卒中相关性肺炎：从免疫抑制到床旁管理及未来研究方向

文献信息

中文摘要

背景： 卒中相关性肺炎（SAP）是急性卒中后最常见的并发症之一，约每八名卒中患者中有一人受累。除延长住院时间和增加医疗费用外，它也是死亡和功能恢复不良的主要危险因素。SAP的病理生理由两个汇聚过程驱动：吞咽困难及气道清除反射减弱导致的局部气道防御受损，以及自主神经系统功能障碍驱动的全身性卒中诱导免疫抑制。虽然卒中后免疫抑制是SAP的主要危险因素，但它可能限制脑内不希望的自身免疫反应。反之，SAP本身可能驱动神经炎症并导致卒中后认知障碍。尽管具有临床重要性，指导SAP预防、诊断和治疗的高质量证据仍然稀缺，指南推荐大多基于专家共识。建议SAP的诊断基于标准化临床标准，并在存在不确定性时辅以胸部X线和C反应蛋白作为补充。诊断后，指南建议根据当地方案立即开始经验性抗生素治疗。相反，预防性抗生素即使对高风险患者也不能改善临床结局或降低SAP发生率。因此，目前推荐的SAP预防策略主要集中于吞咽困难管理和早期活动。本综述结合卒中后免疫学的当前知识，整合SAP的病理生理、长期后果和进一步研究方向，以及近期欧洲卒中组织指南和相关指南中规定的SAP预防、诊断和治疗。

英文摘要

Stroke-associated pneumonia (SAP) is one of the most frequent complications after acute stroke, affecting approximately one in eight stroke patients. Besides prolonged hospitalisation and increased healthcare costs, it is also a major risk factor for mortality and poor functional recovery. The pathophysiology of SAP is driven by two converging processes: impaired local airway defence due to dysphagia as well as reduced airway clearance reflexes, and systemic stroke-induced immunodepression driven by dysfunction of the autonomic nervous system. While post-stroke immunodepression is a major risk factor for SAP, it might limit unwanted autoimmune responses within the brain. Conversely, SAP itself may drive neuroinflammation and contribute to post-stroke cognitive impairment. Despite its clinical importance, high-quality evidence to guide practice on prevention, diagnosis, and treatment of SAP remains scarce and guideline recommendations are mostly based on expert consensus. Diagnosis of SAP is suggested to be based on standardised clinical criteria supported by chest radiography and C-reactive protein as an adjunct where uncertainty persists. After diagnosis, guidelines suggest prompt empirical antibiotic therapy according to local protocols. In contrast, preventive antibiotics, even for high-risk patients, neither improve clinical outcome nor reduce SAP frequency. Currently recommended preventive strategies for SAP therefore mostly focus on dysphagia management and early mobilisation. This review integrates the pathophysiology, long-term consequences of SAP and further research directions based on the current knowledge on post-stroke immunology with prevention, diagnosis and treatment of SAP as set out in the recent European Stroke Organisation guideline and related guidelines.