Stroke and pneumonia - you can't think of anything worse. How to protect yourself from congestive pneumonia after a stroke

Smirnova Olga Leonidovna

Neurologist, education: First Moscow State medical University named after I.M. Sechenov. Work experience 20 years.

Articles written

Most patients have to deal with such a complication as pneumonia after a stroke. This dangerous disease can significantly worsen the patient's condition and complicate the treatment of an already complex disease. It is important to detect the presence of pneumonia as early as possible, before it leads to significant health problems for the weakened patient.

It is believed that stroke and developing pneumonia are interrelated, since one disease becomes a risk factor that provokes the second. The statistics in this case are simply inexorable: up to half of all patients with a stroke suffer from pneumonia after a “hit”, and in 15% of such patients, pneumonia paired with a stroke leads to a fatal outcome.

Basically, pneumonia is provoked by the fact that the patient long time is motionless, in a static position on the back. This is largely due to paresis and paralysis resulting from the disease, but the following negative factors may also affect:

The advanced age of a person.
The presence of problems with the lungs even before the development of a stroke.
Previous heart disease or circulatory or respiratory disorders.
Stay in a coma.
Connection to a ventilator, especially for a long time.
Overweight, obesity.
Too long a stay in the hospital in a lying state.
The use of certain medicines.

In some cases, pneumonia develops in especially weakened patients without any external causes.

Types of pneumonia

Most often, pneumonia in a stroke is of two types:

The congestive or hypostatic form occurs in severely ill patients, for a long time chained to a hospital bed. Due to the constant presence in one position on the back, blood circulation in the lungs is disturbed, due to a static state and partial compression of the chest, natural ventilation is disturbed, sputum accumulates, which the patient cannot remove on his own. It becomes a favorable environment for the development of inflammation, and there are plenty of infectious agents in any hospital.
Aspiration pneumonia is also in most cases associated with the supine position of the patient with a stroke. The situation is often provoked by the fact that the patient is partially paralyzed, he cannot swallow normally. Often, a small piece of food or a drop of liquid is accidentally inhaled and enters the lungs. This fragment clogs the lumen of the bronchi, interfering with normal air circulation. Then microorganisms rapidly develop on the nutrient medium, mainly bacteria that cause pneumonia. The patient suffers from a painful cough and high fever.

Both types of pneumonia are equally dangerous to the health and life of the patient, and therefore require rapid detection and elimination.

Signs of the disease

Diagnose inflammation of the lungs in bedridden patients on early stages extremely difficult, since its signs overlap and are "smeared" by the signs of a stroke.

The main symptoms of pneumonia are the appearance of a cough, a rise in temperature and the patient's complaints about severe pain in the chest, which are aggravated by coughing. The patient becomes pale, sweats on the slightest exertion, suffers from suffocation and weakness.

Complications of pneumonia

Inflammation of the lungs in people with a stroke threatens to develop the following complications:

violations of the respiratory function, which require mandatory connection to a mechanical ventilation device. It is necessary to do this, since during a stroke, the brain and tissues already suffer from a lack of oxygen. If pneumonia joins, then the brain may be in a critical situation, which will have an extremely negative impact on the prognosis;
general intoxication. With the development of pneumonia, an already severely affected organism is literally poisoned by the waste products of microorganisms. The myocardium, the heart muscle, suffers the most, which leads to heart failure and often to a fatal end. The danger is also the fact that it is very difficult to diagnose congestion in the lungs, with them even a blood test does not show acute leukocytosis.

It is believed that aspiration pneumonia gives fewer complications, is easier to detect and treat than congestive pneumonia, which is more often fatal.

Treatment of the disease

When caring for patients, not only medical workers, but also relatives and friends should pay attention to their condition. At the slightest suspicion of a violation in the work of the lungs, it is necessary to report this to the doctor.

The treatment of pneumonia is a long and troublesome task, especially in a patient with such a severe and complex diagnosis as a stroke. The main method of treatment remains antibiotic therapy, only with their help it is possible to achieve the cessation of acute inflammatory process.

But, in addition to antibiotics, a whole range of medicines is used to treat the disease. Depending on the patient's condition and the stage of stroke development, its severity, the patient is prescribed the use of drugs that stimulate blood circulation, anti-inflammatory, antipyretic, diuretic and analgesic drugs, as well as vasodilators, antispasmodic and antitussive drugs, if their intake does not contradict the treatment of the underlying disease - stroke.

With complex disorders, the heart weakens and constantly needs support. It is provided by special preparations that do not allow cardiac activity to be disturbed, support normal rhythm and stimulate full blood circulation, the work of the heart muscle.

In hospitals, bilateral pneumonia is quite common. This is a very severe form of pneumonia, especially for patients severely weakened by a stroke. It often leads to the death of a person who has suffered a stroke and is completely or partially paralyzed.

The use of drugs is constantly changing, as the doctor makes adjustments according to the patient's condition. Since there are no identical patients, it cannot be said that there is any one, standard form of treatment that is universal in all cases of pneumonia. For each specific case of the disease, an individual treatment is selected, including physiotherapy and.

In the presence of respiratory disorders, a patient with a stroke has to be connected to a ventilator, and this indicates the need to introduce nutrition “through a tube”, because such a person cannot eat on his own. This further complicates the already difficult condition of the patient. To prevent the development of a severe form of pneumonia, it is necessary to take preventive measures in advance to protect a person from the development of pneumonia after a stroke, or at least catch it in the earliest stages.

Preventive actions

To prevent such a dangerous complication as pneumonia, a number of preventive measures must be taken to help avoid dangerous and even fatal consequences:

Accurate compliance with all medical prescriptions, including those related to the use of physiotherapy and exercise therapy. They are necessary in order to prevent congestion in the lungs.
The hygiene of the patient, bedding, premises and all things in his use plays a paramount role, because the causative agents of the disease can be on them.
Application modern means and devices. First of all, this concerns the tube for the artificial lung ventilation apparatus. The newer the model, the lower the risk of developing the disease.

