[Dysphagia] pneumonia question

[nando11504 at hotmail.com (nando poppy)]

i have a Resident with CHF, COPD and now recurrent left lower lobe 
infiltrates with bilaterl plueral effusion.  this has been happening over 
the past 3 months.  his chest will clear for a few weeks then effusions and 
LLL infiltrates occurr.  he does not want any interventions such as fluid 
restriction or whaterver.  can someone please explain to me what else can 
cause that infiltrate in his lungs other than aspiration?  i believe he does 
aspirate silently.


thanks,
marc

>From: <wabeach@hsc.vcu.edu>
>To: "juliespeech" <speechhuffman@nc.rr.com>
>CC: dysphagia@b9.com
>Subject: Re: [Dysphagia] reflux and feeding tubes
>Date: Thu, 16 Feb 2006 07:22:04 -0500
>
>Just a brief thought. Living wills are not adequate to determine how
>aggressive medical management should be since they only obtain when
>the patient is terminally ill. A durable medical power of attorney,
>held by someone who will honor your wishes, is required to ensure that
>in non-terminal cases your wishes (whatever they are) will be carried
>out. State laws vary so make sure that you cover situations like PVS
>(which is not terminal so would not be covered by living wills).
>
>Woodford A. Beach, Ph.D., CCC/SP
>Senior Speech Pathologist
>Adjunct Asst. Professor, Neurology & PM&R
>Asst. Clinical Professor, Otolaryngology/Head & Neck Surgery
>Virginia Commonwealth University Medical Center
>Richmond, VA 23298
>Phone: 804-828-0207
>Fax: 804-828-8281
>
>-------------------
> > Its so sad to me that we are universally not recognizing how
>inappropriate
> > it is to tube-feed an individual with advanced Alzheimer's.  It
>certainly
> > makes me want to make sure my living will, and that of my family's
>is ready
> > to go!  All the literature is so clear in this area-- why is it
>still
> > happening when these poor folks end up hospitalized...
> >
> > Additionally, we can't as dysphagia therapists treat any one without
>knowing
> > a great deal about the esophagus, what symptoms are consistent with
> > esophageal dysphagia, and what recommendations would be
>contraindicated for
> > a person with esophageal problems (how about meds in applesauce
>without any
> > fluids before or after in someone with a severe motility disorder???
>yikes).
> > For anyone out there still wanting to say, "that's not my part of
>the
> > body... leave it to GI" a terrible disservice is being done.  No, we
>don't
> > treat esophageal problems, but we can educate, properly
>differentiate
> > oropharyngeal vs esophageal symptoms and make sure what we recommend
>is
> > appropriate in the least!
> >
> > By the way, here's what ASHA has to say about it in case you think
>the above
> > is out of our scope of practice for the SLP.  See--
> > American Speech-Language-
> >
> > Hearing Association. (2004). Guidelines for Speechlanguage
> >
> > pathologists performing videofluoroscopic
> >
> > swallowing studies. ASHA Supplement 24, pp. 77Â?92.
> >
> >
> > Julie Huffman
> > ----- Original Message -----
> > From: <Drirenect@aol.com>
> > To: <malindam@samhealth.org>; <dysphagia@b9.com>
> > Sent: Wednesday, February 08, 2006 9:38 AM
> > Subject: Re: [Dysphagia] reflux and feeding tubes
> >
> >
> > It is unfortunate that many if not most of the difficulties
>associated with
> > swallowing in the patient with advanced dementing illness are
>exacerbated if
> > not  caused by the use of anticholinergic, dopamine antagonist
> > antipsychotics.
> > This  has been apparent for decades but only now getting more
>attention.
> > SLPs
> > could  contribute significantly to the literature on the causes of
>death -
> > among them  the malnutrition and dehydration that go along with
>decreased
> > intake
> > of food as  a result of the side efects of these medications. The
> > contribution
> > of these meds  to mortality is high:
> >
> > Dec. 2, 2005
> > N Engl J Med. 2005;353:2335-2341 Â? Conventional antipsychotics are
>at  least
> > as likely as atypical agents to increase the risk for death among
>elderly
> > persons, and they should not replace atypical agents discontinued in
>
> > response to
> > the U.S. Food and Drug Administration (FDA) warning, according to
>the
> > results
> > of  a retrospective cohort study reported in the Dec. 1 issue of The
>New
> > England  Journal of Medicine.
> > "Recently, the FDA issued an advisory stating that atypical
>antipsychotic
> > medications increase mortality among elderly patients," write Philip
>S.
> > Wang,
> > MD, DrPH, from the Brigham and Women's Hospital, Harvard Medical
>School in
> > Boston, Massachusetts, and colleagues. "However, the advisory did
>not apply
> > to
> > conventional antipsychotic medications; the risk of death with these
>older
