Prevention of pneumonia after stroke: The effect of metoclopramide on aspiration and pneumonia in stroke patients fed via nasogastric tubes

Introduction: Pneumonia contributes significantly to the morbidity and mortality in stroke patients, especially those fed via nasogastric tubes. Methods: This project was conducted in two steps; 1. A randomised controlled trial: The efficacy of prokinetic agent metoclopramide was tested in a double-blind randomised controlled trial. Acute stroke patients with no pneumonia needing nasogastric feeds were randomized to 10 mg metoclopramide or placebo three times daily via the nasogastric tube for 21 days or until feeds discontinued. Participants were examined daily for clinical evidence of pneumonia. 2. A secondary analysis of data collected for the diagnosis of pneumonia. This was performed to identify early diagnostic markers of post-stroke pneumonia. Results: 1) For the MAPS study 60 patients (mean age 78 years, mean NIHSS 19) were randomized, 30 in each group. Pneumonia was diagnosed in 26/30 and 08/30 in placebo and treatment group respectively (p <0.001). 2) Signs and symptoms of 47 radiologically confirmed pneumonia revealed that hypoxia, tachypnoea and inspiratory crackles were the most consistent signs in early pneumonia and pyrexia, cough, and purulent sputum were less commonly observed. CRP of 40 mg/l had the best predictive value for early diagnosis of post-stroke pneumonia. Conclusion: Treatment with metoclopramide treatment was associated with a significant reduction of aspiration and pneumonia. However, the incidence of pneumonia in the control gourp was very high and may have led to a false positive result. The findings of this study should therefore be confirmed in a larger study. A raised CRP of 40 mg/l or above was a senditive and specific diagnostic marker for post-stoke pneumonia

Pharyngeal electrical stimulation for treatment of dysphagia in subacute stroke

Background and Purpose: Dysphagia is common after stroke, associated with increased death and dependency, and treatment options are limited. Pharyngeal electric stimulation (PES) is a novel treatment for poststroke dysphagia that has shown promise in 3 pilot randomized controlled trials. Methods: We randomly assigned 162 patients with a recent ischemic or hemorrhagic stroke and dysphagia, defined as a penetration aspiration score (PAS) of ≥3 on video fluoroscopy, to PES or sham treatment given on 3 consecutive days. The primary outcome was swallowing safety, assessed using the PAS, at 2 weeks. Secondary outcomes included dysphagia severity, function, quality of life, and serious adverse events at 6 and 12 weeks. Results: In randomized patients, the mean age was 74 years, male 58%, ischemic stroke 89%, and PAS 4.8. The mean treatment current was 14.8 (7.9) mA and duration 9.9 (1.2) minutes per session. On the basis of previous data, 45 patients (58.4%) randomized to PES seemed to receive suboptimal stimulation. The PAS at 2 weeks, adjusted for baseline, did not differ between the randomized groups: PES 3.7 (2.0) versus sham 3.6 (1.9), P=0.60. Similarly, the secondary outcomes did not differ, including clinical swallowing and functional outcome. No serious adverse device-related events occurred. Conclusions: In patients with subacute stroke and dysphagia, PES was safe but did not improve dysphagia. Undertreatment of patients receiving PES may have contributed to the neutral result. Clinical Trial Registration: URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25681641

The stroke oxygen pilot study: a randomized control trial of the effects of routine oxygen supplementation early after acute stroke--effect on key outcomes at six months

