Abstract
Stroke-associated pneumonia (SAP) is one of the most common poststroke complications, significantly affecting patient prognosis. Early pulmonary rehabilitation (PR) has gained increasing attention in SAP management; however, evidence-based, systematic, and standardized programs remain lacking in clinical practice. This study aimed to summarize domestic and international evidence on SAP PR via evidence-based nursing, develop a comprehensive early PR program, and evaluate its efficacy. A quasi-experimental study design was employed. A total of 70 patients diagnosed with SAP who were admitted to the Department of Neurology of our hospital between July 2024 and June 2025 were enrolled in this study. Using a historical control approach, 35 SAP patients admitted from July to December 2024 were allocated to the control group, and 35 SAP patients admitted from January to June 2025 were allocated to the observation group. The control group received standard nursing care, while the observation group received nursing care incorporating an evidence-based PR program in addition to standard nursing care. Outcome measures included pulmonary ventilation function assessed by peak expiratory flow, respiratory muscle function assessed by maximal inspiratory pressure, pulmonary infection status assessed by the Clinical Pulmonary Infection Score, limb motor function assessed by the Fugl-Meyer Assessment Scale, and activities of daily living assessed by the Modified Barthel Index. Before the intervention, there were no statistically significant differences in peak expiratory flow, maximal inspiratory pressure, Clinical Pulmonary Infection Score, Fugl-Meyer Assessment Scale score, and Modified Barthel Index score between the 2 groups (all P > .05). After the intervention, all indicators in both groups improved compared with baseline, and all indicators in the observation group were significantly better than those in the control group, with statistically significant differences (all P < .05). The evidence-based comprehensive early PR program for SAP patients developed in this study has clinical practicability, operability, and generalizability. Clinical verification confirmed that this program exerts positive effects on improving pulmonary function, limb motor function, and self-care ability in SAP patients, and can effectively alleviate pulmonary infection. It is therefore suitable for further clinical promotion and implementation.
Keywords: early pulmonary rehabilitation, evidence-based, limb motor function, lung function, stroke-related pneumonia
1. Introduction
Stroke remains the most prevalent cerebrovascular disease, characterized by high mortality, disability, and recurrence rates. According to the latest Global Burden of Disease Study, the overall lifetime risk of stroke in China is 39.9%, the highest globally.[1] The 2020 China Stroke Burden Study showed that the age-standardized prevalence rate was 2.6%, the incidence rate was 505.2 per 100,000 person-years, and the mortality rate was 343.4 per 100,000 person-years among adults aged 40 years and older.[2] Epidemiological surveys indicate that cerebrovascular disease is the leading cause of death and disability.[3] More than two-thirds of stroke patients succumb not to the initial event but to various complications, with poststroke pulmonary infection being the most common, exhibiting a mortality rate of up to 70.9%.[4] Stroke-associated pneumonia (SAP) is a lower respiratory tract infection secondary to stroke.[5] This concept was initially introduced by Hilker et al in 2003.[6] SAP specifically refers to pneumonia developing within 7 days poststroke in patients who are not mechanically ventilated.[7] The incidence of SAP in China ranges from 11% to 26%.[8] SAP significantly elevates mortality rates among stroke patients, extends hospitalization duration, hinders neurological recovery, and complicates the treatment and rehabilitation processes.[4]
In recent years, the efficacy and significance of pulmonary rehabilitation (PR) have gained increasing recognition among clinical practitioners. International stroke rehabilitation guidelines strongly advocate for the early implementation of PR for poststroke patients, particularly those with SAP, encompassing passive vibration expectoration, active exercise training, and respiratory muscle training.[9] PR is an evidence-based, multidisciplinary approach that includes health education, exercise training, psychological support, and nutritional intervention.[10] It targets patients with primary or secondary chronic respiratory diseases experiencing reduced daily living capabilities due to symptoms.[11] Historically, numerous studies have examined PR in the context of various lung diseases, such as chronic obstructive pulmonary disease, acute respiratory distress syndrome, lung cancer, interstitial lung disease, and pulmonary fibrosis, with a particular focus on chronic obstructive pulmonary disease. Conversely, fewer studies have explored PR in stroke patients. However, recent research has demonstrated that PR, particularly breathing training, can enhance lung function and activity endurance in SAP patients.