCAO, however, were not observed. Conclusion This is the first report to demonstrate a significant reduction of lymphocytes and multiple proinflammatory chemokines in the lungs following ischemic stroke in mice. These findings suggest that ischemic stroke directly impacts pulmonary immunity.

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“…Finally, accumulating evidence suggests that a stroke induces an immunodepressive state increasing susceptibility for stroke‐associated pneumonia (SAP). Although the FBAS reliably estimates aspiration risk in the very acute phase of stroke management, dysphagia remains an important risk factor for SAP and should be formally evaluated after initial stroke work‐up in order to make informed physiology‐based treatment decisions.…”

Section: Discussionmentioning

confidence: 99%

“…It is known that hospitals that adhere to formal screening protocols can significantly lower their rates of pneumonia 49 and that acute stroke patients who are not screened early for swallowing risk present with a higher risk of developing pulmonary complications. 2,14,50 Finally, accumulating evidence 51,52 suggests that a stroke induces an immunodepressive state increasing susceptibility for stroke-asso-…”

Section: Discussionmentioning

confidence: 99%

Predictive value of a novel pragmatic tool for post‐stroke aspiration risk: The Functional Bedside Aspiration Screen

Virvidaki

Giannopoulos

Nasios

et al. 2019

Neurogastroenterology Motil

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Background There is still a strong need for an optimal clinician‐friendly screening tool for the identification of aspiration risk in stroke patients. In this study, we present the development of a novel, context‐specific screening tool for the prediction of aspiration risk on recent stroke survivors, the Functional Bedside Aspiration Screen (FBAS), and examine its construct validity, reliability with the predictive values toward pragmatic patients' outcomes. Methods We conducted a prospective validation study of 104 acute ischemic stroke patients admitted to clinical wards in a tertiary university hospital. A group of experts developed and administered the FBAS 10‐point scale to all patients. Outcome measures were compared with those of the validated Yale Swallow Protocol (YSP, reference measure) and health indicators. Key Results A strong association was found between the FBAS cutoff criterion and the YSP (Pearson χ2 = 54.92, P < .001). A score of ≤8 on the FBAS presented with 93.3% sensitivity and 83.3% specificity in deeming patient with reduced safety for oral nutrition (AUC = 0.934, CI = 0.884‐0.985). An inverse relationship was found between performance on the FBAS and in‐hospital and long‐term outcome indicators. Patients who failed the FBAS were 1.82 times more likely to develop aspiration pneumonia (95% CI = 1.42‐2.35) and 1.35 times more likely to develop pneumonia within 3 months postonset (95% CI = 1.15‐1.59). Conclusions and Inferences The FBAS is a potentially useful tool for timely prediction of aspiration risk and health outcome in acute stroke.

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Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia – The PREDICT study

Cited by 161 publications

References 42 publications

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

Ischemic stroke alters immune cell niche and chemokine profile in mice independent of spontaneous bacterial infection

Predictive value of a novel pragmatic tool for post‐stroke aspiration risk: The Functional Bedside Aspiration Screen

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