Introduction: Post-stroke hypoxia is common, and may adversely affect outcome. We have recently shown that oxygen supplementation may improve early neurological recovery. Here, we report the six-month outcomes of this pilot study. Methods: Patients with a clinical diagnosis of acute stroke were randomized within 24 h of admission to oxygen supplementation at 2 or 3 L/min for 72 h or to control treatment (room air). Outcomes (see below) were assessed by postal questionnaire at 6 months. Analysis was by intention-to-treat, and statistical significance was set at p#0.05. Results: Out of 301 patients randomized two refused/withdrew consent and 289 (148 in the oxygen and 141 in the control group) were included in the analysis: males 44%, 51%; mean (SD) age 73 (12), 71 (12); median (IQR) National Institutes of Health Stroke Scale score 6 (3, 10), 5 (3, 10) for the two groups respectively. At six months 22 (15%) patients in the oxygen group and 20 (14%) in the control group had died; mean survival in both groups was 162 days (p= 0.99). Median (IQR) scores for the primary outcome, the modified Rankin Scale, were 3 (1, 5) and 3 (1, 4) for the oxygen and control groups respectively. The covariate-adjusted odds ratio was 1.04 (95% CI 0.67, 1.60), indicating that the odds of a lower (i.e. better) score were non-significantly higher in the oxygen group (p= 0.86). The mean differences in the ability to perform basic (Barthel Index) and extended activities of daily living (NEADL), and quality of life (EuroQol) were also non-significant. Conclusions: None of the key outcomes differed at 6 months between the groups. Although not statistically significant and generally of small magnitude, the effects were predominantly in favour of the oxygen group; a larger trial, powered to show differences in longer-term functional outcomes, is now on-going. Trial Registration: Controlled-Trials.com ISRCTN12362720; Eudract.ema.europa.eu 2004-001866-4

Pharyngeal electrical stimulation for neurogenic dysphagia following stroke, traumatic brain injury or other causes: Main results from the PHADER cohort study

BackgroundNeurogenic dysphagia is common and has no definitive treatment. We assessed whether pharyngeal electrical stimulation (PES) is associated with reduced dysphagia.MethodsThe PHAryngeal electrical stimulation for treatment of neurogenic Dysphagia European Registry (PHADER) was a prospective single-arm observational cohort study. Participants were recruited with neurogenic dysphagia (comprising five groups – stroke not needing ventilation; stroke needing ventilation; ventilation acquired; traumatic brain injury; other neurological causes). PES was administered once daily for three days. The primary outcome was the validated dysphagia severity rating scale (DSRS, score best-worst 0–12) at 3 months.FindingsOf 255 enrolled patients from 14 centres in Austria, Germany and UK, 10 failed screening. At baseline, mean (standard deviation) or median [interquartile range]: age 68 (14) years, male 71%, DSRS 11·4 (1·7), time from onset to treatment 32 [44] days; age, time and DSRS differed between diagnostic groups. Insertion of PES catheters was successfully inserted in 239/245 (98%) participants, and was typically easy taking 11·8 min. 9 participants withdrew before the end of treatment. DSRS improved significantly in all dysphagia groups, difference in means (95% confidence intervals, CI) from 0 to 3 months: stroke (n = 79) –6·7 (–7·8, –5·5), ventilated stroke (n = 98) –6·5 (–7·6, –5·5); ventilation acquired (n = 35) –6·6 (–8·4, –4·8); traumatic brain injury (n = 24) -4·5 (–6·6, –2·4). The results for DSRS were mirrored for instrumentally assessed penetration aspiration scale scores. DSRS improved in both supratentorial and infratentorial stroke, with no difference between them (p = 0·32). In previously ventilated participants with tracheotomy, DSRS improved more in participants who could be decannulated (n = 66) –7·5 (–8·6, –6·5) versus not decannulated (n = 33) –2·1 (–3·2, –1·0) (

Sensitivity and specificity of CRP at different cut-off values.

<p>Sensitivity and specificity of CRP at different cut-off values.</p

Diagnostic statistics for cutoffs of CRP with 95% confidence intervals (CIs).

<p>Diagnostic statistics for cutoffs of CRP with 95% confidence intervals (CIs).</p

Symptoms, signs and laboratory results on the day of the diagnosis of first and recurrent pneumonias.

<p>Symptoms, signs and laboratory results on the day of the diagnosis of first and recurrent pneumonias.</p