[12] For instance, Güngen et al showed that PR guided by physical therapists, which includes joint movements, eccentric contractions, muscle strengthening, walking exercises, and pursed lip-abdominal breathing, improves lung function and ventilation efficiency in SAP patients.[13] Similarly, Ma et al reported that PR training effectively enhances diaphragm function and daily living activities in SAP patients.[14] However, existing studies on PR for SAP still have 3 main limitations: oversimplified programs that mostly focus on single intervention measures (e.g., only respiratory muscle training or sputum clearance) and lack comprehensive integration of assessment, multimodal rehabilitation strategies, safety monitoring, and nursing care; non-standardized procedures with significant heterogeneity in key parameters such as rehabilitation initiation timing, training intensity, frequency, and duration across studies, hindering standardized clinical implementation; and a weak evidence base where most existing programs are derived from expert consensus or small-sample pilot studies rather than standardized programs developed through systematic evidence-based methods and rigorous clinical validation. To address these limitations, the innovations and complementary value of this study lie in 3 aspects: first, we systematically searched high-quality domestic and international evidence using the 6S evidence-based model, combined with FAME attribute evaluation (feasibility, appropriateness, clinical significance, effectiveness) and 2 rounds of expert consultation, to develop a multicomponent comprehensive rehabilitation program encompassing “assessment-intervention-monitoring-nursing care” 4 dimensions; second, we standardized key parameters including rehabilitation initiation timing, intensity, and frequency (e.g., initiation within 48 hours after clinical stabilization, 30 to 45 minutes per session, 5 days per week), enhancing the program’s operability and generalizability; and third, we verified the comprehensive clinical effects of this program on pulmonary function, pulmonary infection, limb motor function, and self-care ability via a quasi-experimental study design, providing preliminary clinical validation evidence for evidence-based early PR programs for SAP.
2. Materials and methods
2.1. General information
A quasi-experimental study design was employed, and patients with SAP who were admitted to the Department of Neurology of our hospital between July 2024 and June 2025 were enrolled as study participants. The inclusion criteria were as follows: meeting the diagnostic criteria for acute ischemic stroke[15]; fulfilling the clinical diagnostic criteria for SAP[16]; being hemodynamically stable and deemed by physicians to be capable of participating in PR training; and providing voluntary informed consent to participate in the study and comply with the relevant treatments. Exclusion criteria included: presence of consciousness, psychiatric, or cognitive impairments hindering cooperation; critical illness requiring mechanical ventilation; existence of other contraindications to PR; and occurrence of severe adverse events during rehabilitation that prevented continuation of treatment.
The Clinical Pulmonary Infection Score (CPIS) was used as the primary outcome measure for sample size calculation. The formula for comparing means between 2 independent samples was applied, with a two-sided significance level (α) set at 0.05 and a statistical power (1−β) of 0.90. Based on preliminary trial results, the estimated difference in CPIS score reduction between the control and observation groups (δ = 1.85 points) was used as the minimal detectable effect size, and the calculated standard deviation (σ = 2.12 points) served as the parameter estimate. Substituting into the formula n1 = n2 = 2 × ([Zα/2 + Zβ] × σ/δ)2, where Zα/2 = 1.96 and Zβ = 1.282, the theoretical sample size was calculated to be 28 per group, or 56 in total. Accounting for an estimated dropout rate of approximately 20%, a final sample size of 70 was determined. Using a historical control approach, 35 SAP patients admitted from July to December 2024 were allocated to the control group, and 35 SAP patients admitted from January to June 2025 were allocated to the observation group. This study employed a historical control design rather than randomization for the following reasons: first, this study aimed to evaluate the effectiveness of the comprehensive rehabilitation program developed based on new evidence as a complex intervention, which consists of multiple components, making it difficult to design an equivalent “placebo” rehabilitation program. Additionally, to avoid the ethical and administrative issues associated with implementing different nursing protocols for concurrently hospitalized patients, this design allows for a more realistic and feasible evaluation of the program’s preliminary effectiveness in clinical practice.