Prevention of the disease also consists in avoiding aspiration pneumonia. To do this, you need to properly feed the patient, do it slowly, in small quantities, without rushing him and giving him the opportunity to chew food, giving it to drink if necessary. It is important to properly process products. If the patient has difficulty swallowing, he should be allowed to eat pureed and semi-liquid food until the ability to chew normally and swallow harder pieces is restored. Bread crumbs and drops of liquid are especially dangerous. In no case should food be given while a person is coughing. You must first stop the attack, and then start feeding.

The correct approach to the treatment and prevention of the disease will avoid the development of pneumonia and life-threatening consequences.

The stroke itself is serious illness, which can easily make a bed invalid out of a person. What can I say, when after one "hit" on health follows a second, no less serious - pneumonia. The congestive variant of this disease most often develops, which is a complication of earlier stroke.

According to statistics, the incidence of pneumonia after a stroke is from 35 to 50%. Approximately 15% of cases of complications of pneumonia is the cause of death. It would seem that a person survived after one illness, but could not cope with the second. Any pneumonia with a stroke has its own causes, it makes sense to deal with them in more detail.

Any disease, including pneumonia after a stroke, has its own causes and risk factors. Such knowledge will help prevent complication and prevent its occurrence in principle.

Often with inflammation of the lungs after a stroke, elderly and senile people experience. Their normal drainage function of the lungs is disturbed, and after a stroke, sputum separation is practically absent, especially if the disease is severe. The risk of pneumonia increases significantly after a person is 65 years old.

Excess weight itself is a predisposing factor for the development of stroke. In the case of a complication in the form of pneumonia, the chances are much higher. Pneumonia can occur in people who had chronic forms of heart and lung disease before the stroke.

After a stroke, a person can often be in a coma, which contributes to the development of a congestive process in the lungs. The cause of this condition is a violation or complete absence outflow of sputum. Similar state occurs with prolonged artificial ventilation of the lungs, which is carried out in the absence of spontaneous breathing. Often a week is enough for pneumonia to develop. Sometimes, even in the mind, the patient is on bed rest, which contributes to stagnant processes in the pulmonary system.

Development mechanism

It is no secret that the prognosis after a stroke is often sad. There are some reasons that trigger the pathological mechanism of the development of the disease. They consist:

in an oppressed mind for a certain time;
central respiratory dysfunction;
lack of active movements;
violation of the blood supply to the lungs.

The degree of damage depends on the massiveness of the damage to the brain tissue, as well as the place where the hemorrhage or blockage of the vessel occurred. As a result, the function of sputum drainage from the lungs suffers in some patients. Reduces or absent cough reflex or urge to cough, it is he who is protective and promotes sputum discharge. There is a replacement of microorganisms with more aggressive ones that can cause disease. Further, it is just a matter of time and the disease does not take long to wait, the inflammatory process develops rapidly.

Other factors

But not always artificial ventilation lung system after a stroke is the cause of the development of the disease. Often an infection joins, which is constantly in the hospital, especially in the intensive care unit. The level of immune protection also decreases, the body is not able to resist infection.

Symptoms of the disease

Diagnosing pneumonia after a stroke, even at the present stage of development of medicine, can be very difficult. The problem remains open for the next generations of doctors. It is difficult diagnosis that is the factor that contributes to human mortality. In general, manifestations can be easily veiled by the primary disease.

Some of the symptoms may turn on:

the temperature rises moderately;
type of breathing disorder pathological variant Cheyne-Stokes or Kussmaul;
as a result of a violation of the cough reflex, there is no sputum separation;
on auscultation heard wheezing of various calibers.

Features of aspiration pneumonia

This variant develops as a result of food particles entering the Airways. After such a segment of the lung ceases to perform its function normally, and the bacteria that are there are rapidly developing.

With aspiration pneumonia, the manifestations resemble intoxication or poisoning. Initially draws on a cough, which is excruciating. The hilar variant of aspiration pneumonia is difficult to diagnose. A high temperature joins, it becomes painful to cough. A dangerous option is the situation when a large bronchus is blocked by pieces of food.

Late symptoms

Diagnosis of the late version of the disease is much easier. To make a proper diagnosis, a doctor will need certain symptoms. Among them it is worth noting:

rapidly developing fever, numbers above 38 degrees;
in the blood test is of interest increased amount leukocytes;
pus is present in sputum or discharge from the trachea;
clearly visible on x-ray pathological changes lung tissue.

Final diagnosis

In addition to the symptoms, there are some standards for instrumental diagnosis of the problem. Initially, it is worth listening to the chest with a phonendoscope, if there is a suspicion of pneumonia, then an X-ray examination of the lungs is prescribed. In the picture, in addition to stagnation, the most intense focus of shading will be clearly visible.

The sputum or washings from the bronchi are subject to research. This analysis will determine the type of pathogen, after which its individual sensitivity to antibacterial drugs is carried out. This analysis will later allow the doctor to prescribe an effective treatment.

Treatment

In case of pneumonia, which could complicate a stroke, measures are aimed at eliminating hypoxia as soon as possible. The tissues should receive more oxygen, this is done with the help of artificial ventilation of the lungs or the use of oxygen pillows. It is necessary to pay attention that pulmonary edema often joins, which is why prevention of this condition is carried out.

In parallel, the treatment of the underlying disease is carried out, which is prescribed by a neuropathologist. After establishing the type of pathogen and its sensitivity to antibiotics, appropriate drugs are used. Prior to this analysis, broad-spectrum antibacterial drugs are indicated. The dose of the antibiotic is selected individually, but, as a rule, they are used in large quantities.

IN without fail diuretics are used, they help reduce swelling and prevent pulmonary edema. Cardiac preparations and expectorants are indicated. If there are problems with expectoration due to its viscosity, the doctor may prescribe drugs to thin it.

Additionally

After stabilizing the condition for a stroke, physiotherapy is recommended for a person. Excellent helps to remove sputum electrophoresis with potassium iodide. Exercise therapy is also shown under the guidance of an instructor, it is mainly aimed at restoring breathing.

Still in bed, the doctor can recommend a person breathing exercises. If the patient is able to breathe on his own, then in bed he is recommended to inflate balloons. Special drainage positions are also used to help expel sputum from the lungs. Massage in the acute period is undesirable, but in a mild form it helps to remove sputum and is carried out by a massage therapist.

