Download PDF
Semin Respir Crit Care Med 2002; 23(3): 248-260
DOI: 10.1055/s-2002-33033
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Respiratory Complications of Stroke

Carolyn L. Rochester, Vahid Mohsenin
  • Section of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, Connecticut
Further Information

Publication History

Publication Date:
02 August 2002 (online)

    Permissions and Reprints

ABSTRACT

Stroke is the third leading cause of death in the United States. Stroke survivors often experience medical complications and long-term disability. Disturbances in respiratory system function and complications affecting the respiratory system are common after stroke. The nature of these disorders depends on the severity and site of neurological injury. Alterations in breathing control, respiratory mechanics, and breathing pattern are common and may lead to gas exchange abnormalities or the need for mechanical ventilation. Stroke can lead to sleep disordered breathing such as central or obstructive sleep apnea. Sleep disordered breathing may also play a role in the pathogenesis of cerebral infarction. Venous thromboembolism, swallowing abnormalities, aspiration, and pneumonia are among the most common respiratory complications of stroke. Neurogenic pulmonary edema occurs less often. Close observation of the stroke patient for these potential disturbances, and implementation of prophylactic measures can prevent significant morbidity and mortality.

KEYWORDS

Apnea - venous thromboembolism - dysphagia - aspiration - neurogenic pulmonary edema

REFERENCES

  • 1 Johnston K C, Li J Y, Lyden P D. Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial.  Stroke . 1998;  29 447-453
    CrossrefPubMedSearch in Google Scholar
  • 2 Stewart D G. Stroke rehabilitation, I: Epidemiologic aspects and acute management.  Arch Phys Med Rehabil . 1999;  80 S4-S7
    CrossrefPubMedSearch in Google Scholar
  • 3 McGuire J R, Harvey R L. The prevention and management of complications after stroke.  Phys Med Rehabil Clin N Am . 1999;  10 857-874
    PubMedSearch in Google Scholar
  • 4 National Stroke Association. Cost of stroke.  Stroke Clin Updates . 1994;  5 9-12
    PubMedSearch in Google Scholar
  • 5 Wijdicks E FM, Borel C O. Respiratory management in acute neurologic illness.  Neurology . 1998;  50 11-20
    CrossrefPubMedSearch in Google Scholar
  • 6 Becker K. Intensive care unit management of the stroke patient.  Neurol Clin. 2000;  19(2)10(4) 439-454-857-874
    PubMedSearch in Google Scholar
  • 6a Von Euler C. Brainstem mechanisms for generation and control of breathing pattern. In: Fishman AP ed., Handbook of Physiology Sec III. Vol. 11. 2nd ed. Bethesda, MD: American Physiologic Society 1986: 1-68.
    Search in Google Scholar
  • 7 Frank J I. Abnormal breathing patterns. In: Hacke W, ed. Neurocritical Care Heidelberg, Berlin, New York: Springer-Verlag 1994: 366-373
    Search in Google Scholar
  • 8 Howard R S, Williams A J. Chronic respiratory failure of neurogenic origin. In: Miller DH, Raps EC, eds. Critical Care Neurology Boston, Mass: Butterworth- Heinemann 1999: 249-277
    Search in Google Scholar
  • 9 Bassetti C, Aldrich M S, Quint D. Sleep-disordered breathing in patients with acute supra- and infratentorial strokes: a prospective study of 39 patients.  Stroke . 1997;  28 1765-1772