2.2. Methods
The control group received standard nursing care for SAP patients, which included the following: posture management: repositioning every 2 hours and monitoring the patient’s skin condition; lifecare: regular nail trimming, hair combing, and body scrubbing; dietary care: timely feeding for patients who can eat orally, and enteral or parenteral nutrition with nasogastric feeding for those who cannot; medication management: administering medications according to physician orders; airway management: encouraging patients to cough, frequent repositioning, chest percussion, and maintaining airway care; condition monitoring: observing changes in vital signs, consciousness, muscle strength, swallowing ability, and preventing complications; and additional supportive therapies: these included acupuncture treatment (3 sessions per week), daily neuromuscular electrical stimulation (20 minutes per session), and passive/active joint range of motion exercises conducted by rehabilitation therapists (once daily, 5 days a week). All control group patients received these supportive therapies as part of standard care.
The observation group received the same standard care as the control group, with the addition of an evidence-based PR program. The specific components of this enhanced care protocol are as follows.
2.2.1. Establishment of an evidence-based team
An interdisciplinary team coordinated the evidence-based practice project. Planning was managed by 1 head nurse from the Department of Neurology and 1 from the Department of Respiratory Medicine. Two deputy chief physicians oversaw clinical consultation and collaborative efforts. A specialist nurse from the Department of Neurology formulated review indicators and quality control measures. The introduction of evidence was facilitated by 3 nurses from the Department of Neurology, 2 rehabilitation therapists, and 1 nutritionist. Additionally, 2 research nurses were responsible for summarizing evidence, training in research methodologies, and collecting and analyzing data.
2.2.2. Evidence-based PR program
Establishing evidence-based questions: This study formulated research questions using the “PIPOST” model.[17] The research population (P) consisted of SAP patients, with the intervention (I) being PR training. The professionals (P) implementing the intervention included medical staff in neurology or intensive care, rehabilitation therapists, and physical therapists. Outcomes (O) measured included lung function, diaphragm range of motion, limb range of motion, and adherence to PR training. The setting (S) for applying the evidence was the neurology ward or intensive care unit, and the types of evidence (T) considered were clinical practice guidelines, evidence summaries, systematic reviews, and randomized controlled trials.
Literature search: A comprehensive literature search was conducted following the 6S evidence-based model.[18] Chinese databases included CNKI, Wanfang, Chinese Stroke Society, and VIP Chinese Journals, while foreign databases encompassed Web of Science, Ovid, PubMed, BMJ Clinical Evidence, Embase, and the American Heart Association/Stroke Association. Inclusion criteria were studies involving SAP patients, literature on PR training for SAP patients, and types of literature, including guidelines, evidence summaries, systematic reviews, expert consensus, and randomized controlled trials. Chinese and English were considered. Exclusion criteria were literature without full text, drafts, plans, abstracts, reports, and literature of low quality or repeated publication. Search terms included “Stroke,” “Stroke associated pneumonia,” “Pneumonia,” “pulmonary infection,” “Pulmonary Rehabilitation,” “Lung Rehabilitation,” “Pulmonary function,” “Respiratory Rehabilitation,” “Respiratory Muscle Training,” “Inspiratory Muscle Training,” and “Respiratory Training,” using a combination of subject terms and free words. For example, the search strategy is detailed in Table 1. The search covered publications up to July 31, 2024. After removing duplicates, incomplete data, and invalid studies, 10 articles were included: 8 foreign[13,19–25] and 2 Chinese.[26,27] The detailed search strategy is depicted in Figure 1. Subsequently, a quality assessment and evidence synthesis of the included literature were conducted.
Literature quality assessment and evidence extraction: Two research nurses, trained at the Evidence-Based Nursing Center of Fudan University and holding full-time master’s degrees, independently assessed the quality of the included literature. They employed the Clinical Guideline Evaluation System (Appraisal of Guidelines for Research and Evaluation II)[28] and the 2016 Joanna Briggs Institute authenticity evaluation tool for opinion and expert consensus articles.[29] Additionally, they evaluated the primary sources cited in manuals and evidence summaries. In instances of evaluation discrepancies, a third-party arbitrator was consulted, 13 pieces of evidence pertinent to PR for SAP patients were extracted.
Table 1.