Prevent pneumonia

When there is an understanding of the mechanism of the development of the disease, it is possible to prevent the development of the disease. Based on this, certain preventive measures were developed, the observance of which will reduce the risk of developing the disease. An approximate list of them can be presented as follows:

It is worth reducing the pathogenic factor, because the risk of developing the disease largely depends on medical workers, the quality of their performance of their duties. In the intensive care unit, in addition to processing instruments and surfaces, sanitation of the bronchial tree is mandatory.
It is required to carefully observe the rules of hygiene, including personal. Medical workers should adhere to the rules of asepsis and antisepsis.
The tube that is used for ventilation of the lungs must be for individual use and after use it is processed and disposed of. The same applies to the rest of the instruments that can come into contact with the human respiratory system.

Prevention

There are some steps you can take to help prevent the development of pneumonia after a person has had a stroke. Some moments will require efforts from the carer and staff, but then they will fully justify themselves.

Initially, it is worth ensuring a constant flow fresh air. This can be done by ventilating the room, but with certain precautions to prevent hypothermia. A person should be covered with a blanket, and in the cold season with several.

Oral hygiene is mandatory, when a person is unable to cope with it himself, those who care for him help him. To prevent stagnation, the position in bed changes every two hours. In the normal state of the patient, he is given a semi-recumbent position at an angle of 45 degrees.

Additionally, breathing exercises are shown, which is carried out no earlier than one and a half hours after the last meal. It is useful to inflate baby balloons. Additionally carried out special massage approximately three sessions throughout the day.

As the symptoms of a stroke regress, a person must be activated, first in bed, and then within the ward. This approach will prevent the accumulation of sputum and prevent congestion.

Not really

Inflammation of the lungs is the most frequent complication with severe stroke. According to various literature data, pneumonia accompanies from 30% to 50% of all patients with stroke, and in 10%-15% it is the cause of death.

Risk factors for this complication include:

old age over 65;
excess body weight;
chronic lung and heart diseases;
a sharp depression of consciousness after a stroke (below 9 points on the Glazko coma scale);
prolonged mechanical ventilation for more than 7 days;
prolonged hospitalization and weakness;
taking a number of drugs (H2 blockers).

Causes of pneumonia in stroke

The pathophysiological causes of pneumonia after a stroke include:

oppression of consciousness;
central respiratory failure;
hypodynamic changes in blood flow in the pulmonary circulation.

Massive damage to the brain causes damage to the mechanisms of self-regulation and self-defense of the body. The drainage function of the lungs is disturbed, the cough reflex decreases, the normal microflora is replaced by highly virulent strains of nosocomial infection, which contributes to the rapid development of the disease.

Prolonged mechanical ventilation after a stroke or aspiration are also direct causes of pathogenic flora entering the respiratory tract.

The most common causative agents of pneumonia after a stroke:

golden staphylococcus aureus;
pneumoniae streptococcus;
Pseudomonas aeruginosa;
klebsiella;
eterobacter;
coli and other gram-negative pathogens characteristic of nosocomial pneumonia.

Types of inflammation of the lungs after a stroke

Allocate early and late inflammation of the lungs, which differ in the mechanism of development. In the pathogenesis of early pneumonia, which occurs in the first 2-3 days of hospitalization, the decisive role belongs to the dysregulation of the central nervous system. The rate of development of the complication depends on the area of the brain in which the focus of ischemic or hemorrhagic changes occurs. At the same time, edema and foci of plethora are found in the lungs.

In more late dates- 2-6 weeks, the main cause of the development of pathological inflammatory changes in the lungs are hypostatic processes.

Clinical picture and diagnosis

Even at the current level of development of medicine, the diagnosis of pneumonia in the presence of a stroke remains an unresolved problem. Delayed correct diagnosis contributes to the development of a number of complications, which lead to death.

Symptoms of early pneumonia are veiled by manifestations of the underlying disease and are often non-specific:

increase in body temperature;
respiratory disorders - shortness of breath, pathological Cheyne-Stokes and Kussmaul;
cough is rarely observed due to inhibition of the central cough reflex;
with the development of pulmonary edema, bubbling breathing, fine bubbling rales are added.

Late pneumonia develops already against the background of positive dynamics in the neurological status and does not present such difficulties.

The main clinical and laboratory indicators of pneumonia are:

Fever above 38°C and temperature drop below 36°C;
Severe blood leukocytosis, less often leukopenia with a shift of the leukocyte formula to the left;
Purulent discharge from the trachea;
Focal changes in the lungs are detected during x-ray studies;
Violation of the gas composition of the blood.

Pneumonia is suspected when three of the above criteria are present, and a combination of four features allows the diagnosis of pneumonia to be established.

Treatment of pneumonia in severe stroke

Therapeutic measures are aimed at suppressing the infection, stopping cerebral edema, and combating pulmonary edema.

Antibacterial drugs are empirically prescribed immediately after diagnosis and in high dosages, often combining drugs from different groups. After 72 hours, the choice of antibiotic is adjusted depending on:

the type of pathogen identified later;
the sensitivity of the strain to chemotherapy drugs;
body response.

In addition, diuretics, cardiotonics, expectorants, mucolytics are administered, oxygenation, physiotherapy, and breathing exercises are used.

Prevention of pneumonia after a stroke

Preventive measures are as follows:

Reducing the amount of pathogenic flora in the upper respiratory tract - an elevated head end of the patient, daily sanitation of the nasopharynx and physiotherapy;
Compliance with the hygiene of therapeutic measures, the rules of asepsis and antisepsis;
The use of modern tracheostomy tubes and careful monitoring of the patient.

The appointment of antibacterial drugs as a prophylaxis of pneumonia is not recommended.

(No ratings, be the first)

The appearance of edema can be prevented altogether or reduced by following simple rules:

It is necessary to ensure that the sore leg never hangs and is always suspended;

If the patient is sitting, then you should put a pillow on the armrest, on which to lay the sore arm. And for a sore leg, use a stand, which should ensure the maximum horizontal position of the limb. Keep your back straight while sitting. It is advisable to put a small pillow on the stand, it will increase the area of \u200b\u200bsupport and reduce swelling;

To normalize blood circulation, you need to change the position of swollen legs more often.

