Risk of pneumonia associated with zero-degree head positioning in acute ischemic stroke patients treated with intravenous tissue plasminogen activator.
In the hyperacute phase of ischemic stroke, a 0° position is recommended to increase cerebral perfusion in nonhypoxic patients able to tolerate lying flat. However, use of 0° positioning is not uniformly applied in clinical practice, most likely due to concerns of aspiration pneumonia. We aimed to determine the risk of pneumonia associated with 0° head of bed positioning in acute stroke patients treated with thrombolytic therapy.



A retrospective descriptive study was conducted using prospectively collected, consecutive acute ischemic stroke patients treated with IVtPA whose head of bed was positioned at 0° for the first 24 h. Rates of hospital-acquired pneumonia were determined using a strict adjudication process to insure accuracy of pneumonia diagnoses. Quantitative characteristics were analyzed in SPSS to compare differences between "true" pneumonia cases and nonpneumonia cases.



Twenty-four of 333 (7.2%) patients had mention the diagnosis of pneumonia in the registry and/or medical record. Of these cases, only 15 (4.5%) met evidence-based diagnostic criteria for hospital-acquired pneumonia. The 15 adjudicated cases had similar median admission NIHSS scores to nonpneumonia cases (10 vs. 9, respectively; P = ns), but were older (74 ± 15 vs. 64 ± 17 years; mean difference 9.889, 95 CI = 1.2-18.6; P = 0.026). A total of eight patients with pneumonia were intubated and mechanically ventilated, and one patient received bilevel positive airway pressure ventilation during the 0° positioning period. Pneumonia cases had significantly longer hospitalizations (14.5 ± 12 vs. 6.6 ± 9 days; mean difference 7.97, 95% CI = 1.1-14.8; P = 0.026) and higher median discharge mRS score (4 vs. 3: P = 0.003).



Zero-degree head of bed positioning in the first 24 h following an acute ischemic stroke treated with IV-tPA was associated with acceptable rates of pneumonia. Rates for pneumonia may be further reduced by eliminating use of a 0° protocol in intubated/mechanically ventilated patients.
Department of Neuroscience S. Giovanni Calibita-Fatebenefratelli Hospital Rome Italy.
Paola
P
Palazzo
University of Alabama at Birmingham Birmingham Alabama.
Amy
A
Brooks
University of Alabama at Birmingham Birmingham Alabama.
David
D
James
University of Alabama at Birmingham Birmingham Alabama.
Randy
R
Moore
Department of Neurology University of Tennessee Health Science Center Memphis Tennessee.
Andrei V
AV
Alexandrov
Department of Neurology University of Tennessee Health Science Center Memphis Tennessee; Australian Catholic University Sydney New South Wales.
Anne W
AW
Alexandrov
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006257:Head; D006801:Humans; D008875:Middle Aged; D056888:Patient Positioning / Q000009:adverse effects; D011014:Pneumonia / Q000150:complications / Q000453:epidemiology*; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000627:therapeutic use; D012042:Registries; D012189:Retrospective Studies; D012306:Risk; D020521:Stroke / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator
Acute ischemic stroke; head of bed positioning; hospital‐acquired pneumonia