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[Dysphagia] Re: Dysphagia Digest, Vol 22, Issue 4
May we all be as wise as Irene. I suspect the majority are either not
listening or more tragically not processing. How many times does it need to
be said? It would be such a wonderful world if everyone would practice
least restrictive, common knowledge, back to the basics nutritional
intervention. Forget the DPNS, Vital Stim, et. al. Patti Dirzulaitis, MS,
CCC-SLP
----- Original Message -----
From: <dysphagia-request@b9.com>
To: <dysphagia@b9.com>
Sent: Saturday, September 03, 2005 2:00 PM
Subject: Dysphagia Digest, Vol 22, Issue 4
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> Today's Topics:
>
> 1. PEG feeding and Down syndrome (Irene Campbell-Taylor)
> 2. Dilatation vs myotomy (Irene Campbell-Taylor)
> 3. Franquet et al (Irene Campbell-Taylor)
> 4. acoutsic neuroma resection (Bonnie Heintskill)
>
>
> ----------------------------------------------------------------------
>
> Message: 1
> Date: Fri, 2 Sep 2005 14:37:16 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley@yahoo.com>
> Subject: [Dysphagia] PEG feeding and Down syndrome
> To: dysphagia@b9.com
> Message-ID: <20050902213716.15421.qmail@web30203.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
>
> Paula Leslie wrote:
>
>
>
> The local consultant is asking for evidence to support our experience
>
> that
>
>
>
> 1) Dysphagia occurs in the middle/late third of the condition, not as a
>
> new symptom in the terminal stages (ie hours or days) as in other forms
>
> of dementia.
>
>
>
> *** There is NO form of dementia in which swallowing impairment manifests
in the last hours or days. It exists and progresses for a considerable time.
See: Campbell-Taylor I, Fisher RH JAGS 1987; Finucane et al JAMA 2001;
Gillick M. NEJM 2003 and many others.
>
>
>
> 2) PEG feeding improves the quality of life of these patients by
>
> reducing chest infections and preventing symptoms of malnourishment
>
>
>
> *** PEG feeding, especially in the older person and those with
developmental disabilities does not diminish but increases the risk of
aspiration pneumonitis and is NO guarantee of either adequate nutrition or
hydration.
>
>
>
> 3) Not inserting a PEG results in a prolonged illness of repeated chest
>
> infections and malnutrition symptoms which, if the patient can manage
>
> some feeding, may go on for more than 6 months (18 months in one of our
>
> ladies).
>
>
>
> *** The exact opposite is the case. Having said the above, I would add
that I find the prevalent view of , at best, paternalism re the DD
population to be appalling and decisions made about restricting the rights
of those with Down syndrome and other neurodevelopmental disorders to be
totally unacceptable in any civilized society. The NHS is particularly bad
in this respect. The guidelines for use of PEG feeding in adults is that it
be used ONLY for those who either cannot or will not eat. There must be a
functioning gut and ready access. The assumption that persons with
swallowing impairment will necessarily aspirate and, as a result, develop
respiratory infections is unfounded. The far more common scenario,
especially with children and adults with DD is that of reflux induced
aspiration pneumonitis sometimes followed by bacterial pneumonia, GERD
having a very high incidence/prevalence in children and adults with DD. (See
Franquet et al )The repeated chest infections refer!
> red to
> above are of this nature- pneumonitis followed by bacterial pneumonia. In
any patient who is failing and for various reasons becoming
immunocompromised, it is, in the final stages, unavoidable. The latest
information is that there is little or no discomfort associated with
restriction of food and fluid in the terminally ill -note terminally.
Without knowing the patient I cannot comment of the wisdom of withholding
PEG feeding in this case but the reasons given by the consultant are
spurious although the consensus of opinion is that for persons suffering
progressive neurological disease and approaching death, PEG feeding is not
indicated while careful spoon feeding is desirable.
>
>
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 2
> Date: Fri, 2 Sep 2005 14:40:46 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley@yahoo.com>
> Subject: [Dysphagia] Dilatation vs myotomy
> To: dysphagia@b9.com
> Message-ID: <20050902214046.62402.qmail@web30214.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
>
> can anyone help me with this one? is dilation the best route to
>
> perform when there is a dysfunction at the UES as opposed to the surgical
>
> invasion of myotomy? how long will the dilation remain intact before it
> may retract again?
>
> *** The basic question is "Why is the UES not opening?" Is it due to
denervation through the RLN and PP, failure of anterior hyoid movement,
scarring due to chronic LPR etc. etc. For each, there is a different answer.
>
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 3
> Date: Fri, 2 Sep 2005 14:56:48 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley@yahoo.com>
> Subject: [Dysphagia] Franquet et al
> To: dysphagia@b9.com
> Message-ID: <20050902215648.20502.qmail@web30203.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
> Having previously cited this article, I strongly recommend it:
>
>
>
>
> Aspiration Diseases: Findings, Pitfalls, and Differential Diagnosis1
Radiographics. 2000;20:673-685.)