> > agents is not known."
> > This retrospective cohort study included 22,890 patients 65 years of
>age or
> > older who had drug insurance benefits in Pennsylvania and who began
> > receiving
> > a  conventional or atypical antipsychotic medication between 1994
>and 2003.
> > The  investigators used analyses of mortality rates and Cox
> > proportional-hazards
> >  models to compare the risk for death within 180 days, less than 40
>days, 40
> > to  79 days, and 80 to 180 days after starting therapy with an
>antipsychotic
> > drug.
> > For all intervals studied, conventional antipsychotic medications
>were
> > associated with a significantly higher adjusted risk for death than
>were
> > atypical
> > antipsychotic medications (</=180 days: relative risk [RR], 1.37;
>95%
> > confidence interval [CI], 1.27 - 1.49; <40 days: RR, 1.56; 95% CI,
>1.37 -
> > 1.78; 40 -
> > 79 days: RR, 1.37; 95% CI, 1.19 - 1.59; and 80 - 180 days: RR, 1.27;
>  95%
> > CI,
> > 1.14 - 1.41). This increased risk for death persisted in all
>subgroups
> > defined by the presence or absence of dementia or nursing home
>residency.
> > The greatest increases in risk occurred soon after therapy was
>started and
> > with higher dosages of conventional antipsychotic drugs. Increased
>risks for
> > conventional vs atypical antipsychotic medications persisted in
>confirmatory
> > analyses using propensity-score adjustment and instrumental-variable
> > estimation.
> > "If confirmed, these results suggest that conventional antipsychotic
> > medications are at least as likely as atypical agents to increase
>the risk
> > of  death
> > among elderly persons and that conventional drugs should not be used
>to
> > replace atypical agents discontinued in response to the FDA
>warning," the
> > authors
> > write. "To place this magnitude of risk in perspective, only cancer,
> > congestive heart failure, and HIV infection conferred greater
>adjusted risks
> > in  our
> > analyses."
> > Study limitations include possible underestimation of mortality
>resulting
> > from the use of conventional agents, study based on nonexperimental
>data,
> > lack
> > of information on potential mechanisms through which conventional
> > antipsychotic  medications might increase the risk for death in the
>short
> > term, and lack
> > of  data on the causes of death.
> > "Beyond arousing new concern about conventional agents, our data
>provide no
> > guidance with regard to which pharmacologic or nonpharmacologic
> > interventions
> > should be used to manage the many conditions and symptoms for which
> > antipsychotic medications are used," the authors conclude.
>"Traditionally,
> > the
> > benefits and risks of treatments in the elderly have simply been
> > extrapolated  from
> > studies involving younger populations. As the recent FDA advisory
>and the
> > results of this study show, such a practice can be misleading, given
>the
> > unique
> > needs and susceptibilities of older persons."
> > The National Institute of Mental Health and the Agency for
>Healthcare
> > Research and Quality have disclosed that they supported this study.
> > In an accompanying perspective, Wayne A. Ray, PhD, from the
>Vanderbilt
> > University School of Medicine in Nashville, Tennessee, notes that
>the
> > relative
> > efficacy and long-term safety, including effects on mortality, of
>many
> > widely
> > used medications, are poorly understood. He discusses methodologic
> > limitations
> > of various approaches designed to fill this information gap.
> > "Randomized trials would provide the most reliable data; however, in
>the
> > absence of material reform of the system for the approval of new
>drugs,
> > there is
> > little incentive to conduct such trials," Dr. Ray writes.
>"Nonrandomized
> > studies  can provide valuable information, as does the thoughtful
>study by
> > Wang
> > and  colleagues. However, observational studies of overall mortality
>are
> > particularly  susceptible to numerous biases and thus must be
>conducted with
> > extreme
> > care."
> >
> > _______________________________________________
> > Dysphagia mailing list
> > Dysphagia@b9.com
> > http://lists.b9.com/mailman/listinfo/dysphagia
> >
> >
> > _______________________________________________
> > Dysphagia mailing list
> > Dysphagia@b9.com
> > http://lists.b9.com/mailman/listinfo/dysphagia
> >
> >
>Woodford A. Beach, Ph.D., CCC/SP
>Senior Speech Language Pathologist, VCUMC
>Adjunct Asst. Professor, Neurology
>Adjunct Asst. Professor, PM&R
>Asst. Clinical Professor, Otolaryngology/Head & Neck Surgery
>Virginia Commonwealth University
>Richmond, VA 23298
>
>_______________________________________________
>Dysphagia mailing list
>Dysphagia@b9.com
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