• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of jnnpsycJournal of Neurology, Neurosurgery and PsychiatryCurrent TOCInstructions for authors
J Neurol Neurosurg Psychiatry. Jun 2004; 75(6): 852–856.
PMCID: PMC1739077

Pneumonia in acute stroke patients fed by nasogastric tube

Abstract

Background: Aspiration pneumonia is the most important acute complication of stroke related dysphagia. Tube feeding is usually recommended as an effective and safe way to supply nutrition in dysphagic stroke patients.

Objective: To estimate the frequency of pneumonia in acute stroke patients fed by nasogastric tube, to determine risk factors for this complication, and to examine whether the occurrence of pneumonia is related to outcome.

Methods: Over an 18 month period a prospective study was done on 100 consecutive patients with acute stroke who were given tube feeding because of dysphagia. Intermediate outcomes were pneumonia and artificial ventilation. Functional outcome was assessed at three months. Logistic regression and multivariate regression analyses were used, respectvely, to identify variables significantly associated with the occurrence of pneumonia and those related to a poor outcome.

Results: Pneumonia was diagnosed in 44% of the tube fed patients. Most patients acquired pneumonia on the second or third day after stroke onset. Patients with pneumonia more often required endotracheal intubation and mechanical ventilation than those without pneumonia. Independent predictors for the occurrence of pneumonia were a decreased level of consciousness and severe facial palsy. The NIH stroke scale score on admission was the only independent predictor of a poor outcome.

Conclusions: Nasogastric tubes offer only limited protection against aspiration pneumonia in patients with dysphagia from acute stroke. Pneumonia occurs mainly in the first days of the illness and patients with decreased consciousness and a severe facial palsy are especially endangered.

