Pneumonia After Stroke: Causes and Prevention

One of the most common medical complications after stroke is aspiration pneumonia. In fact, according to most estimates, one in three stroke survivors will develop pneumonia at least once during their recovery. This can take a negative toll on a survivor’s overall health and can make an already challenging recovery even more so.

Aspiration pneumonia occurs after a person accidentally inhales a foreign substance, such as solid food or liquid. This can then lead to a serious infection in the lungs. Fortunately, there are several strategies you can use to prevent this and avoid developing pneumonia after stroke.

To help you better understand pneumonia after stroke, we will begin by reviewing the root causes and common symptoms. Then, once you better understand these causes, you can take effective preventative measures.

To help navigate this article, use the links below to jump straight to any section:

• Cause
• Signs
• Diagnosis
• Prevention
• Compensation techniques

Causes of Pneumonia After Stroke

The primary cause of pneumonia after stroke is dysphagia, which refers to difficulty swallowing. This condition is caused by weakness of the muscles in the mouth and throat. When an area of the brain is affected by stroke, that area of the brain can become damaged and lose its important functions. This can include changes in sensation, cognition, and muscle activation. While weakness of the limbs is common after stroke, the muscles necessary for chewing and swallowing are also frequently affected.

There are several different types of dysphagia, but most stroke survivors are affected by oropharyngeal dysphagia. The weakness of the muscles in the throat caused by stroke makes it difficult to move food and liquid from your mouth into your esophagus correctly. In addition to causing aspiration pneumonia, dysphagia can also lead to malnutrition or dehydration if survivors cannot ingest sufficient food or liquid.

The severity of dysphagia can vary depending on the severity of the stroke as well as other factors. Some stroke patients can still swallow soft food or liquids while others cannot swallow at all. Other symptoms of dysphagia besides difficulty swallowing can include:

• Weak voice
• Loss of gag reflex
• Drooling
• Decreased tongue control
• Coughing or spitting up food
• Weight loss

These problems can all lead to an increased risk of choking, malnutrition, and pneumonia after stroke. When someone accidentally inhales food or liquid, this can irritate the lungs and make it more difficult to breathe. In addition, inhaling foreign objects can bring bacteria into the lungs and lead to a serious infection.

Silent Aspiration and the Signs of Pneumonia After Stroke

Aspiration is usually accompanied by fits of coughing and wheezing as the body tries to force the foreign objects out of the lungs. If the person can cough hard enough, they may be able to clear out their lungs before pneumonia can develop.

Unfortunately, many stroke patients do not have this cough reflex. Due to the injury caused to their brain by the stroke, some muscles and reflexes can be inhibited. As a result, the survivor may aspirate food and water without even feeling it or coughing it up. Doctors call this silent aspiration, and it can be extremely dangerous.

Some studies speculate that as many as 67% of stroke patients experience silent aspiration. Since silent aspiration can cause serious cases of pneumonia after stroke, caregivers ought to familiarize themselves with the symptoms of aspiration pneumonia. These symptoms are sometimes difficult to notice, but early detection is the key to effective treatment. For example, a person with aspiration pneumonia can display symptoms such as:

• Chest pain or heartburn
• Fever
• Shortness of breath and fatigue, especially while eating
• Blue discoloration of the skin
• Coughing up blood, green sputum, or a foul odor
• Bad breath
• Excessive sweating
• Crackling sounds in the lungs

Sometimes people who aspirate do not display these symptoms immediately, and they may not have all these symptoms. However, if a stroke survivor displays any of these symptoms, caregivers should contact their doctor or care team to receive timely treatment.

Diagnosing and Treating Aspiration Pneumonia

While survivors can exhibit the symptoms listed above, a physical exam is usually required to diagnose pneumonia after stroke. Doctors will look for signs such as decreased airflow, rapid heart rate, and crackling or other abnormal sounds in the lungs to rule in this infection. In addition, they may order specialized tests to confirm the presence of pneumonia. These tests can include:

• Chest X-ray or CT scan
• Blood test
• Arterial blood gas test
• Sputum or blood culture
• Bronchoscopy
• Additional swallow testing

Once diagnosed, your doctor will begin treatment right away to help clear the infection. Mild cases of pneumonia can be treated with a course of antibiotics, but more severe cases may require hospitalization. At the hospital, the person might receive supplemental oxygen and steroids. Additionally, doctors may need to remove the foreign substances from the lungs using suction. In extreme circumstances, the survivor may need the help of a ventilator to breathe.

How to Prevent Pneumonia After Stroke

Pneumonia can be a serious, life-threatening condition. Fortunately, it is also preventable through various treatment techniques. The best way to minimize the risk of pneumonia after stroke is to treat dysphagia. If the stroke survivor can improve their swallowing abilities, they can reduce aspiration and prevent infections from occurring.

Recovery from stroke is a lengthy process and you will be working with a variety of rehab professionals along your journey. In addition to treating the secondary effects of stroke like decreased sensation, weakness, or difficulty walking, your rehab team will address your ability to swallow. The following are a few effective ways to improve swallowing skills and avoid stroke-related pneumonia as you recover:

1. Work with a Speech Therapist

Since swallowing muscles are involved in speech, a speech-language pathologist (SLP) can help patients improve their dysphagia. The speech therapist will assess a survivor’s unique condition, including their swallowing abilities, speech, and cognitive function. This assessment will allow the therapist to design a program that meets the survivor’s specific needs. 

