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Myasthenia Gravis

A response to your question on Myasthenia Gravis -

3 issues to consider:

1.    Plasma Exchange (PLEX) will usually make a big difference in their 
voice and swallowing abilities.  For example - we may have a patient 
pre-plex who is at risk for aspiration with all p.o. as demonstrated via 
MODBASW and/or FEES  - yet following 6 PLEXs - patient is able to 
tolerate mechanical soft diet with thin/thick liquids utilizing some 
compensatory techniques.   However, use this example with caution - all 
these patients need thorough evaluation pre-plex, during-plex, and 
post-plex to determine appropriate p.o.

2.  Also, one important thing to consider - find out if your patient is 
on the drug, Mestinon.  Patients tend to really trough and peak on this 
drug.  For example if you have a patient who is receiving Mestinon every 
four hours - so lets say she receives her Mestinon at 8:00am, 12:00 noon, 

etc.  She may start troughing around 7:00 am and then start to improve 
around 8:30 - 8:45am.  Thus, the moral of the story - is know at what 
time they are in their medication dosage for when you are testing.  You 
may see a patient tolerate solids well if you objectively test this 
patient (on above time schedule) at 9:30am; however, at 12:00 noon - if 
you test the same patient she may only be able to tolerate purees.  Again 

- this is an example - each patient needs individual assessment and care 
plan.  If we do see the above - we may schedule meals around peaks of 

3.  Last but not least - We often do  both a MODBASW and FEES(Fiberoptic 
Endoscopic Evaluation of Swallowing) on these patients.  Reason - the 
MODBASW gives us a good idea of what their pharyngeal contraction and 
hyolaryngeal excursion, etc looks like - however the FEES is the test 
that we use to actually put these patients on diets.  The MODBASW is 
restricted to a short amount of time.  These patients are at a high risk 
for fatigue through the course of a meal - Thus, following the MODBASW - 
we order a diet - then do a FEES while the patient eats her first meal of 

the diet we recommended.  We OFTEN will see a patient tolerate the 
proposed diet for the first 5-10 minutes, but then begin to fatigue and 
no longer be able to tolerate recommended diet.  So we then alter diet 
recommendations or restrict patients to short but frequent meals.   If 
you are having to work around Mestinon peaks - however - the short and 
frequent meals can be difficult to schedule during waking hours- so you 
may have to go with the more restrictive diet - one they are not 
aspirating following fatigue..  

I believe by appreciating the above as well as general swallowing issues 
- we help these patients achieve the least restrictive form of p.o. but 
with a good amount of caution given their susceptibility to respiratory 

Good luck

Susan Hiss
UNC Hospitals

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