1. Predictors and Outcomes
of Pneumonia in Patients
With Spontaneous
Intracerebral Hemorrhage
Alsumrain M, et al
J Intensive Care Med
February 14, 2012
Journal Reading
Ersifa Fatimah, dr.
Pembimbing: dr. Hendro Susilo, SpS(K)
Pengamat: dr. Yudha Haryono, SpS
2. Introduction
ICH, common form of stroke 1/5 of all cases
Respiratory tract infection in ICU 30-60% of all infection
Pneumonia have the highest mortality rate among all
medical complications after stroke
To predict which patients will benefit from early & more
aggressive treatment
There is little data on the incidence of pneumonia in patients
with ICH / neuro-ICU
2
4. Methods
290 consecutive patients with sICH admitted within 24 hours of stroke onset, at New
Jersey Neuroscience Institute - J F Kennedy Hospital, from January 2006 to July 2009
Data
Demographic data GCS & mRS Pneumonia & exposure
Additional data
Site & type pneumonia, LoS, PPI, H2B, ACE-I, smoking, alcohol
Statistical analysis
4
5. Definitions
Pneumonia
• Dx: 2007 consensus guidelines from the Infectious Diseases Society of
America & the American Thoracic Society
• Include: a constellation of suggestive clinical features, a
demonstrable infiltrate by chest radiograph or other imaging
technique, with / without supporting microbiological data.
Ventilator-associated pneumonia (VAP)
• Exposure to MV at any point during hospital course
• Px developed pneumonia after 48 hours on the ventilator
• Uses VAP bundle according to the Joint Commission on
Accreditation of Healthcare Organizations for the prevention of
pneumonia in mechanically ventilated patients.
Dysphagia
• diagnosed after a standardized speech and swallow evaluation
completed by a team of speech therapist.
Tube feeding
• Started within 48 hours of hospitalization.
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6. Results & Discussion
• 290 patients (-10?)
• 159 (56.5%) male
• mean age of 66.6 years (SD +/- 16.2).
• 13.93% patients developed pneumonia.
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7. Cont.
• Patients who developed pneumonia had a lower GCS (mean = 9.1) &
higher mRS (mean = 4) on admission. Those without pneumonia, the mean
of GCS = 12.6 & mRS = 2.77
Substantial risk of pneumonia is associated with
(each of these parameters, cut offs):
mRS 2.5 (=< 2 vs =>3) ORa 5.18 (2.10 – 12.8)
GCS 13.5 (=<13 vs =>14) ORa 6.27 (2.84 – 13.9)
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8. PPI , H2-blockers and Pneumonia
Normal gastric juice with a pH below 4 most
pathogens are killed
• Suppression of gastric acid no defense from bacteria
multiplying colonization of pathogens, particularly gram-
positive bacteria, from the upper GIT
• Aspiration is important mechanism in the development of
nosocomial pneumonia.
Degree of bacterial overgrowth depends on
the degree of reduction in gastric acid
secretion
• Bacterial overgrowth is considerably higher in patients
treated with PPI compared with H2-receptor antagonist.
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9. ACE inhibitors & Pneumonia
Our study Other studies
The use of ACE-I predisposes those ACE-I beneficial for elderly patients
with sICH to develop pneumonia with intracerebral hemorrhage or
stroke, who are at risk of
pneumonia.
Protective effects of ACE-I
• Attributed to an increase in substance P & bradykinin.
ACE-I has different effects on racial populations:
• Most of the studies involving ACE-I involve only Asian population.
• Studies involving a general white population show no reduced
hospitalization for community acquired pneumonia for patients using
ACE-I.
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10. • 93(33.2%)patients required mechanical ventilation at one point of
their disease course VAP 76%.
• The most common site of pneumonia: the right lower lobe (41%).
• The most common isolated organisms: Pseudomonas aeruginosa &
Klebsiella pneumoniae, from 12 patients (30.7%) with pneumonia
Univariate analysis: Variables & OR (95% CI)
Mechanical ventilation 9.42 (4.24 - 20.9)
Tube feeding 22.3 (8.91 – 55.8)
Dysphagia 13.1 (4.66 – 36.7)
Tracheostomy 26.8 (8.02 – 89.3)
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11. Multivariate analysis • Relatively small
differences in ORa
after adjusting for
potential
confounders
• Most interaction
terms were not
significant
• Exception:
o H2-blockers for MV
o GCS & mRS for all but
dysphagia & MV [only
GCS yielded a
significant interaction].
All potential
confounders left the 4
primary exposures
statistically significant
after adjustment.
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12. • Primary route of
bacterial entry into
the trachea:
• aspiration of
oropharyngeal
pathogens
• leakage of
bacteria around
the endotracheal
tube cuff.
• Frequent need of
MV in px with sICH
at a higher risk of
pneumonia than
any other group of
patients. (in this
study, 76.9% of
patients who
developed
The minimum ORa was 3.72 (95% CI: 1.68 - 8.26) pneumonia were on
when adjusted for GCS MV)
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13. • The bronchial
colonization of
bacteria in upper
airways during
tracheostomy
reservoir for the
lower airways
colonization
increases risk of
pneumonia.