Full Text

The Full Text of this article is available as a PDF (168K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Daniels SK, Brailey K, Foundas AL. Lingual discoordination and dysphagia following acute stroke: analyses of lesion localization. Dysphagia. 1999 Spring;14(2):85–92. [PubMed]
  • Smithard DG, O'Neill PA, Park C, England R, Renwick DS, Wyatt R, Morris J, Martin DF. Can bedside assessment reliably exclude aspiration following acute stroke? Age Ageing. 1998 Mar;27(2):99–106. [PubMed]
  • Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999 Apr;30(4):744–748. [PubMed]
  • Robbins J, Levine RL, Maser A, Rosenbek JC, Kempster GB. Swallowing after unilateral stroke of the cerebral cortex. Arch Phys Med Rehabil. 1993 Dec;74(12):1295–1300. [PubMed]
  • Smithard DG, O'Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter? Stroke. 1996 Jul;27(7):1200–1204. [PubMed]
  • Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN. Aspiration following stroke: clinical correlates and outcome. Neurology. 1988 Sep;38(9):1359–1362. [PubMed]
  • Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed) 1987 Aug 15;295(6595):411–414. [PMC free article] [PubMed]
  • Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry. 1989 Feb;52(2):236–241. [PMC free article] [PubMed]
  • Finestone HM. Safe feeding methods in stroke patients. Lancet. 2000 May 13;355(9216):1662–1663. [PubMed]
  • Smithard DG. Percutaneous endoscopic gastrostomy feeding after acute dysphagic stroke. Gag reflex has no role in ability to swallow. BMJ. 1996 Apr 13;312(7036):972–974. [PMC free article] [PubMed]
  • Nakajoh K, Nakagawa T, Sekizawa K, Matsui T, Arai H, Sasaki H. Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. J Intern Med. 2000 Jan;247(1):39–42. [PubMed]
  • Teramoto S, Matsuse T, Fukuchi Y, Ouchi Y. Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia. Lancet. 1999 Apr 10;353(9160):1243–1243. [PubMed]
  • Teramoto S, Fukuchi Y. Detection of aspiration and swallowing disorder in older stroke patients: simple swallowing provocation test versus water swallowing test. Arch Phys Med Rehabil. 2000 Nov;81(11):1517–1519. [PubMed]
  • DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol. 1992 Dec;49(12):1259–1261. [PubMed]
  • Hilker Ruediger, Poetter Carsten, Findeisen Nahide, Sobesky Jan, Jacobs Andreas, Neveling Michael, Heiss Wolf-Dieter. Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke. 2003 Apr;34(4):975–981. [PubMed]
  • Huxley EJ, Viroslav J, Gray WR, Pierce AK. Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med. 1978 Apr;64(4):564–568. [PubMed]
  • Joshi N, Localio AR, Hamory BH. A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med. 1992 Aug;93(2):135–142. [PubMed]
  • Nishino T, Takizawa K, Yokokawa N, Hiraga K. Depression of the swallowing reflex during sedation and/or relative analgesia produced by inhalation of 50% nitrous oxide in oxygen. Anesthesiology. 1987 Dec;67(6):995–998. [PubMed]
  • Nishino T, Hiraga K. Coordination of swallowing and respiration in unconscious subjects. J Appl Physiol (1985) 1991 Mar;70(3):988–993. [PubMed]
  • Moulton C, Pennycook AG. Relation between Glasgow coma score and cough reflex. Lancet. 1994 May 21;343(8908):1261–1262. [PubMed]
  • Wang Y, Lim LL, Levi C, Heller RF, Fischer J. A prognostic index for 30-day mortality after stroke. J Clin Epidemiol. 2001 Aug;54(8):766–773. [PubMed]
  • Reith J, Jørgensen HS, Pedersen PM, Nakayama H, Raaschou HO, Jeppesen LL, Olsen TS. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet. 1996 Feb 17;347(8999):422–425. [PubMed]
  • Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665–671. [PubMed]
  • Cole MJ, Smith JT, Molnar C, Shaffer EA. Aspiration after percutaneous gastrostomy. Assessment by Tc-99m labeling of the enteral feed. J Clin Gastroenterol. 1987 Feb;9(1):90–95. [PubMed]
  • Balan KK, Vinjamuri S, Maltby P, Bennett J, Woods S, Playfer JR, Critchley M. Gastroesophageal reflux in patients fed by percutaneous endoscopic gastrostomy (PEG): detection by a simple scintigraphic method. Am J Gastroenterol. 1998 Jun;93(6):946–949. [PubMed]
  • Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GK. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996 Jan 6;312(7022):13–16. [PMC free article] [PubMed]
  • Hassett JM, Sunby C, Flint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet. 1988 Nov;167(5):383–388. [PubMed]
  • Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand J Gastroenterol Suppl. 1992;194:95–98. [PubMed]
  • Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ, Russell RI, Mills PR. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ. 1992 May 30;304(6839):1406–1409. [PMC free article] [PubMed]
  • Mayer SA, Copeland D, Bernardini GL, Boden-Albala B, Lennihan L, Kossoff S, Sacco RL. Cost and outcome of mechanical ventilation for life-threatening stroke. Stroke. 2000 Oct;31(10):2346–2353. [PubMed]
  • Berrouschot J, Rössler A, Köster J, Schneider D. Mechanical ventilation in patients with hemispheric ischemic stroke. Crit Care Med. 2000 Aug;28(8):2956–2961. [PubMed]
  • Bushnell CD, Phillips-Bute BG, Laskowitz DT, Lynch JR, Chilukuri V, Borel CO. Survival and outcome after endotracheal intubation for acute stroke. Neurology. 1999 Apr 22;52(7):1374–1381. [PubMed]
  • Santoli F, De Jonghe B, Hayon J, Tran B, Piperaud M, Merrer J, Outin H. Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year. Intensive Care Med. 2001 Jul;27(7):1141–1146. [PubMed]
  • Treloar DM, Stechmiller J. Pulmonary aspiration in tube-fed patients with artificial airways. Heart Lung. 1984 Nov;13(6):667–671. [PubMed]
  • Pavlin EG, VanNimwegan D, Hornbein TF. Failure of a high-compliance low-pressure cuff to prevent aspiration. Anesthesiology. 1975 Feb;42(2):216–219. [PubMed]
  • Seegobin RD, van Hasselt GL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J. 1986 May;33(3 Pt 1):273–279. [PubMed]
  • Indredavik B, Bakke F, Slordahl SA, Rokseth R, Hâheim LL. Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important? Stroke. 1999 May;30(5):917–923. [PubMed]

Articles from Journal of Neurology, Neurosurgery, and Psychiatry are provided here courtesy of BMJ Group

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

  • MedGen
    MedGen
    Related information in MedGen
  • PubMed
    PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...