PubMed search strategy.
| #1 | “Stroke” [Title/Abstract] OR “Stroke associated pneumonia” [Title/Abstract] OR “Pneumonia” [Title/Abstract] OR “pulmonary infection” [Title/Abstract] |
| #2 | “Pulmonary Rehabilitation” [Title/Abstract] OR “Lung Rehabilitation” [Title/Abstract] OR “Pulmonary function” [Title/Abstract] OR “Respiratory Rehabilitation” [Title/Abstract] OR “Respiratory Muscle Training” [Title/Abstract] OR “Inspiratory Muscle Training” [Title/Abstract] OR “Respiratory Training” |
| #3 | #1 AND #2 |
Figure 1.
Flowchart of literature screening. * Specifically including PubMed (n = 1054), Web of Science (n = 82), Embase (n = 38), BMJ Clinical Evidence (n = 25), American Heart Association/Stroke Association (n = 70), China National Knowledge Infrastructure (n = 840), Wanfang (n = 423), VIP (n = 212), and Chinese Stroke Society (n = 131).
The evidence-based team then appraised the extracted evidence using the FAME framework, considering feasibility, appropriateness, clinical significance, and effectiveness. This assessment informed the initial draft of an early PR program tailored to the clinical context for SAP patients. The draft underwent 2 rounds of expert consultation conducted via email and WeChat, during which feedback was incorporated to refine and finalize the early PR program (see Table 2).
Table 2.
Early pulmonary rehabilitation program for SAP patients.
| Evidence dimensions | Evidence content | Evidence level | Recommendation strength | |
|---|---|---|---|---|
| Pre-pulmonary rehabilitation assessment | A multidisciplinary SAP rehabilitation treatment team is formed under the leadership of the neurology department of a general hospital, including professional neurologists, nurses, physiotherapists, speech therapists, psychologists, rehabilitation assistants, and social volunteers. | 1 | A | |
| Content of the evaluation: assessment of neurological function: NIHSS score, imaging studies, and assessment of major systems; motor function assessment: limb function assessment using the Brunnstrom Functional Assessment Scale to assess the motor ability of the upper and lower limbs; rehabilitation evaluation: the physician will give rehabilitation-related medical orders after evaluating the disorders of each functional system, and the rehabilitation staff will provide specific rehabilitation opinions and measures after the evaluation; pulmonary function evaluation: professional evaluators will evaluate pulmonary function at the bedside, and the evaluation indicators include pulmonary ventilation function and respiratory muscle function evaluation; cognitive and psychological evaluation: the MMSE and MoCA are used to screen for cognitive impairment, and the PHQ-9 depression assessment scale is used to assess psychological status; and nutritional risk assessment: all admitted patients are screened for nutritional risk using the nutritional risk assessment scale in the care system. | 1 | A | ||
| Assessment time: neurological and motor functions should be assessed within 24 h of admission and the rest within 48 h of stabilization. | 1 | A | ||
| Pulmonary rehabilitation strategy | Pulmonary rehabilitation time | After stabilization of the SAP patient’s condition (specific clinical manifestations include stable vital signs and no progression of neurological symptoms and signs), rehabilitation treatment should be initiated as soon as possible, and the physician should give appropriate rehabilitation instructions. | 1 | A |
| Pulmonary rehabilitation intensity | Comprehensive assessment of the patient’s condition and classification of the patient’s severity according to the NIHSS score, i.e., mild SAP (1–6 points), moderate SAP (8–16 points), and severe SAP (>16 points). Combined with assessing the patient’s physical strength, exercise tolerance, and cardiopulmonary function, rehabilitation treatment should be initiated as early as possible. Each rehabilitation session lasts 30–45 min, 1–2 times a day, 5 d/wk. | 2 | B | |
| Pulmonary rehabilitation measures | Rehabilitation exercises in bed: supine position of the healthy limb (optional supine position, healthy side/affected side), 2 h/session, daily; bed-supine position change; active and passive range of motion exercises for both limbs, 2 times/d, 5 d/wk. | 3 | A | |
