[Dysphagia] "Aspiration tolerance"

[lobsterpam at aol.com (lobsterpam at aol.com)]

 The fact people who have had no respiratory complications may aspirate what appear to be huge quantities of multiple consistencies is evidence that the concept of "aspiration tolerance" exists. In the more compromised patient, there would be less "aspiration tolerance." To me, this is evaluated in a decision making process, by noting such things as mobility status, respiratory status, nutrition/hydration status, medical condition and the nature of the diagnosis, general medical condition overall, alertness, oral hygiene status, etc. I don't know of an objective measure from the SLP literature (would love to see one, if it exists), but I've been working on an evaluation schematic to illustrate the importance of co-morbidities (email me if you're interested in seeing it; it's in process), and there are items in the medical literature which are objective in nature. They aren't designed to address how aggressively SLP interventions might proceed, but can help guide the decisions.
 
 Here's an online tool that Irene has mentioned (Pneumonia severity calculator) http://pda.ahrq.gov/clinic/psi/psi.htm
 
 Here's another print tool:
 http://www.aafp.org/fpm/20060400/41outp.html#box_a
 
 In the case you describe, assuming clinically the person looked good but had a history of significant medical issues that appeared to be resolving, I might initiate controlled p.o. trials but would monitor very closely and proceed with caution as the patient tolerated. Part of monitoring patient tolerance is his/her overall status, not just how well he/she is swallowing what we give them. It's vital that we see the patient as a whole. I tell students that we don't really "treat dysphagia," but we manage patients, and that in order to do that, one not only needs to know how to evaluate clinically, but also recognize the importance of comorbidities.
 
 Pam Smith, Ph.D.
 Bloomsburg University
 Bloomsburg, PA
  
 -----Original Message-----
 From: HAL9600 at aol.com
 To: dysphagia at b9.com
 Sent: Mon, 8 Jan 2007 6:52 PM
 Subject: [Dysphagia] "Aspiration tolerance"
 
  Is this a meaningful concept to those on the listserv, and, if so, how is  it 
evaluated clinically?
SLP's involvement is to evaluate the integrity of the swallow and thus  
determine causes of unsafe swallow and to minimize those to allow a person to  
eat 
and drink. However, especially in the case of someone who is NPO due to  a 
severe loss of motor integrity from a stroke or TBI, we confront a decision  
regarding when to start and how aggressively to proceed with individuals who may  

seem no worse on clinical and instrumental exam than others with whom we  
work.  The difference, however, is that these same individuals are  virtually or 

literally immobile due to paralysis or severe paresis, were  sometimes in 
prolonged coma and in compromised cognitive state, and  sometimes have a h/o or 
URI 
even while on NPO.  The same individual may be  progressing in terms of 
mobility so that we can be guardedly optimistic that the  immobility is 
temporary 
rather than permanent.
 
In our thought process we try to take into account that even normals  
aspirate but tolerate it.  We understand the major risk is aspiration of  
infected 
secretions from poor oral hygiene.  But in the scenario I  describe, would you 
opt to wait a bit, work on other motor competencies, provide  as much cognitive 
rehabilitation as possible, until, hopefully, this person can  move about a 
bit and is more resistant to URI as a result?  Are there other  factors than 
immobility that put the individual with otherwise adequate  respiratory function 

at risk and that would cause you to wait, and, if so, how  are these 
evaluated objectively?
 
 
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