Treatment of edema of the lower extremities after a stroke

Massage with ice cubes. It's best to make ice out of medicinal plants. Make an infusion of mountain arnica, yarrow, eucalyptus, or peppermint and freeze it. Before going to bed, massage your sore leg with such a piece of ice.
Cold compress. Soak overnight in cold water cotton cloth, wrap it around the affected leg, and wrap it with cellophane on top. In the morning, remove the compress and massage your feet with movements that are directed from top to bottom.

You can wear not ordinary socks or tights, but special stockings - medical. It is also recommended to drink as little liquid as possible after seven o'clock in the evening.

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We have repeatedly said that congestive pneumonia or, as people say, pneumonia can be considered the most frequent and rather dangerous complication that occurs after a stroke.

According to various authors of the medical literature, congestive or hypostatic pneumonia can accompany from 35% to 50% of all cases of apoplexy. Moreover, in approximately 15% of stroke patients, this complication is main reason lethality.

The main risk factors for this dangerous complication primary apoplexy physicians include:

Deeply elderly or even senile age of patients, when the victims of a brain stroke crossed the 65-year mark.
Overweight patient.
History of chronic lung or heart disease.
The development during a stroke pathology of too sharp depression of consciousness ( we are talking about conditions when the scores on the Glazko coma scale are below nine points).
Too long artificial ventilation of the lungs, usually more than a week.
Excessively long hospitalization, with being in a static position and with weakness.
Long-term use of certain drugs (say, such as H2 blockers).

Why does pneumonia occur in post-stroke patients?

The main pathophysiological reasons why pneumonia can develop in patients who are hospitalized after a stroke are:

Prolonged depression of the patient's consciousness.
Central disorders of respiratory function.
These or other hypodynamic changes in the physiologically normal blood flow going through the pulmonary circulation, which is responsible for the blood supply to the lungs.

It is important to understand that after a stroke, the victims experience massive damage to certain parts of the brain, which ultimately leads to varying degrees of damage to the mechanisms of full self-regulation, as well as self-defense of the human body.

As a result, in such patients, the drainage function of the pulmonary system may be impaired, the cough reflex (allowing to get rid of sputum) may decrease or be completely absent, the healthy microflora may be deformed, which is simply replaced by highly virulent strains of a particular nosocomial infection. Naturally, all this can contribute to a fairly rapid development and progress of the disease.

In addition, long-term artificial ventilation of the lungs, necessary for resuscitation, aspiration, can also be direct reasons why pathogenic flora can penetrate into the respiratory tract, due to the growth of which pneumonia develops.

Most often, neurotrophic pneumonia has the ability to develop in the most acute period after a severe form of stroke, when there is a pathological effect of the focus directly on the hypothalamus or brain stem. The prognosis for the course of the disease, in this case, is the least favorable.

Further, in the acute period, after the primary manifestations of a stroke, pneumonia occurs in almost 25% of all patients with medium degree severity of apoplexy and in almost 85% of patients with severe cerebral stroke. The so-called second wave of pneumonia usually occurs in the third or maximum fifth week. recovery period(this is a late form of pulmonary pathology).

As we have already noted, doctors distinguish two forms of pneumonia in patients after a stroke, these are:

Early.
And, accordingly, late pneumonia, which initially differ in their development mechanism.

So, in the pathogenesis of early inflammation of the lungs lie dysregulation of the entire central nervous system, and the rate of development of pulmonary complications depends on where exactly the focus of ischemia or hemorrhage is located.

And, here, at a later date, the development of pneumonia is due to pathological inflammatory changes directly in the lungs, which are provoked by hypostatic processes.

Symptoms and treatment of post-stroke pneumonia

Unfortunately, today, the diagnosis of inflammation of the lungs that occurs after a stroke remains a huge unresolved problem. Often, untimely diagnosis of a pulmonary problem contributes to the development of a number of complications that can lead to death.

The clinical picture of early post-stroke pneumonia is non-specific and can often be veiled by manifestations of the primary pathology:

Moderate increase in body temperature.
Breathing disorders - the same shortness of breath, pathological Cheyne-Stokes or Kussmaul breathing.
Absence of cough due to violations of the cough reflex, etc.

At the same time, late pneumonia is much easier to diagnose. The main clinical and laboratory indicators of the development of post-stroke pneumonia can be considered:

The development of fever with body temperature above 38 ° C.
Pronounced leukocytosis.
The presence of purulent discharge from the trachea (sputum).
Focal pathological changes in the lungs on x-rays, etc.

With this pathology, therapeutic measures are always reduced to the most rapid relief of hypoxia, to the prevention of pulmonary edema, to the suppression of the infectious agent. As a rule, in addition to drugs for the treatment of the underlying disease, antibiotics are prescribed, and in fairly large doses, oxygen therapy, the appointment of diuretics, cardiotonic and expectorant (mucolytic) agents may be required.

Sometimes, such patients may be prescribed various techniques Exercise therapy, massage or physiotherapy. It is important to understand that in some cases, after two or three days of treatment, it may be necessary to adjust the choice of antibiotic, depending on:

Pathogens identified during research.
The real sensitivity of a particular strain to the selected chemotherapy drugs.
The resulting reaction of the body.

Pneumonia in patients with severe stroke

Piradov M.A. Ryabinkina Yu.V. Gnedovskaya E.V.

Pneumonia is the most common and dangerous infectious complication severe stroke. It occurs in half sick and in 14% of cases is the main cause of death.

High frequency of development pneumonia at heavy forms stroke due to deep depression of consciousness appearing almost from the first day, central disorders of breathing, swallowing and hemodynamic changes in blood flow in the lungs. In the vast majority of patients with heavy forms stroke. who are in the intensive care unit (ICU), there is a "hospital", or the so-called nosocomial pneumonia. This term denotes pneumonia. developed 48 hours or more after admission sick to a hospital with the exclusion of infectious diseases with lung damage, which could be at the time of hospitalization in incubation period.

Highly virulent flora with rapidly increasing resistance to traditional antibacterial drugs leads to the development heavy forms pneumonia With high rates lethality. An additional factor is the need for prolonged mechanical ventilation, while the frequency of development pneumonia increases by 6-20 times. The risk of ventilator-associated pneumonia, the so-called ventilator-associated pneumonia (VAP), increases significantly with increasing ventilator time. The onset of pneumonia severe stroke increases length of stay sick in neuro intensive care units for an average of 10 days.