This program will likely include guidance on the types and textures of foods and liquids that a survivor can handle. For example, the speech therapist may recommend that the survivor eat only pureed foods initially. Later, the therapist may progress them to a “chopped” diet where all their food needs to be chopped into small pieces. Some survivors will also need to have their liquids thickened to minimize aspiration.

In addition to diet modifications, a speech pathologist will also guide the patient through exercises to improve swallowing, strength, and coordination. These activities engage neuroplasticity, which is the brain’s natural ability to rewire itself and regain lost function. Through repetition of the provided therapy exercises, the survivor can improve the strength of the muscles used for chewing, swallowing, and speech.

If you struggle with consistency or motivation, consider using speech therapy apps for dysphagia patients. These apps can make rehab more engaging and can help you achieve greater repetition of therapy exercises. In addition to exercise, your therapist may also suggest certain strategies to help prevent aspiration. We will review more of these compensation strategies later in this article.

2. Try Electrical Stimulation

Electrical stimulation (e-stim) can help boost muscle activity and speed up recovery for survivors with different motor and sensory impairments. This modality works by sending mild electrical impulses to the targeted muscles and nerves via small electrodes on the skin. In addition to treating larger muscle groups necessary for walking and balance, electrical stimulation can be used to address dysphagia.

When used simultaneously, this can help maximize neuroplasticity and promote the return of muscle function. Talk to your therapist to determine if electrical stimulation is a good option for you. Do not try e-stim on your neck or throat area without the direct supervision of a trained therapist as this can be very dangerous when performed incorrectly.

3. Consider Botox Injections

After stroke, many survivors can experience spasticity or abnormal tone in certain muscle groups. In addition to conditions like contractures, post stroke pain, and curled fingers after stroke, spasticity can also cause dysphagia.

After the brain experiences tissue damage due to stroke, the misfiring of neural connections can lead to spasticity, or increased muscle spasm. Much like other areas of the body, the muscles in the throat can benefit from the use of Botox to reduce this spasticity. In fact, a recent study has shown Botox to be an effective intervention for dysphagia after neurological conditions such as stroke.

While Botox is not the first line of treatment for dysphagia, it can be helpful for those with severe symptoms who are at great risk for aspirating. Botox may be temporary, but it can provide the opportunity to make your rehab more effective and improve dysphagia symptoms. Talk with your doctor and rehab team if you feel this could be an appropriate treatment for you.

Compensation Techniques to Prevent Aspiration and Pneumonia

Speech therapy, electrical stimulation, and Botox are effective ways to treat dysphagia and prevent aspiration pneumonia after stroke. However, treatment will require consistent effort and results take time to appear. Therefore, you may need to take advantage of compensation techniques while eating with dysphagia to ensure your safety.

Compensation techniques allow you to reduce your risk of aspirating when you eat or drink. Subsequently, this can reduce your risk of developing pneumonia after stroke. Ask your speech therapist for safety advice when eating and drinking. To help you get started, the following are a few practices your therapist may recommend to reduce your risk of aspirating:

• Drink thick liquids. Therapists may recommend thicker liquids for some individuals. Thick liquids such as milkshakes and smoothies move slower than thin liquids and can decrease your risk of choking or aspirating.
• Sit up straight. Always stay upright when eating or drinking. When you are upright, gravity can help move the food down your throat safely, which can’t happen when you lie on your back. Additionally, try tucking your chin slightly to make swallowing easier.
• Eat slowly. Take your time and chew your food completely, focusing on taking small bites. Many speech therapists recommend chewing for at least one minute to avoid aspiration.
• Avoid complex foods. Try to avoid foods with varying consistencies, such as chunky soup. These foods can be dangerous for stroke patients with dysphagia as the combination of varying textures makes aspiration more likely.
• Reduce distractions. Take the time to focus on eating and avoid talking while you eat to ensure a more thorough swallow. If you can, reduce background distractions like television so you can focus on your meal.

These techniques can help minimize aspiration risk while you are improving your swallowing skills. Collaborate with your speech therapist to create a plan that best meets your unique needs. They will be able to guide you and recommend additional compensatory techniques to maximize your safety. Some survivors might need to avoid solid foods entirely or, in severe cases, may require a feeding tube. The priority is reducing the risk of pneumonia after stroke and preventing malnourishment.

Understanding the Risks of Pneumonia After Stroke

Pneumonia is a common complication of stroke that can occur because of dysphagia, or difficulty swallowing. Approximately half of all stroke patients experience dysphagia, which can cause aspiration and respiratory infections if left untreated. This can lead to serious complications and can significantly slow a survivor’s recovery.

Thankfully, improving swallowing and reducing your risk of pneumonia is possible. Treating dysphagia as soon as possible is important to improve your recovery and boost your nutrition. In addition to working closely with a speech therapist, electrical stimulation and Botox are additional treatment options for survivors affected by dysphagia.

As you work to treat the root cause of aspiration, certain compensation techniques can reduce your risk of developing pneumonia after stroke. These techniques include sitting up straight, eating slowly, avoiding complex foods, and decreasing distractions. While these do not address the root cause of aspiration, they are valuable techniques to improve your safety when eating and drinking.

Be sure to work closely with your doctor and therapy team to achieve the best results as you recover. Pneumonia after stroke can be serious, but there are ways to prevent this by addressing dysphagia and reducing aspiration. We hope this article has helped you better understand the causes of pneumonia after stroke and how to prevent it.