    PubMedSearch in Google Scholar
  • 10 Lee M C, Klassen A C, Resch J A. Respiratory pattern disturbances in ischemic cerebral vascular disease.  Stroke . 1974;  5 612-616
    PubMedSearch in Google Scholar
  • 10a North J B, Jennett S. Abnormal breathing patterns associated with acute brain damage.  Arch Neurol . 1974;  31 338-344
    CrossrefPubMedSearch in Google Scholar
  • 11 Fluck D C. Chest movements in hemiplegia.  Clin Sci . 1966;  31 383-388
    PubMedSearch in Google Scholar
  • 12 Sandin K J. Medical complications of stroke. In: Sandin KJ, Mason KD, eds. Manual of Stroke Rehabilitation Boston, Mass: Butterworth-Heinemann 1996: 23-36
    Search in Google Scholar
  • 13 Houston J G, Morris A D, Grosset D G, Lees K R, Mc Millan N. Bone, I: Ultrasonic evaluation of movement of the diaphragm after acute cerebral infarction.  J Neurol Neurosurg Psychiatry . 1995;  58 738-741
    PubMedSearch in Google Scholar
  • 14 Chalela J A, Kasner S E. Cardiac and respiratory complications of stroke. Up To Date 2001. Available at: http://www.uptodate.com. Accessed September 2001
  • 15 Vingerhoets F, Bogousslavsky J. Respiratory dysfunction in stroke.  Clin Chest Med . 1994;  15 729-737
    PubMedSearch in Google Scholar
  • 15a Nachtmann A, Selder M, Rose G, Sitzer M, Steinmetz H. Cheyne-Stokes respiration in ischemic stroke.  Neurology . 1995;  45 820-821
    PubMedSearch in Google Scholar
  • 16 Plum F. Mechanisms of ``central'' hyperventilation.  Ann Neurol . 1982;  11 636-637
    CrossrefPubMedSearch in Google Scholar
  • 17 Rodriquez M, Baele P L, Marsh H M, Okazaki H. Central neurogenic hyperventilation in an awake patient with brainstem astrocytoma.  Ann Neurol . 1982;  11 625-628
    CrossrefPubMedSearch in Google Scholar
  • 18 Bogousslavsky J, Khurana R, Deruaz J P. Respiratory failure and unilateral caudal brainstem infarction.  Ann Neurol . 1990;  28 668-673
    CrossrefPubMedSearch in Google Scholar
  • 19 Severinghaus J W, Mitchell R A. Ondine's curse: failure of respiratory center automaticity while awake [abstract].  Clin Res . 1962;  10 122
    PubMedSearch in Google Scholar
  • 20 Devereaux M W, Keane J R, Davis R L. Automatic respiratory failure associated with infarction of the medulla.  Arch Neurol . 1973;  29 4652
    PubMedSearch in Google Scholar
  • 21 Mohsenin V, Valor R. Sleep apnea in patients with hemispheric stroke.  Arch Phys Med Rehabil . 1995;  76 71-76
    CrossrefPubMedSearch in Google Scholar
  • 22 Askenasy J JM, Goldhammer I. Sleep apnea as a feature of bulbar stroke.  Stroke . 1988;  19 637-639
    CrossrefPubMedSearch in Google Scholar
  • 23 Bassetti C L, Aldrich M S. Sleep electroencephalogram changes in acute hemispheric stroke.  Sleep Med . 2001;  2 185-194
    PubMedSearch in Google Scholar
  • 24 Dyken M E, Somers V K, Yamada T, Ren Z Y, Zimmerman M B. Investigating the relationship between stroke and obstructive sleep apnea.  Stroke . 1996;  27 401-407
    CrossrefPubMedSearch in Google Scholar
  • 25 Wessendorf T E, Teschler H, Wang Y-M, Konietzko N, Thilmann A F. Sleep-disordered breathing with first-ever stroke.  J Neurol . 2000;  247 41-47
    PubMedSearch in Google Scholar
  • 26 Bassetti C, Aldrich M S. Sleep apnea in acute cerebrovascular diseases: final report on 128 patients.  Sleep . 1999;  22 217-223