Etiology and pathogenesis

The main cause of pneumonia in severe stroke- a bacterial infection, the causative agents of which are characterized by severe pneumotropism. The main pathogens are Pseudomonas aeruginosa, Enterobacter, Klebsiella, Escherichia coli, Proteus. Often there are also Staphylococcus aureus, streptococcus pneumoniae, less often anaerobic flora.

According to our data, up to 20% of pneumonias that develop in sick with a severe stroke almost immediately after hospitalization (early pneumonia), are caused by gram-negative flora. Pneumonia that occurs after 3 days in the ICU - late pneumonia - more than 50% sick also caused by gram-negative strains.

There are some differences in the pathogenesis of early and late pneumonia. In the development of early pneumonia, violations of corticovisceral regulation are of decisive importance. The rapid development of early pneumonia in stroke, its predominant occurrence in patients with localization of the focus in the area of the higher vegetative centers or with a secondary effect on the hypothalamus and stem structures, the presence in the lungs of patients with signs of circulatory disorders in the form of plethora, hemorrhages and edema confirm the role of central disorders in the genesis of this complication. In the development of late pneumonia, the hypostasis factor plays a decisive role.

With the development of VAP in terms of less than 7 days from the start of mechanical ventilation, the causative agents of pneumonia are pneumococci, Haemophilus influenzae, Staphylococcus aureus and anaerobic bacteria. With the development of VAP at a later date after the start of mechanical ventilation greater value acquire drug-resistant strains of enterobacteria, Pseudomonas aeruginosa, Acinetobacner spp. and methicillin-resistant strains Staphylococcus aureus(MRSA). Sudden outbreaks of pneumonia caused by Legionella pn. primarily associated with infection of humidifiers, inhalers, tracheostomy tubes, tap water, and air conditioners. In patients receiving long-term antibiotics or glucocorticoids, pneumonia may be due to fungi (eg, Aspergillius spp.).

Risk factors for the development of pneumonia in severe stroke are: the level of consciousness on the Glasgow coma scale less than 9 points, dysphagia, tracheal intubation, mechanical ventilation for more than 7 days, prolonged hospitalization, age over 65 years, the presence of chronic lung and heart diseases, the use of H2-histamine receptor blockers, smoking, obesity, hyperglycemia, unbalanced nutrition, uremia.

The main route of entry of microorganisms into the respiratory tract in patients with severe stroke is the bronchogenic route. It is associated with microaspiration of the contents of the nasopharynx and stomach due to bulbar disorders, inhibition of the cough reflex and the reflex that provides reflex spasm of the glottis.

Extensive brain damage (more than any other critical condition) is accompanied by damage to the nonspecific defense mechanisms of the body, including local cellular and humoral immunity, which also facilitates the bronchogenic penetration of microorganisms into the respiratory sections of the lungs. The change in the composition of the normal microflora of the upper respiratory tract to a highly virulent and very often resistant to traditional antibiotics microflora contributes to the rapid infection of the lungs.

Great importance It also has a violation of the drainage function of the respiratory tract: a decrease in the rate of mucociliary transport, which develops from the first hours of a stroke, which is often accompanied by increased production of tracheobronchial secretions. In addition, infection through ventilators and during the necessary invasive procedures (sanitation of the tracheobronchial tree, fibrobronchoscopy), infection of the tracheostomy wound (or wound infection of the tracheostomy) increase the risk of invasion of microorganisms. It should be remembered that in each specific case features of pathogenesis and clinical course are determined by the properties of the pathogen, the initial state of the patient and various systems organism involved in inflammation, and the body's response to infection.

Clinic and diagnostics

Clinical diagnosis of pneumonia in severe stroke is still a challenge and continues to be developed. Difficulties in establishing a diagnosis are associated with both overdiagnosis and underdiagnosis, and late diagnosis is one of the reasons for the development of complications and death.

In patients with severe stroke, the clinical signs of pneumonia are masked by symptoms of the underlying disease. Diagnosis of early pneumonia is especially difficult, since it clinical manifestations hidden behind the severity of cerebral and focal neurological symptoms. Diagnosis of late pneumonia against the background of an improving neurological condition of the patient is less difficult. Complicates the examination process and the severity of the underlying disease, as well as the need for prolonged use of mechanical ventilation.

The clinical picture of pneumonia consists of signs of local pulmonary inflammation, extrapulmonary manifestations of pneumonia, laboratory and radiological changes. Diagnosis of pneumonia is usually based on the following clinical and laboratory signs (Table 1). It should be remembered that in conditions of severe stroke, each of these criteria is non-specific.

Diagnosis of pneumonia is made only in the presence of 4 of the listed criteria, and the presence of 3 of them makes the diagnosis of pneumonia likely.

Comprehensive treatment of pneumonia should be aimed at suppressing the infection, restoring pulmonary and general resistance, improving the drainage function of the bronchi, and eliminating the complications of the disease.

Antibacterial drugs are the mainstay of treatment for pneumonia. The choice of the most effective one depends on many factors, including:

Accurate pathogen identification

Determination of its sensitivity to antibiotics

Early initiation of adequate antibiotic therapy

Nevertheless, even with a well-equipped microbiological laboratory, the etiology of pneumonia can only be established in 50-60% of cases. Moreover, it takes at least 24-48 hours to obtain the results of microbiological analysis, while antibiotic therapy should be prescribed as soon as the diagnosis of pneumonia is established.

The diversity of the etiology of nosocomial pneumonia, the simultaneous detection of several pathogens in one patient, and the lack of methods for express diagnostics of the sensitivity of microorganisms to antibacterial drugs make it difficult to plan therapy. Under these conditions, there is a need for the use of empirical antibiotic therapy, which ensures the study of drugs with the maximum a wide range activity. The choice of a drug is based on an analysis of the specific clinical and epidemiological situation in which the patient developed pneumonia, and taking into account factors that increase the risk of infection with a particular pathogen.

