Pulmonary complications in patients with stroke requiring mechanical ventilation

Background and purpose

Prior studies have suggested that the outcome of patients with acute stroke who require mechanical ventilation is poor. In most patients swelling of ischemic tissue determines outcome but pulmonary complications may be equally important. Our purpose was to assess the impact of pulmonary complications on the outcome of patients with stroke who need prolonged mechanical ventilatory support.

Methods

We reviewed data on 50 patients with acute stroke who were mechanically ventilated for 5 days or more. We collected information on stroke type and location, time to intubation, reason for intubation, length of ventilatory support, duration of ICU stay. All pulmonary complications requiring therapeutic intervention were recorded. We defined outcome using the Glasgow outcome scale (GOS). Proportions were compared using the Fisher exact test and continuous variables using the paired t-test.

Results

Fifty-two percent of the strokes were ischemic and 58% of them involved the posterior circulation. Sixty-two percent of the hemorrhagic strokes were intraparenchymal hematomas and more than half were infratentorial. The reason for initial intubation was airway protection in 58% of patients, respiratory distress in 24% (usually due to aspiration or pulmonary edema), and respiratory arrest in 18%. Intubation was performed within 48 hours of stroke onset in 88% of cases. All patients received a tracheostomy. The mortality rate was 20% upon discharge and 32% among patients available for follow up at 1 year. Meaningful functional recovery (GOS 4–5) was achieved by 16% of patients both upon discharge and at 1 year. Pulmonary complications occurred in 70% of patients, including 62% of patients with pneumonia and 8% with ARDS. Presence of pulmonary complications was associated with longer duration of ventilatory support (24 ± 26 days versus 14 ± 9 days; P = 0.05) and ICU stay (27 ± 17 days versus 13 ± 6 days; P = 0.004), but not with clinical outcome.

Conclusions

Pulmonary complications are very common and serious among patients with stroke who require prolonged mechanical ventilation and need a tracheostomy. Although pulmonary complications lead to prolonged duration of ventilatory support and ICU length of stay and cost, mortality is not increased. Long-term ventilation in patients with stroke is not futile; recovery of functional independence is possible and continuation of full level of care seems warranted.