    PubMedSearch in Google Scholar
  • 26a Good D C, Henkle J Q, Gelber D, Welsh J, Verhulst S. Sleep-disordered breathing and poor functional outcome after stroke.  Stroke . 1996;  27 252-254
    CrossrefPubMedSearch in Google Scholar
  • 27 Sandberg O, Frankllin K A, Bocht G, Eriksson S, Gustafson V. Nasal continuous positive airway pressure in stroke patients with sleep apnea: a randomized treatment study.  Eur Respir J . 2001;  18 630-634
    CrossrefPubMedSearch in Google Scholar
  • 27a Sakai F, Meyer J S, Karacan I, Derman S, Yamamoto M. Normal human sleep: regional cerebral hemodynamics.  Ann Neurol . 1980;  7 471-478
    CrossrefPubMedSearch in Google Scholar
  • 27b Lenzi P, Zoccoli G, Walker A M, Franzini C. Cerebral blood flow regulation in REM sleep: a model for flow-metabolism coupling.  Archives Italiennes de Biologie . 1999;  137 165-179
    PubMedSearch in Google Scholar
  • 27c Madsen P L, Holm S, Vorstrup S, Friberg L, Lassen N A, Wildschiodtz G. Human regional cerebral blood flow during rapid-eye-movement sleep.  J Cerebral Blood Flow Metab . 191;  11 502-507
    PubMedSearch in Google Scholar
  • 27d Fischer A Q, Taormina M A, Akhtar B, Chaudhary B A. The effect of sleep on intracranial hemodynamics: a transcranial Doppler study.  J Child Neurol . 1991;  6 155-158
    PubMedSearch in Google Scholar
  • 27e Madsen P L, Schmidt J F, Holm S, Vorstrup S, Lassen N A, Wildschiodtz G. Cerebral oxygen metabolism and cerebral blood flow in man during light sleep (stage 2).  Brain Res . 1991;  557 217-220
    CrossrefPubMedSearch in Google Scholar
  • 27f Droste D W, Berger W, Schuler E, Krauss J K. Middle cerebral artery blood flow velocity in healthy persons during wakefulness and sleep: a transcranial Doppler study.  Sleep . 1993;  16 603-609
    PubMedSearch in Google Scholar
  • 27g Hoshi Y, Mizukami S, Tamura M. Dynamic features of hemodynamic and metabolic changes in the human brain during all-night sleep as revealed by near-infrared spectroscopy.  Brain Res . 1994;  652 257-262
    CrossrefPubMedSearch in Google Scholar
  • 27h Hajak G, Klingelhofer J, Schulz-Varszegi M, Matzander G, Sander D, Conrad B, Ruther E. Relationship between cerebral blood flow velocities and cerebral electrical activity in sleep.  Sleep . 1994;  17 11-19
    PubMedSearch in Google Scholar
  • 27i Klingelhofer J, Hajak G, Matzander G, Schultz-Varszegi M, Sander D, Ruther E, Conrad B. Dynamics of cerebral blood flow velocities during normal human sleep.  Clin Neurol Neurosurg . 1995;  97 142-148
    CrossrefPubMedSearch in Google Scholar
  • 28 Jennum P, Borgesen S E. Intracranial pressure and obstructive sleep apnea.  Chest . 1989;  95 279-283
    PubMedSearch in Google Scholar
  • 29 Netzer N, Werner P, Jochums I, Lehman M, Strohl K P. Blood flow of the middle cerebral artery with sleep-disordered breathing: correlation with obstructive hypopneas.  Stroke . 1998;  29 87-93
    PubMedSearch in Google Scholar
  • 30 Loeppky J A, Voyles W F, Eldridge M W, Sikes C W. Sleep apnea and autonomic cerebrovascular dysfunction.  Sleep . 1987;  10 25-34
    PubMedSearch in Google Scholar
  • 31 Balfors E M, Franklin K A. Impairment of cerebral perfusion during obstructive sleep apneas.  Am J Respir Crit Care Med . 1994;  150 1587-1591
    PubMedSearch in Google Scholar