| Based on the severity of the patient’s condition (NIHSS score) and tolerance, rehabilitation therapists or trained nurses will guide the implementation of rehabilitation protocols following physician evaluation and prescription. Specific protocol: patients with mild to moderate SAP may initiate progressive bedside activities (e.g., sitting at bedside, standing balance training) twice daily, 5 d/wk, starting 24 h post-onset if vital signs are stable and physician approval is obtained. Patients with severe SAP should commence standing and adaptive walking training as soon as possible after condition stabilization (stable vital signs, no progression of neurological symptoms), using assistive devices and under dedicated supervision, twice daily, 5 d/wk. | 2 | B | ||
| Muscle strength training: SAP patients should perform muscle strength training on the hemiplegic side in the early stage and do progressive resistance training and flexion-extension muscle strengthening training for the muscles, which can be combined with physical therapy such as electrical stimulation and electromyographic biofeedback therapy, 2 times/d, 5 d/wk. | 2 | A | ||
| Airway clearance techniques: expectoration training: manual expectoration combined with expectoration equipment can be adapted for expectoration training twice/d, 5 d/wk; Breathing training: lip pursing-abdominal breathing + chest relaxation training + diaphragmatic breathing training can be adopted, twice/d, 5 d/wk. Cough training: the patient assumes a semi-seated position, leans forward slightly, takes a deep and slow breath, and then uses an explosive cough. The trainer places his hand on the patient’s abdomen to guide him in exerting force. After 1 training session, the next training session is performed at 30-s intervals for 15 min, once a day, 5 d/wk. | 1 | A | ||
| Dysphagia rehabilitation: use traditional rehabilitation methods such as orbicularis oris muscle training, tongue extension exercise, induced swallow reflex, throat stimulation combined with empty swallowing, and other training methods; physical methods use neuromuscular electrical stimulation, 2 times/d, 5 d/wk. | 2 | A | ||
| Dietary management: patients should undergo nutritional risk screening within 48 h of admission. The physician advises that patients with abnormal screening should receive timely nutritional support. Feeding methods include enteral nutrition via a nasogastric or naso-stomach tube. Patients who require prolonged tube use should have regular assessments of nutritional status and swallowing function. | 2 | B | ||
| Pulmonary rehabilitation monitoring | During pulmonary rehabilitation, dyspnea, lung sounds, sweating, blood pressure, heart rate, and oxygen saturation should be monitored. Supplemental oxygen can be given to maintain blood oxygen saturation >88%. If the patient’s heart rate is <50 beats/ min or >120 beats/min; respiratory rate is <5 breaths/min or >35 breaths/min; systolic blood pressure is >200 mm Hg or <90 mm Hg; neurological function deteriorates, including progressive cerebral stroke, brain herniation, and other hypoxemia, exercise should be stopped. | 2 | A | |
| Pulmonary rehabilitation nursing | After receiving SAP patients, the Department of Neurology/Stroke Unit should carry out early rehabilitation management for poststroke patients in a systematic and planned manner, focusing on regular health education and nursing guidance for patients and their caregivers during the rehabilitation process, fully mobilize the enthusiasm of patients and their caregivers to participate in rehabilitation and health management; establish rehabilitation beliefs; and achieve the overall goal of improving the quality of rehabilitation for poststroke patients. | 2 | A | |
MMSE = Mini-Mental State Examination, MoCA = Montreal Cognitive Assessment, NIHSS = National Institutes of Health Stroke Scale, PHQ-9 = Patient Health Questionnaire-9, SAP = stroke-associated pneumonia.
2.3. Intervention time and evaluation time
The intervention duration for both the observation and control groups was set at 2 weeks. Assessments were conducted at baseline (pre-intervention) and immediately post-intervention (at 2 weeks). The 2-week period was selected based on prior evidence indicating that the critical window for early pulmonary function recovery after stroke occurs between 2 and 4 weeks.[13] This duration balances the ability to observe meaningful rehabilitative effects with practical clinical feasibility.
2.4. Evaluation indicators
2.4.1. Pulmonary function
The pulmonary ventilation function index, peak expiratory flow (PEF), and respiratory muscle function index, maximal inspiratory pressure (MIP), were assessed using a bedside pulmonary function analyzer (Xiamen Saike Company).