> Tom?s Franquet, MD, Ana Gim?nez, MD, Nuria Ros?n, MD, Sof?a Torrubia, MD,
Jos? M. Sabat?, MD and Carmen P?rez, MD
>
>
>
> http://radiographics.rsnajnls.org/cgi/reprint/20/3/673
>
>
>
> Abstract
>
> The aspiration of different substances into the airways and lungs may
cause a variety of pulmonary complications. These disease entities most
commonly involve the posterior segment of the upper lobes and the superior
segment of the lower lobes. Esophagography and computed tomography (CT) are
especially useful in the evaluation of aspiration disease related to
tracheoesophageal or tracheopulmonary fistula. Foreign body aspiration
typically occurs in children and manifests as obstructive lobar or segmental
overinflation or atelectasis. An extensive, patchy bronchopneumonic pattern
may be observed in patients following massive aspiration of gastric acid or
water. CT is the modality of choice in establishing the diagnosis of
exogenous lipoid pneumonia, which can result from aspiration of hydrocarbons
or of mineral oil or a related substance. Aspiration of infectious material
manifests as necrotizing consolidation and abscess formation. The relatively
low diagnostic accuracy of c!
> hest
> radiography in aspiration diseases can be improved with CT and by being
familiar with the clinical settings in which specific complications are
likely to occur. Recognition of the varied clinical and radiologic
manifestations of these disease entities is imperative for prompt, accurate
diagnosis, resulting in decreased morbidity and mortality rates.
>
> In this article, we discuss and illustrate the spectrum of radiologic
manifestations, diagnostic pitfalls, and differential diagnoses associated
with a variety of aspiration diseases. These include diseases associated
with tracheoesophageal or tracheopulmonary fistula; diseases caused by
aspiration of foreign bodies, liquids, or infectious material; and other
aspiration diseases (lentil aspiration pneumonia, aspiration bronchiolitis,
obliterative bronchiolitis).
>
> With respect to the aspiration of water, for example, they say:
> Near Drowning
> The acute aspiration of massive amounts of water produces a pulmonary
edema that is radiographically indistinguishable from pulmonary edema from
other causes. The clinical significance of near drowning depends more on the
volume of water aspirated than on whether the aspirate is fresh water or
salt water.
> Classic chest radiographic findings in severe near drowning consist of
alveolar edema with extensive "fluffy" areas of increased opacity that tend
to coalesce throughout both lungs. In mild near drowning, findings range
from normal to confluent irregular perihilar areas of increased opacity in a
subsegmental or segmental distribution with peripheral sparing. Pneumonia
may be a complication of the aspiration of either fresh or salt water, and,
depending on the water source, may be caused by a variety of microorganisms
including bacteria, fungi, and mycobacteria. (i.e. not the water itself but
its microbial content.)
>
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 4
> Date: Fri, 2 Sep 2005 18:38:59 -0500
> From: "Bonnie Heintskill" <bonnieh4455@sbcglobal.net>
> Subject: [Dysphagia] acoutsic neuroma resection
> To: "dysphagia" <Dysphagia@b9.com>
> Message-ID: <001901c5b017$7e696560$220110ac@gateway.2wire.net>
> Content-Type: text/plain; charset="iso-8859-1"
>
> I have a patient who had an acoustic neuroma resected in January 2005. It
was done by Gamma knife and damaged not only the 8th nerve, but also the
7th, 9th and 10th nerves. He has a cuffed trach and has a g-tube. Was in
rehab in two different hospitals and a SNF. He had collagen injections of
the right vocal cord in January then had it aspirated out (I'm assuming
that's what the reports mean) plus nerve and muscle grafts which were
unsuccessful.
>
> I have him now for homecare. I've been doing oral stim via thermal stim,
taste sensation, tapping on his face, and neuromuscular retraining. This
will be the 3rd week I will be treating. He had a poor swallow when I
initially eval'd him but now, has no swallow. He also has right sided
weakness (possible stroke after surgery?). He saw the ENT a week ago and
was scoped. The right vocal cord is paralyzed in the open position.
>
> Home care nurse went in with me on Wed and deflated his trach cuff, which
he did NOT tolerate very well - major coughing, what looked like/sounded
like sneezes. He had to keep suctioning orally and still had difficulty
until the nurse reinflated his cuff. He has maxed out for OT/PT and nursing.
I have checked with local hospitals in his area for other types of treatment
(DPNS, Vitalstim, EMG feedback). One hospital does the DPNS and Vitalstim so
all the therapists and RN have agreed he should be discharged to outpatient
therapy so he can get more specialized OT/PT/ST.
>
> Insurance has limited coverage (contrary to what spouse is saying) for
therapies.
>
> Have I missed anything?
>
> Thanks
> Bonnie Heintskill, MS, CCC/SLP
>
>
> ------------------------------
>
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> End of Dysphagia Digest, Vol 22, Issue 4
> ****************************************
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