  • 32 Diomedi M, Placidi F, Cupini L M, Bernardi G, Silvestrini M. Cerebral hemodynamic changes in sleep apnea syndrome and effect of continuous positive airway pressure treatment.  Neurology . 1998;  51 1051-1056
    CrossrefPubMedSearch in Google Scholar
  • 33 Hayakawa T, Terashima M, Kayukawa Y, Ohta T, Okada T. Changes in cerebral oxygenation and hemodynamics during obstructive sleep apneas.  Chest . 1996;  109 916-921
    PubMedSearch in Google Scholar
  • 34 Marler J R, Price T R, Clark G L. Morning increase in onset of ischemic stroke.  Stroke . 1989;  20 473-476
    PubMedSearch in Google Scholar
  • 35 Angoli A, Manfredi M, Mossuto L, Piccinelli A. Rapport entre les rythmes hemeronyctaux de la tension arterielle et sa pathogenie de l'insuffisance vasculaire cerebrale.  Rev Neurol (Paris) . 1975;  131 597-606
    PubMedSearch in Google Scholar
  • 36 Partinen M, Palomaki H. Snoring and cerebral infarction.  Lancet . 1985;  2 1325-1326
    PubMedSearch in Google Scholar
  • 37 Palomaki H. Snoring and the risk of ischemic brain infarction.  Stroke . 1991;  22 1021-1025
    PubMedSearch in Google Scholar
  • 38 Sacco R L. Risk factors and outcomes for ischemic stroke.  Neurology . 1995;  S10-S14
    PubMedSearch in Google Scholar
  • 39 Nieto F J, Young T B, Lind B K. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study.  JAMA . 2000;  283 1829-1836
    CrossrefPubMedSearch in Google Scholar
  • 40 Klingelhofer J, Hajak G, Sander D, Schulz-Varszegi M, Ruther E, Conrad B. Assessment of intracranial hemodynamics in sleep apnea syndrome.  Stroke . 1992;  23 1427-1433
    PubMedSearch in Google Scholar
  • 41 Bokinsky G, Miller M, Ault K, Husband P, Mitchell J. Spontaneous platelet activation and aggregation during obstructive sleep apnea and its response to therapy.  Chest . 1995;  108 625-630
    CrossrefPubMedSearch in Google Scholar
  • 42 Wessendorf T E, Thilmann A F, Wang Y-M, Schreiber A, Konietzko N, Teschler H. Fibrinogen levels and obstructive sleep apnea in ischemic stroke.  Am J Respir Crit Care Med . 2000;  162 2039-2042
    CrossrefPubMedSearch in Google Scholar
  • 43 Warlow C. Venous thromboembolism after stroke.  Am Heart J . 1978;  96 283-285
    CrossrefPubMedSearch in Google Scholar
  • 44 Kamran S I, Downey D, Ruff R L. Pneumatic sequential compression reduces the risk of deep vein thrombosis in stroke patients.  Neurology . 1998;  50 1683-1688
    PubMedSearch in Google Scholar
  • 45 Wijdicks E FM, Scott J P. Pulmonary embolism associated with acute stroke.  Mayo Clin Proc . 1997;  72 297-300
    PubMedSearch in Google Scholar
  • 46 Rosenberg A, Bauer K. Does a prethrombotic state exist?.  <~>If so, what is it? Am J Clin Nutr . 1992;  (suppl) 7876-7885
    PubMedSearch in Google Scholar
  • 47 Menon I S, Dewar H A. Increased fibrinolytic activity in venous blood of hemiplegic limbs.  Br Med J . 1967;  2 613-615
    PubMedSearch in Google Scholar
  • 48 Black P M, Crowell R M, Abbott W M. External pneumatic calf compression reduces deep venous thrombosis in patients with ruptured intracranial aneurysms.  Neurosurgery . 1986;  18 25-28
    PubMedSearch in Google Scholar
  • 49 Bromfield E, Reding M. Relative risk of deep venous thrombosis or pulmonary embolism poststroke based on ambulatory status.  Neurorehabilitation . 1988;  2 51-57