2.4.2. CPIS
CPIS was utilized to gauge the severity of pulmonary infection, incorporating parameters such as body temperature, white blood cell count, airway secretions, gas exchange index, chest X-ray infiltration, and sputum culture. Each parameter is scored from 0 to 2, culminating in a total possible score range of 0 to 12, with higher scores indicating more severe infection.[30]
2.4.3. Fugl-Meyer assessment for limb motor function
This scale includes 33 items assessing upper and lower limb motor function, each rated from 0 to 2 points. A score of 0 denotes the inability to perform the item, 1 indicates partial performance, and 2 signifies full performance. The maximum score is 66, with higher scores reflecting superior limb motor function.[31]
2.4.4. Modified Barthel Index (MBI)
The MBI is an adaptation of the original Barthel score, consisting of 10 items that evaluate abilities such as feeding, transferring between bed and chair, and wheelchair use, with a maximum score of 100. The MBI categorizes scores into 1 to 5 levels, representing varying degrees of independence, with higher levels indicating greater independence.[32]
2.5. Quality control
An electronic questionnaire was developed using the Questionnaire Star platform to assess the medical staff’s awareness of the SAP PR program. The questionnaire was designed to be completed within 30 minutes, with a restriction of one submission per IP address. Participants who did not complete the questionnaire received one-on-one training. Daily supervision was carried out by the head of the nursing team, with random inspections conducted by the evidence-based practice team. Additionally, the head nurse performed weekly reviews and provided quality control feedback to ensure the effective implementation of the SAP PR measures.
2.6. Statistical analysis
Quantitative data conforming to a normal distribution were expressed as mean ± standard deviation (x̄ ± s), and inter-group comparisons were conducted using the t test. Qualitative data were presented as frequency and percentage (%), with inter-group comparisons performed using the χ2 test. No missing data were observed in this study, and all 70 enrolled patients completed the 2-week intervention and follow-up assessments.
2.7. Ethical approval
This study was conducted in strict accordance with the ethical principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethics Committee of The First People’s Hospital of Yancheng (Approval No.: 2024-K-209). All enrolled patients or their legal guardians were fully informed of the study objectives, procedures, potential risks, and benefits, and provided written informed consent voluntarily before participating in the study.
3. Results
3.1. Comparison of general information between the 2 groups of patients
A total of 70 SAP patients were included in this study. Comparisons between the 2 groups were made concerning gender, age, underlying diseases, smoking history, drinking history, Glasgow Coma Scale score, and National Institutes of Health Stroke Scale score. No significant differences were observed in the general characteristics between the 2 groups (see Table 3 for details).
Table 3.
Comparison of general information between the 2 groups of patients.
| Control group n = 35 |
Observation group n = 35 |
χ2/t | P | |
|---|---|---|---|---|
| Gender | ||||
| Male | 31 | 30 | 0.128 | .721 |
| Female | 4 | 5 | ||
| Age (yr) | 68.78 ± 12.13 | 67.95 ± 11.02 | 0.235 | .611 |
| Basic diseases | ||||
| Hypertension | 16 | 18 | 0.266 | .876 |
| Coronary heart disease | 14 | 13 | ||
| Diabetes | 5 | 4 | ||
| Smoking history | ||||
| Yes | 28 | 26 | 0.324 | .569 |
| No | 7 | 9 | ||
| Drinking history | ||||
| Yes | 20 | 18 | 0.230 | .631 |
| No | 15 | 17 | ||
| GCS score (points) | 12.31 ± 1.42 | 12.43 ± 1.52 | 0.258 | .442 |
| NIHSS score (points) | 9.98 ± 2.03 | 10.02 ± 1.84 | 0.348 | .337 |
GCS = Glasgow Coma Scale, NIHSS = National Institutes of Health Stroke Scale.
3.2. Comparison of lung function indices between the 2 groups
The results are shown in Table 4. There was no significant difference in the PEF and MIP values between the 2 groups before the intervention (P > .05). After the intervention, both groups showed improvements in PEF and MIP values compared with their pre-intervention levels. Notably, the pulmonary function values of the observation group were significantly better than those of the control group (PEF: t = 8.442, P < .001; MIP: t = 5.637, P = .001).
Table 4.
Comparison of ventilation function indicators between the 2 groups of patients.
| Group | PEF (L/min) | MIP (cm/H2O) | ||
|---|---|---|---|---|
| Before intervention | After intervention | Before intervention | After intervention | |
| Observation group | 48.20 ± 9.04 | 64.57 ± 11.23 | 14.43 ± 3.24 | 19.49 ± 3.98 |
| Control group | 47.83 ± 8.12 | 55.98 ± 10.92 | 14.89 ± 2.98 | 16.23 ± 4.02 |
| t value | 0.437 | 8.442 | 0.544 | 5.637 |
| P value | .381 | .000 | .299 | .001 |
MIP = maximal inspiratory pressure, PEF = peak expiratory flow.