For nosocomial pneumonia in severe forms of stroke, the weight of gram-negative microflora, staphylococcus and anaerobic bacteria is the highest. Therefore, cephalosporins of the I-III generation (in combination with aminoglycosides) or fluoroquinolones are most often used as initial therapy.

The following combinations and monotherapy regimens may be effective:

Combination of ceftazidime with "respiratory" fluoroquinolones

Combination of “protected” antipseudomonal ureidopenicillins (ticarcillin/clavulanic acid, piperacillin/tazobactam) with amikacin

Monotherapy with IV generation cephalosporin (cefepime)

Monotherapy with carbapenems (imipenem, meropenem)

Combination of ceftazidime or cefepime or meropenem or imopenem with second-generation fluoroquinolones (ciprofloxacin) and modern macrolides

The course of the pneumonia resolution process is assessed using clinical or microbiological studies. Clinical indicators are: a decrease in the amount of purulent sputum, a decrease in leukocytosis, a decrease in body temperature, signs of resolution of the inflammatory process in the lungs according to radiography or computed tomography. It is believed that during the first 72-2 hours of empiric therapy, the selected treatment regimen should not be changed.

With a progressive increase in inflammatory infiltration, it is necessary to adjust antibiotic therapy. It is recommended, if possible, to identify the microorganism and prescribe targeted (etiotropic) antimicrobial therapy. The subsequent change of antibiotic therapy should be carried out according to the results of only a microbiological examination of sputum.

Considering the type of causative agent of pneumonia, the proposed pathogenetic mechanism for the development of pneumonia and the time of its development from the onset of a stroke, the recommendations given in Table 2 can be followed.

The average duration of antibiotic therapy in patients with pneumonia is presented in Table 3. In most cases, with an adequate choice of antibiotics, 7-10 days of its use is sufficient. With atypical pneumonia, staphylococcal infection, the duration of treatment increases. Treatment of pneumonia caused by gram-negative enterobacteria or Pseudomonas aeruginosa should be at least 21-42 days.

One of essential conditions successful treatment of pneumonia is to improve the drainage function of the bronchi. For this purpose, expectorant, mucolytic and mucoregulatory agents are used, chest massage (percussion, vibration, vacuum), breathing exercises are used. Broncho-lytics are prescribed for severe course pneumonia and in persons prone to the occurrence of bronchospastic syndrome. In the ICU, it is preferable to prescribe intravenous infusions of a 2.4% solution of aminophylline, less often inhaled forms of b2-adrenergic stimulators, M-anticholinergics.

In severe forms of pneumonia, infusions of native and / or fresh frozen plasma are carried out. Currently, the issue of the need for immunocorrective and immunoreplacement therapy with immunoglobulins and hyperimmune plasma is being considered. Patients with severe forms of pneumonia also undergo detoxification therapy, taking into account cerebral edema and concomitant pathology of the heart and heart failure.

Prevention

Prevention of pneumonia in severe stroke is based on three main approaches.

1. Elevated position of the upper half of the patient's body at an angle of 450, frequent sanitation of the nasopharynx and physiotherapy of the chest. These simple methods reduce the flow of secretions from the upper respiratory tract into the trachea and bronchi, i.e. microaspiration.

2. Personal hygiene of personnel (elementary frequent washing of hands with a disinfectant solution), careful observance of aseptic and antiseptic rules, strict adherence to the protocols for changing and cleaning tracheostomy tubes, humidifier reservoirs and inhalers reduces the growth rate and the addition of additional microflora.

3. Application certain type tracheostomy tube (with supracuff aspiration) and its correct location, timely aspiration of secretions accumulating over the cuff, orotracheal intubation, insertion of a tube for enteral nutrition through the oral cavity reduce the risk of infection of the lower respiratory tract with nasopharyngeal flora. In addition, it helps to reduce the risk of developing sinusitis.

Until now, a unified view on the prophylactic prescription of antibiotics has not been formed all over the world. In our opinion, this approach definitely does not solve the problem of preventing pneumonia in stroke, especially VAP. It must be remembered that pneumonia is a process characterized by certain features of the course associated with the initial state of the patient and his reaction to the infection, and the role of antibiotics is limited only to the suppression of the infectious agent. In addition, with the prophylactic administration of antibiotics, the development of superinfection caused by antibiotic-resistant strains of microorganisms is possible.

Conclusion

Our data and analysis of the literature suggest that the occurrence of pneumonia in patients with severe stroke worsens the condition of patients. In patients who have survived a period of neurological complications, pneumonia often causes death. Preventive measures should be started already from the first hours of a stroke, and rational therapy of pneumonia should be started immediately after its diagnosis.

Literature

1. Vilensky B.S. Somatic complications of stroke // Neurological journal. - No. 3. - 2003. - pp. 4-10.

2. Koltover A.N. Lyudkovskaya I.G. Vavilova T.I. Viktorova N.D. Gulevskaya T.S. Levina G.Ya. Lozhnikova S.M. Morgunov V.A. Chaikovskaya R.P. The role of pathology internal organs in the pathogenesis, course and outcome of strokes. // Materials of the Plenum of the Board of the Society of Neurologists and Psychiatrists "Disorders of the nervous system and mental activity with somatic diseases. - Naberezhnye Chelny. - 1979. - S.198-201.

3. Krylov V.V. Tsarenko S.V. Petrikov S.S. Diagnosis, prevention and treatment of nosocomial pneumonia in critically ill patients with intracranial hemorrhages. // Neurosurgery. - 2003. - No. 4. - S. 45-48.

4. Martynov Yu.S. Kevdina O.N. Shuvakhina N.A. Sokolov E.L. Medvedeva M.S. Borisova N.F. Pneumonia in stroke. // Neurological journal. - 1998. - No. 3. - S. 18-21.

5. Addington W.R. Stephens R.E. Gilliland K.A. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. // Stroke. - 1999. - 30. - 6. - R.1203-1207.

6 Chastre J. and J.-Y. Fagon Ventilator-associated pneumonia .//Am. J. Respir. Crit. Care Med. April 1.-2002. - 165(7). - R.867 - 903.

7. Collard H. R. S. Saint, and M. A. Matthay Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review Ann Intern Med. //March 18. - 2003. - 138(6). - R.494 - 501.