    PubMedSearch in Google Scholar
  • 50 Scmidt E V, Smirnov V E, Ryabova V S. Results of the seven-year prospective study of stroke patients.  Stroke . 1988;  19 942-949
    CrossrefPubMedSearch in Google Scholar
  • 51 Harvey R, Roth E, Yarnold P. Deep vein thrombosis in stroke: the use of plasma D-dimer level as a screening test in the rehabilitation setting.  Stroke . 1996;  27 1516-1520
    PubMedSearch in Google Scholar
  • 52 Brandstater M E, Roth E J, Siebens H C. Venous thromboembolism in stroke: literature review and implications for clinical practice.  Arch Phys Med Rehabil . 1992;  73 S379-S391
    PubMedSearch in Google Scholar
  • 53 Savitz S I, Gupta G, Singh M, Rosenbaum D M. Antithrombotic and thrombolytic therapy for ischemic stroke.  Clin Geriatric Med . 2001;  17(1) 149-161
    PubMedSearch in Google Scholar
  • 54 International Stroke Trial Collaborative Group. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke.  Lancet . 1997;  349 1569-1581
    CrossrefPubMedSearch in Google Scholar
  • 55 Koopman M, Prandoni P, Piovella F. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low molecular weight heparin administered at home.  N Engl J Med . 1996;  334 682-687
    CrossrefPubMedSearch in Google Scholar
  • 56 Turpie A, Gent M, Cote R. A low-molecular-weight heparinoid compared with unfractionated heparin in the prevention of deep vein thrombosis in patients with acute ischemic stroke: a randomized, double-blind study.  Ann Intern Med . 1992;  117 353-357
    PubMedSearch in Google Scholar
  • 57 Agnelli G, Piovella F, Buoncristiani P. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery.  N Engl J Med . 1998;  339 80-85
    CrossrefPubMedSearch in Google Scholar
  • 58 Merli G J. Low-molecular-weight heparins versus unfractionated heparin in the treatment of deep vein thrombosis and pulmonary embolism.  Am J Phys Med Rehabil . 2000;  79(suppl) S9-S16
    PubMedSearch in Google Scholar
  • 59 Patel S C, Mody A. Cerebral hemorrhagic complications of thrombolytic therapy.  Prog in Cardiovasc Dis . 1999;  42(3) 217-233
    PubMedSearch in Google Scholar
  • 60 Teasell R W, McRae M, Heitzner J, Bhardwaj A, Finestone H. Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: a comparative study.  Arch Phys Med Rehabil . 1999;  80 294-298
    CrossrefPubMedSearch in Google Scholar
  • 60a Veis S L, Logemann J A. Swallowing disorders in persons with cerebrovascular accident.  Arch Phys Med Rehabil . 1985;  66 372-375
    PubMedSearch in Google Scholar
  • 61 Lugger K E. Dysphagia in the elderly stroke patient.  J Neurosci Nursing . 1994;  26(2) 78-84
    PubMedSearch in Google Scholar
  • 62 Meng N H, Wang T G, Lien I N. Dysphagia in patients with brainstem stroke: incidence and outcome.  Am J Phys Med Rehabil . 2000;  79 170-175
    PubMedSearch in Google Scholar
  • 63 Finestone H M. Safe feeding methods in stroke patients.  Lancet . 2000;  355 1662-1663
    CrossrefPubMedSearch in Google Scholar
  • 64 O'Neill P A. Swallowing and prevention of complications.  Br Med Bull . 2000;  56 457-65
    PubMedSearch in Google Scholar
  • 65 Barer D H. Dysphagia in acute stroke.  BMJ . 1987;  295 1137-1138
    PubMedSearch in Google Scholar
  • 66 Splaingard M L, Hutchins B, Sulton L D, Chaudure G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment.  Arch Phys Med Rehabil . 1988;  69 637-40