3.3. Comparison of pulmonary infection between the 2 groups of patients
The results are shown in Table 5. There was no significant difference in CPIS scores between the 2 groups before the intervention (P > .05). After the intervention, both groups exhibited a decrease in CPIS scores compared with their pre-intervention levels. The CPIS score of the observation group was significantly lower than that of the control group, with a statistically significant difference (t = 6.227, P = .001).
Table 5.
Comparison of lung infection between the 2 groups.
| Group | CPIS score (points) | |
|---|---|---|
| Before intervention | After intervention | |
| Observation group | 8.23 ± 1.12 | 4.24 ± 0.54 |
| Control group | 8.11 ± 0.95 | 6.21 ± 0.81 |
| t value | 0.281 | 6.227 |
| P value | .617 | .001 |
CPIS = Clinical Pulmonary Infection Score.
3.4. Comparison of limb motor function between the 2 groups of patients
The results are shown in Table 6. There was no significant difference in Fugl-Meyer Assessment Scale scores between the 2 groups before the intervention (P > .05). After intervention, the scores of both groups improved compared with their pre-intervention levels. The Fugl-Meyer Assessment Scale score of the observation group was significantly higher than that of the control group, with a statistically significant difference (t = 10.721, P < .001).
Table 6.
Comparison of limb motor function between the 2 groups.
| Group | Fugl-Meyer score (points) | |
|---|---|---|
| Before intervention | After intervention | |
| Observation group | 30.68 ± 5.74 | 42.17 ± 4.06 |
| Control group | 30.51 ± 6.05 | 36.59 ± 3.92 |
| t value | 0.727 | 10.721 |
| P value | .438 | .000 |
Fugl-Meyer = Fugl-Meyer Assessment Scale for limb motor function.
3.5. Comparison of self-care ability between the 2 groups of patients
The results are shown in Table 7. There was no significant difference in the MBI scores between the 2 groups before the intervention (P > .05). After the intervention, the scores of both groups improved compared with those before intervention. The MBI score of the observation group was significantly higher than that of the control group, with a statistically significant difference (t = 12.340, P < .001).
Table 7.
Comparison of self-care ability between the 2 groups of patients.
| Group | MBI score (points) | |
|---|---|---|
| Before intervention | After intervention | |
| Observation group | 55.62 ± 8.57 | 72.19 ± 7.53 |
| Control group | 56.11 ± 7.83 | 66.43 ± 6.09 |
| t value | 0.846 | 12.340 |
| P value | .207 | .000 |
MBI = Modified Barthel Index.
4. Discussion
4.1. Evidence-based SAP early PR program can improve patients’ lung function
Clinical lung function indices include pulmonary ventilation indices and respiratory muscle function indices, of which PEF and maximum inspiratory pressure (MIP) are the most commonly used. These 2 indices were chosen in this study to assess lung function in SAP patients.[33] The PEF measurement is the fastest instantaneous expiratory flow rate during the pulmonary function test, and the MIP measurement is the determination of the strength of all respiratory muscles (expiratory and inspiratory muscles) of the subject’s organism.[33] Primary damage to the respiratory center is caused immediately after stroke in SAP patients, resulting in impaired respiratory function, and it has been found that not only short-term pulmonary dysfunction, including pulmonary ventilation dysfunction and respiratory muscle function impairment, is caused after SAP, but also varying degrees of pulmonary function impairment in chronic stroke patients.[4]
4.2. Evidence-based construction of an early PR program for SAP improves lung infections in patients
According to one study, stroke impairs the laryngeal cough reflex in patients, and there is a significant relationship between the incidence of SAP and reduced cough strength and sensitivity.[34] Impaired respiratory muscle function on the hemiplegic side due to hemiplegic limb dysfunction after stroke also leads to a weakened cough reflex, decreased airway clearance, and an increased incidence of SAP, which has been found to increase the mortality rate of stroke patients by 2 to 2.3 times within 1 month.[35] This study can effectively improve the respiratory muscle strength of patients with SAP, promote the recovery of limb motor function on the hemiplegic side, and incorporate relevant rehabilitation methods to improve airway clearance, which can effectively improve the patient’s ability to cough, promote the effective discharge of airway secretions, and have a positive effect on improving the patient’s lung infection. Malnutrition after stroke has been shown to significantly increase the risk of SAP, prolong the hospital stay of stroke patients, and increase the risk of disability and mortality after stroke. Therefore, the nutritional management of patients with SAP is an essential component of standardized stroke management and a potential target for intervention to improve lung infection in SAP. In this study, based on evidence for nutritional management in stroke, patients with SAP were screened for nutritional risk within 48 hours of admission. Nutritional interventions were provided to patients at nutritional risk, and appropriate routes were selected based on swallowing function, risk of aspiration, and changes in condition. At the same time, under proper assessment and effective supervision, progressive exercise training is carried out to prevent the development of fallout pneumonia and to strengthen the respiratory muscles while increasing overall body strength, thus reducing respiratory dyspnea and increasing confidence in recovery from the disease, which contributes to the rehabilitation of lung function.
