ICH & pneumonia


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  • Walopunadahubungansignifikanantaravariabel & outcome, tpitubisadisebabkan/pengaruholeh confounder-nya
  • ICH & pneumonia

    1. 1. Predictors and Outcomes of Pneumonia in Patients With SpontaneousIntracerebral 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. 2. IntroductionICH, common form of stroke  1/5 of all casesRespiratory tract infection in ICU 30-60% of all infectionPneumonia have the highest mortality rate among allmedical complications after strokeTo predict which patients will benefit from early & moreaggressive treatmentThere is little data on the incidence of pneumonia in patientswith ICH / neuro-ICU 2
    3. 3. ObjectivesTo determine thepredictors andoutcomes of thedevelopment ofpneumonia in patientswith sICH. 3
    4. 4. Methods290 consecutive patients with sICH admitted within 24 hours of stroke onset, at NewJersey 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. 5. DefinitionsPneumonia• 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. 5
    6. 6. Results & Discussion• 290 patients (-10?)• 159 (56.5%) male• mean age of 66.6 years (SD +/- 16.2).• 13.93% patients developed pneumonia. 6
    7. 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 = 2.77Substantial 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) 7
    8. 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. 8
    9. 9. ACE inhibitors & PneumoniaOur study Other studiesThe use of ACE-I predisposes those ACE-I beneficial for elderly patientswith 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. 9
    10. 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 pneumoniaUnivariate 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) 10
    11. 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. 11
    12. 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 developedThe minimum ORa was 3.72 (95% CI: 1.68 - 8.26) pneumonia were onwhen adjusted for GCS MV) 12
    13. 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 ofmRS reduced OR to 16.2 (95% CI: 4.98 - 52.8) ventilator-for tracheostomy associated tracheobronchitis ~ precursor for VAP. 13
    14. 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). 14
    15. 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) 15
    16. 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 16
    17. 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. 17
    18. 18. ConclusionIncreased risk of the development ofpneumonia 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 mortalityNeed for increased vigilance & scrupulousadherence to intensive care protocols• designed to reduce the occurrence of pneumonia in patients with sICH. 18
    19. 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 careThe use of strategies to decrease the contamination of equipments used for care in patients on mechancal ventilation. 19
    20. 20. Critical Appraisal 20
    21. 21. 21
    22. 22. Research Question 1 2P Patients with sICH Patients with sICHI MV, tracheostomy, Pneumonia tube feeding, dysphagiaC - -O Increase risk of Increase in development of morbidity, mortality, length pneumonia of stay Prognosis Study design: Retrospective 22
    23. 23. Hierarchy of study designs 23
    24. 24. 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 25
    25. 25. Cohort Study 100 300 200 1000 50 Factor = Disease = early Early onset infant formula of asthma 700 650Present 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) 26
    26. 26. ValidityRecruitment -- “Were the subjects representative?”Patients should ideally be enrolled at a sICH at 24-h onsetuniformly early time in the diseasePatients should also be representative Demographic dataof the underlying population.Patients from tertiary referral centres Single-center, type?may have more advanced diseaseand poorer prognoses than patientsfrom primary care.Adjustment — “If subgroups with different prognoses are identified, didadjustment for important prognostic factors take place?”Adjust for known prognostic factors in Multivariate analysisthe analysis so that the result indicatethe additional prognostic information.
    27. 27. Maintenance --“Was the comparable status of the study groups maintainedthrough equal management? Adequate follow-up?””Prognosis is always conditional on Equal?treatment,  initial and subsequent Protocol to treat pneumoniatreatment should be clearly spelt out, Limitation in ICH therapyFollow-up should be long enough to All px: Discharge or deathdetect the outcome of interest Reasons for loss to follow-up?Measurement: “Were the subjects and assessors kept „blind‟ to which treatmentwas 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, LoSof the study groups.If the outcome is objective (eg death)then blinding is less critical.If the outcome is subjective (egsymptoms or function) then blinding ofthe outcome assessor is critical. 28
    28. 28. Importance• OR, ORa  clinical significance (+)• Statistical significance  available p-value
    29. 29. Applicability• Study population similar to our own• Results will lead to therapy selection• Results useful for counseling patient or family
    30. 30. EndThank You 31