• Subsequent need
for tracheostomy
who required
prolonged use of
MV with
tracheostomy, incre
ased risk of
mRS reduced OR to 16.2 (95% CI: 4.98 - 52.8) ventilator-
for tracheostomy associated
tracheobronchitis ~
precursor for VAP.
13
14. The mechanisms
responsible:
• desensitization of the
pharyngo-glottal
adduction reflex,
• loss of anatomical
integrity of the
esophageal
sphincters,
• migration of gastric
bacteria upward
along the tube
causing colonization
of the pharynx.
• Both GCS and mRS reduced ORa
• GCS to14.7(95% CI: 6.16-35.0)
• mRS to15.7(95% CI: 6.63-37.0).
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15. • Dysphagia is seen in
40 - 70% of patients
who had an acute
stroke 40 - 50%
aspirate increases
the likelihood of
developing
pneumonia by 7-fold.
mRS reduced OR to 7.46 (95% CI: 3.34 -
10.6)
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16. Effect of pneumonia on morbidity:
• Increase in mRS between admission and discharge:
o by 1.07(4-5.07) in patients with pneumonia
o by 0.33 (2.77-3.1) in patients without pneumonia
o P = .003
• The hospital length of stay:
o The pneumonia group (mean = 19.56 days)
o The no-pneumonia group (mean = 9.14 days),
o P <.0001.
• Mortality rate:
o 10 (25.6%) patients died in pneumonia group
o 30 (12%)patients died in no pneumonia group
o P = .041
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17. Limitations
• Retrospective protocol:
o Some limitations, primarily due to existing documentation
• Not include:
o length of time on mechanical ventilation
o the use of hypothermia
o the size and location of ICH.
• The sample size
o adequate in establishing significant associations between
the exposures and outcomes,
o not large enough to avoid fairly broad CIs.
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18. Conclusion
Increased risk of the development of
pneumonia in patients with sICH:
• Mechanical ventilation, tube feeding, dysphagia, and
tracheostomy
• Independently associated with pneumonia, even when
potentially confounding variables are considered: GCS &
mRS on admission and the use of PPI / H2 blockers, ACE-I.
Pneumonia in patients with sICH
• Increased morbidity, hospital length of stay, and mortality
Need for increased vigilance & scrupulous
adherence to intensive care protocols
• designed to reduce the occurrence of pneumonia in
patients with sICH.
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19. Education of health care personnel
Active surveillance of VAP
Minimizing the duration of ventilation
Adherence to hand hygiene guidelines
Maintaining patients in a semi-recumbent position
Good oral care
The use of strategies to decrease the contamination of equipments
used for care in patients on mechancal ventilation.
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22. Research Question
1 2
P Patients with sICH Patients with sICH
I MV, tracheostomy, Pneumonia
tube feeding, dysphagia
C - -
O Increase risk of Increase in
development of morbidity, mortality, length
pneumonia of stay
Prognosis
Study design: Retrospective
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25. Case-Control
Odds diseased
Factor = Exposed to factor
early 37 = (37/18)
infant
formula
50
Odds diseased
13 Unexposed to factor
Disease = = (13/32)
Early onset
of
asthma 18
50 Odds Ratio (OR)
32 =
(37/18)
Present Time
(13/32)
= 5,1
Starting
point
Past Time
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26. Cohort Study
100
300
200
1000
50
Factor = Disease =
early Early onset
infant
formula
of
asthma
700
650
Present Time Past Time
Starting
Relative Risk =
point
Incidence diseased Incidence diseased
Exposed to factor Unexposed to factor (100/300) = 4,7
= (100/300) = (50/700) (50/700)
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27. Validity
Recruitment -- “Were the subjects representative?”
Patients should ideally be enrolled at a sICH at 24-h onset
uniformly early time in the disease
Patients should also be representative Demographic data
of the underlying population.
Patients from tertiary referral centres Single-center, type?
may have more advanced disease
and poorer prognoses than patients
from primary care.
Adjustment — “If subgroups with different prognoses are identified, did
adjustment for important prognostic factors take place?”
Adjust for known prognostic factors in Multivariate analysis
the analysis so that the result indicate
the additional prognostic information.
28. Maintenance --“Was the comparable status of the study groups maintained
through equal management? Adequate follow-up?””
Prognosis is always conditional on Equal?
treatment, initial and subsequent Protocol to treat pneumonia
treatment should be clearly spelt out, Limitation in ICH therapy
Follow-up should be long enough to All px: Discharge or death
detect the outcome of interest Reasons for loss to follow-up?
Measurement: “Were the subjects and assessors kept „blind‟ to which treatment
was being received and/or were the measures objective ?”
Ideal if both the outcome assessors and Outcome: dx pneumonia criteria,
the subjects are blinded to the nature mortality, mRS, LoS
of the study groups.
If the outcome is objective (eg death)
then blinding is less critical.
If the outcome is subjective (eg
symptoms or function) then blinding of
the outcome assessor is critical.
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29. Importance
• OR, ORa clinical significance (+)
• Statistical significance available p-value
30. Applicability
• Study population similar to our own
• Results will lead to therapy selection
• Results useful for counseling patient or family