    PubMedSearch in Google Scholar
  • 67 Hormann M. Swallowing disturbances. In: Hacke W, ed. Neurocritical Care Heidelberg, Berlin, New York: Springer-Verlag 1994: 157-161
    Search in Google Scholar
  • 67a Palmer J B, Drenran J C. Evaluation and treatment of swallowing impairments.  Am Fam Physician . 2000;  61 2453-2462
    PubMedSearch in Google Scholar
  • 68 Addington W R, Stephens R E, Gilliland K, Rodriguez M. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke.  Arch Phys Med Rehabil . 1999;  80 150-154
    CrossrefPubMedSearch in Google Scholar
  • 69 Hamdy S, Rothwell J C, Aziz Q, Thompson D G. Organization and reorganization of human swallowing motor cortex: implications for recovery after stroke.  Clin Sci . 2000;  98 51-157
    PubMedSearch in Google Scholar
  • 69a Kim H, Chung C S, Lee K H, Robbins J. Aspiration subsequent to a pure medullary infarction.  Arch Neurol . 2000;  57 478-483
    CrossrefPubMedSearch in Google Scholar
  • 70 Aviv J E. Clinical assessment of pharyngolaryngeal sensitivity.  Am J Med . 2000;  108(4A) S68-S72
    CrossrefPubMedSearch in Google Scholar
  • 71 Nakagawa T, Sekizawa K, Nakajoh K, Tangi H, Arai H, Sasaki H. Silent cerebral infarction: a potential risk for pneumonia in the elderly.  J Intern Med . 2000;  247 255-259
    CrossrefPubMedSearch in Google Scholar
  • 72 Grau A J, Buggle F, Schnitzler P, Spiel M, Lichy C, Hacke W. Fever and infection early after ischemic stroke.  J Neurol Sci . 1999;  171 115-120
    CrossrefPubMedSearch in Google Scholar
  • 73 Teramoto S, Fukuchi Y. Detection of aspiration and swallowing disorder in older stroke patients: simple swallowing provocation test versus water swallowing test.  Arch Phys Med Rehabil . 2000;  81 1517-1519
    CrossrefPubMedSearch in Google Scholar
  • 74 Smithard D G, O'Neill P A, England R E. The natural history of dysphagia following a stroke.  Dysphagia . 1997;  12 188-193
    CrossrefPubMedSearch in Google Scholar
  • 75 Miller R M, Chang M W. Advances in the management of dysphagia caused by stroke.  Phys Med Rehabil Clin N Am . 1999;  10(4) 925-941
    PubMedSearch in Google Scholar
  • 76 Arai T, Yasuda Y, Takaya T. ACE inhibitors and symptomless dysphagia.  Lancet . 1998;  352 115-116
    CrossrefPubMedSearch in Google Scholar
  • 77 Colice G L, Matthay M A, Bass E, Matthay R A. Neurogenic pulmonary edema.  Am Rev Respir Dis . 1984;  130 941-948
    PubMedSearch in Google Scholar
  • 78 Smith W S, Matthay M A. Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema.  Chest . 1997;  111 1326-1333
    CrossrefPubMedSearch in Google Scholar
  • 79 Simon R P. Neurogenic pulmonary edema.  Neurol Clin . 1993;  11(2) 309-323
    PubMedSearch in Google Scholar
  • 80 Knudsen F, Jensen H P, Petersen P L. Neurogenic pulmonary edema:treatment with dobutamine.  Neurosurgery . 1991;  29 269-270
    PubMedSearch in Google Scholar
  • 81 Koskenvuo M, Kaprio J, Talakivi T, Partinen M, Heikkila K, Sarna S. Snoring as a risk factor for stroke in men.  BMJ . 1987;  294 16-19
    CrossrefPubMedSearch in Google Scholar
  • 82 Neau J PH, Meurice J C, Paquereau J, Chavagnant J J, Ingrand P, Gil R. Habitual snoring as a risk factor for brain infarction.  Acta Neurol Scand . 1995;  92 63-68
    CrossrefPubMedSearch in Google Scholar