Treatment of stroke complications

In ischemic stroke, the fight against complications comes to the fore, since neurological symptoms not very heavy. In the case of hemorrhagic stroke, neurological disorders are so severe that they affect the prognosis of the disease.

cerebral edema

Cerebral edema is a reaction of brain tissue to a decrease or cessation of blood circulation. The more severe the damage to the brain, the greater its swelling.

Cerebral edema develops on days 1-2 after the development of a stroke and has a maximum severity on days 3-5, gradually decreasing on days 7-8.

Therapeutic measures taken to reduce cerebral edema:

decrease in body temperature;
elevated position of the head;
relief of pain;
in extreme cases, they resort to surgical intervention - the removal of a part of the cranial bone that compresses the nervous tissue.

Pneumonia

There are two main causes of pneumonia (pneumonia) in stroke patients:

As a result of impaired swallowing, food or stomach contents enter the respiratory tract. This complication is called aspiration, and pneumonia is aspiration.
Prolonged immobility may result in hypostatic pneumonia.

In case of violation of swallowing, feeding through a tube inserted into the stomach is used. In this case, it is necessary to carefully monitor the condition of the oral cavity - remove mucus and sputum from the oropharynx. Be sure to brush your teeth after every meal with a soft toothbrush.

With prolonged lying, the respiratory sacs in the patient's lungs collapse and this area of \u200b\u200bthe lung tissue stops working, i.e. it does not participate in the exchange of carbon dioxide and oxygen, as a result, an inflammatory process develops. To prevent the collapse of the respiratory sacs, inflation of balloons is prescribed. When the balloon is inflated, residual positive pressure is formed, which pushes the walls of the collapsed breathing sac, it straightens out and begins to work.

Pneumonia is usually treated with antibiotics.

Inflammation of the urinary tract

Urinary incontinence or urinary retention is catheterized, which causes inflammation urinary tract.

To avoid inflammation of the urinary tract, it is recommended:

strict adherence to asepsis rules when placing a catheter;
washing 3-4 times a day of the bladder with a catheter;
in men, the catheter is attached to the abdomen so that it does not bend over and form a bedsore in the urethra;
frequent bacteriological examination of urine.

being treated this type inflammation with antibiotics.

Pulmonary embolism

Pulmonary embolism is a blockage of blood vessels supplying the lungs with blood clots (thrombi). It occurs most often in aged patients, with atrial fibrillation, thrombophlebitis of the lower extremities, prolonged immobility, inflammatory diseases of the pelvic organs, diabetes mellitus, active rheumatism.

This serious complication, which occurs between 2 and 4 weeks after a stroke, causes death in 25% of patients.

bedsores

In places where the bones are close to the surface of the skin (the area of the neck, shoulder blades, elbows, sacrum, knees, heels, buttocks), as a result of circulatory disorders, bedsores (necrosis of integumentary tissues) may occur. Theoretically, bedsores can occur in any place where the integumentary tissues are subjected to strong pressure.

The main danger of bedsores is that necrosis penetrates deep, reaching the bones and cartilage. Such wounds become infected and become a source of infection for the entire body.

Prevention of bedsores:

Regular change in body position (left, right side, back) at least once every 2 hours is the most effective measure to combat pressure sores:
- When turning the patient on a healthy side, it is necessary to put pillows behind the back and under the head, evenly distribute the center of gravity, and achieve a stable position. Extend the healthy leg, slightly bend the affected leg and lay it on the pillow. Straighten the paralyzed arm and lay it on the pillow, slightly bending at the elbow, fingers should be evenly placed on the pillow.
- If the position on the sore side does not cause discomfort to the patient, then it must also be turned to the affected side. The lower leg should be straight, the upper leg bent and on the pillow. The affected arm should lie in front, palm up.
- The position on the back is the least preferred, but not without it. Pillow your shoulders, head, and neck so that your face is facing up and your head is tilted slightly forward. The position must be stable. The shoulder joint of the affected upper limb should lie on the pillow, the shoulder blade should not rest on the pillow, the arm should be turned palm up. A roller is placed under the knee of the paralyzed leg so that there is support and the leg does not roll down. The spine should be straight, under the head of the pillow of the right size.

Leather processing. It is necessary to monitor the condition of the skin in the perineum, armpits, skin folds (in obese women - folds under the breasts). Wipe every 8 hours with special solutions (for example, warm camphor alcohol).

Particular attention should be paid to the surface on which the patient lies. The sheet should be dry, clean, free of debris and wrinkles. If necessary, you can put an oilcloth under the sheet or put a diaper on the patient. In the area of bone protrusions (sacrum, heels, back of the head), special pads made of pure sheepskin, a rubber circle or millet mattresses can be placed.

A daily examination of the skin surfaces is required for the timely detection of bedsores.

Light massage.

Keep away from hot or cold objects.

The patient must have adequate nutrition.

When bedsores form, they must be treated with saline or hydrogen peroxide, followed by careful removal of dead tissue. After this, it is necessary to apply a special wet-drying bandage or a special ointment.

Limited movement in the joints

With prolonged immobility, contracture (stiffness) occurs in the joints. To combat this phenomenon, correct styling limbs when changing the position of the body, conducting a passive therapeutic gymnastics paralyzed limbs combined with massage. These activities must be agreed with the attending physician.

Colon dysfunction

Violation of the large intestine is usually manifested by constipation (lack of stool for more than 2 days). To avoid constipation, you must:

observe a diet - eat at the same time, meals should be fractional (4-5 times a day), the last meal should be at least 4 hours before bedtime;
the diet should be balanced and rich in fiber (beets, carrots, cabbage, prunes, honey), dairy products;
you need to take a lot of fluids (2 liters per day);
eliminate from the diet White bread, sweets, rice, raw milk;
if diets do not help, it is necessary to resort to enemas or laxatives (after consulting a doctor).

In addition to constipation, there may be other disorders. In this case, consultation with a gastroenterologist is necessary.

According to medical data, the main danger for patients who are in a state of ischemic stroke or after it is pneumonia. Pneumonia in stroke develops in 30-60% of patients, and in 10-15% of cases is the cause of death.

Why does pneumonia occur?

