卒中相关性肺炎的临床研究进展

Clinical research progress in stroke-associated pneumonia

卒中相关性肺炎(SAP)是指脑卒中发生7 d内非机械通气患者合并出现的肺部感染疾病谱。SAP是脑卒中后最常见的并发症之一,发病率为7%~38%,与脑卒中的不良预后显著相关。卒中诱导的免疫抑制(SIDS)是SAP的主要发病机制之一,与自身免疫、交感神经系统(SNS)、下丘脑-垂体-肾上腺素轴(HPA轴)、副交感神经系统(PNS)、损伤相关分子模式(DAMPs)等密切相关。而在SAP的发生发展过程中肺部与大脑如何相互作用目前尚不清楚。临床研究表明,人类单核细胞白细胞DR抗原(mHLA-DR)、中性粒细胞/淋巴细胞比值(NLR)、心率变异性(HRV)等可作为预测SAP发生的临床指标。老年人、男性、患有糖尿病等是目前普遍认为的SAP危险因素。据此,研究者制定了A2DS2评分表(年龄、心房颤动、吞咽困难、性别和卒中严重程度)、急性缺血性脑卒中预防性抗菌治疗(PANTHERIS)评分表、急性缺血性脑卒中肺炎评分表(AIS-APS)、ISAN评分表(卒中前独立程度、性别、年龄和卒中严重程度)等多种SAP风险预测工具。根据2015年卒中肺炎共识小组的意见,推荐使用改良美国疾病预防控制中心(CDC)肺炎临床诊断标准来诊断SAP。预防SAP发生是临床诊疗工作中最为重要的环节。不推荐预防性使用抗菌药物,一旦发生SAP,应依据抗菌药物使用策略进行治疗,神经保护和抗炎治疗的方法仍在研究中。

Stroke-associated pneumonia(SAP)is a spectrum of pulmonary infections in non-mechanical ventilation patients within 7 days of stroke.SAP is one of the most common complications after stroke,with an incidence of 7%-38%,which is significantly associated with poor prognosis of stroke.Stroke-induced immune-depression syndrome(SIDS)is one of the main pathogenesis of SAP,which is closely related to autoimmune,sympathetic nervous system(SNS),hypothalamic-pituitary-adrenalin axis(HPA axis),parasympathetic nervous system(PNS),and damage-related molecular patterns(DAMPs).It is unclear how the lungs and brain interact during the development of SAP.Some clinical studies have found that some clinical indicators such as monocyte human leukocyte antigen-DR(mHLA-DR),neutrophil to lymphocyte ratio(NLR)and heart rate variability(HRV)can be used to predict SAP occurrence.Old age,male,and diabetes are currently considered risk factors for SAP.Furthermore,a variety of SAP risk scales such as A2DS2 scale(age,atrial fibrillation,dysphagia,gender and stroke severity),preventive antibacterial therapy in acute ischemic stroke(PANTHERIS)scale,acute ischemic stroke-associated pneumonia scale(AIS-APS),and ISAN scale(pre-stroke independence,gender,age,and stroke severity)have been developed.According to the opinion of Pneumonia in Stroke Consensus in 2015,it is recommended to use the modified Centers for Disease Control and Prevention(CDC)pneumonia clinical diagnostic criteria for the diagnosis of SAP.Prevention of SAP is the most important part of clinical practice.Preventive antibiotics are not recommended,and once SAP is diagnosed,the antibiotic strategies should be followed.Neuroprotective and anti-inflammatory treatments are still being studied.