4.3. An early PR program for SAP based on evidence-based constructs improves limb movement and self-care in patients
Poststroke motor dysfunction is one of the most common and disabling complications after stroke. It may accompany patients throughout their lives, and a major focus of rehabilitation in SAP patients is to promote recovery of motor function and reduce the disability rate.[36] It has been found that the Barthel Index is predictive of rehabilitation outcomes in SAP patients, and the most critical factor influencing the progression of physical ability and activities of daily living in SAP patients in long-term follow-up studies is the degree of motor deficits in patients.[37] Recovery of hemiplegic limb function after stroke is a long-term process that requires continuous and persistent training and rehabilitation. Poststroke patients are usually discharged from hospitals after stabilization of their condition in the acute phase and choose out-of-hospital professional medical rehabilitation facilities and home rehabilitation measures, so the role of this protocol in community and home rehabilitation for stroke still needs to be further verified.
5. Conclusion
This study employed evidence-based nursing methodologies to synthesize pertinent evidence on PR for SAP domestically and internationally, thereby developing a comprehensive early PR program. This program demonstrates clinical practicality, operational feasibility, and potential for widespread clinical adoption. The subsequent clinical validation phase affirmed that the program positively influences SAP patients’ lung function, limb motor function, and self-care capabilities. It effectively mitigates lung infections, supporting its potential for broader clinical implementation. Nonetheless, the study has limitations. The research was confined to a single medical institution, specifically the Department of Neurology at a tertiary hospital, and provided only preliminary validation of the program’s efficacy. Additionally, the study only evaluated short-term outcomes at 2 weeks post-intervention, and long-term effects on patient prognosis, readmission rates, and quality of life require further investigation.
Acknowledgments
The authors thank all patients and their families for their participation and cooperation in this study, as well as the support from all medical and nursing staff of the Department of Neurology and the Department of Rehabilitation Medicine.
Author contributions
Conceptualization: Yuting Bai, Xia Peng.
Formal analysis: Yuting Bai.
Methodology: Yuting Bai, Rong Ding, Yongmei Liu, Fuyan Dong, Hui Li, Xia Peng.
Project administration: Xia Peng.
Writing – original draft: Yuting Bai.
Writing – review & editing: Yuting Bai, Xia Peng.
Abbreviations:
- CPIS
- Clinical Pulmonary Infection Score
- FAME
- feasibility, appropriateness, meaningfulness, effectiveness
- MBI
- Modified Barthel Index
- MIP
- maximal inspiratory pressure
- PEF
- peak expiratory flow
- PIPOST
- population, intervention, professional, outcome, setting, type of evidence
- PR
- pulmonary rehabilitation
- SAP
- stroke-associated pneumonia
The authors have no funding and conflicts of interest to disclose.
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Bai Y, Ding R, Liu Y, Dong F, Li H, Peng X. Application effects of early pulmonary rehabilitation evidence-based nursing protocol in patients with stroke-associated pneumonia: A historical controlled quasi-experimental study. Medicine 2026;105:26(e49363).
Contributor Information
Yuting Bai, Email: baiyuting19852023@163.com.
Rong Ding, Email: 15366552890@163.com.
Yongmei Liu, Email: 15995192987@163.com.
Fuyan Dong, Email: 13851051503@163.com.
Hui Li, Email: 13505115672@163.com.
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