The high incidence of pneumonia in these patients is due to several factors. Patients with severe ischemic stroke have extensive brain damage. As a result of oppressed consciousness, they go astray defense mechanisms organism. The brain is out of control internal systems and organs, stops regulating the course of important biochemical processes. But what is especially fatal with such a lesion is that the body loses its ability to heal itself.

The imbalance of the entire system contributes to the weakening of the immune system and the rapid development of pneumonia during a stroke or after it. The impetus for the occurrence of pneumonia are violations in the work of the respiratory system, in particular:

Failure of swallowing and cough reflexes
Decrease in the rate of blood microcirculation in the bronchi
Cut off the supply of nutrients and oxygen to the respiratory system
Violation of the functioning of the drainage system of the bronchi
Displacement of normal microflora by pathogenic, contributing to the development of infection.

It aggravates the condition of a patient with an ischemic stroke or after it a forced permanent lying position. As a result, the diaphragm, which helps the lungs pump blood, ceases to function. The fluid accumulating in the lungs becomes a breeding ground for the development of pathogenic microorganisms and then pneumonia.

What contributes to pneumonia

Factors that accelerate the development of pneumonia after ischemic stroke include:

Old age (over 65 years old)
Long-term (more than 7 days) artificial lung ventilation
Overweight patient
Chronic cardiovascular diseases
Pathologies of the respiratory system
hyperglycemia
Uremia
Long stay in the hospital
Lying state
Taking certain medications.

Difficulties in diagnosis

Even today, with the availability of modern equipment, it is extremely difficult to diagnose pneumonia in patients with ischemic stroke in time. The main difficulty lies in the fact that the symptoms of inflammation in early dates stroke are often mistaken for signs of an underlying disease. A delayed diagnosis of pneumonia leads to the fact that by the time the diagnosis is made, the disease has already taken a severe form or caused complications.

It is much easier to determine the inflammation that has arisen against the background of an improvement in the condition of the underlying disease. In this case, the picture is clearer, and doctors quickly navigate the diagnosis. In a severe stroke, the symptoms of pneumonia tend to be more vague and therefore difficult to identify.

How does pneumonia develop?

Patients admitted to the hospital with ischemic stroke most often develop hospital-acquired pneumonia. That is, pneumonia manifests itself a few days after a stay in a medical facility. This does not include patients with pneumonia who at the time of admission already had lung lesions or the infection was in the incubation period.

Early pneumonia develops on 2-3 days of being in the hospital. The reason for its development are violations in the regulation of the central nervous system.

The disease manifests itself elevated temperature, the appearance of wheezing when breathing, shortness of breath. Cough is usually absent due to inhibition of the cough reflex. The occurrence and severity of complications depends on which part of the brain is affected and how severely.

Late pneumonia develops after 2-6 weeks in the hospital. It is provoked by hypostatic processes arising from the supine position. The normal circulation of blood in the small pulmonary circle is disturbed, fluid accumulates in the lungs. The disease is difficult to diagnose, and as a result of delay in treatment, death can occur.

Symptoms of pneumonia are manifested in the form of high fever, cough, wheezing in the bronchi. Their severity depends on the patient's condition, his immunity and the stage of the disease. When determining the disease, doctors are guided by the presence / absence of fever (temperature rise to 38 ° or decrease to 36 °), the number of leukocytes in the blood, the development of purulent processes in the trachea, and changes in the gas composition of the blood.

Laboratory and X-ray studies are used to make a diagnosis.

Treatment of pneumonia

The main directions of therapy:

Suppression of the inflammatory process
Neutralization of infection
Prevention of cerebral edema
Restoration of the drainage function of the bronchi
Resuming normal lung function
Immunity Boost
Prevention or treatment of complications.

To suppress the inflammatory process, drugs with antibacterial action are primarily prescribed. The appointment is made based on the patient's condition, determining the type of pathogen, its resistance to drugs, the presence or absence of allergic reaction in a patient with comorbidities.

Unfortunately, even in the presence of well-equipped laboratories, it is possible to immediately determine the cause of the disease only in 50-60% of cases. The situation is complicated not only by the presence of several pathogens, but also by their resistance to drugs that has developed in hospital conditions. But in order to prevent the aggravation of the disease and the development of complications, it is extremely important to correctly and timely prescribe drugs.

The effectiveness of the treatment is checked after 1-5 days using laboratory or microbiological studies, and, if necessary, the treatment regimen is adjusted. The performance indicators are:

Temperature drop
Decreased amount of purulent sputum
Decreased leukocytosis
Slow down or stop the inflammatory process.

Further appointment is made on the basis of the data obtained from the previous treatment. The duration of the use of antibiotics can take from 5 days to one and a half months - depending on the type of pathogen, the severity of the patient's condition.

To improve the patient's condition, it is of great importance to take measures to improve the drainage function of the lungs. To do this, drugs with expectorant and mucolytic effects are prescribed, physiotherapy is carried out: massage, breathing exercises.

In a severe form of the disease, patients undergo plasma transfusion, and detoxification therapy is prescribed.

Methods for preventing pneumonia after a stroke

To prevent the development of pneumonia in patients with ischemic stroke, it is necessary:

Provide fresh air: ventilate the room more often, taking the necessary precautions to prevent hypothermia of the patient.

Perform oral hygiene. This will prevent the development of infection. If the patient is not able to independently carry out the procedures, you will need to help him with this.

Frequent change of position: it will be necessary to turn the patient every two hours to ensure normal air movement and reduce congestion.

If the patient's condition allows, he needs to provide a semi-recumbent position (at an angle of 45 °) - it will improve ventilation of the lungs.

Therapeutic massage is necessary to improve the separation and release of sputum. The session is held three times a day.

Breathing exercises. To restore the functions of the respiratory system, inflating balloons or children's toys helps a lot. The procedure is recommended to be carried out as often as possible, one and a half hours after eating.

Banks or mustard plasters.

Early activation of the victim. Doctors recommend stimulating the patient to do breathing exercises, and, if possible, to roll over on their own, take sitting position. The start of rehabilitation exercises is determined by the doctor, based on the patient's condition.

The prognosis for treating pneumonia in people with or after a stroke depends on many factors. Of great importance is the prevention of the disease, timely diagnosis, proper treatment.