[Dysphagia] "Aspiration tolerance"

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

 Of course; information from the medical tools has to be interpreted within the context of how they're designed. But SLPs don't operate in a vaccuum. The info is useful to the extent that if factors complicate a patient medically, then the factors are important for us to be aware of as aggravating factors. After all, if it'll make it worse, it's not a good thing for a patient, and we should be aware of that. 
 
 But these tools aren't designed to tell us directly how to do proceed. Their role can be to help us understand the comorbities big picture. To my knowledge, we don't HAVE an objective measure to guide our interventions.
 
 ps
  
 -----Original Message-----
 From: NBurnett at cmh.org
 To: dysphagia-bounces at b9.com; lobsterpam at aol.com
 Sent: Tue, 9 Jan 2007 9:25 AM
 Subject: RE: [Dysphagia] "Aspiration tolerance"
 
  I?d be very interested in your work on a tool to highlight co-morbidities!  How useful is the online pneumonia severity index calculator for folks who do not yet have pneumonia? It looks like it?s intended to address morbidity risk for those who actually have pneumonia????? Many thanks,  Nancy Burnett, 
 Speech-Language Pathologist, 
 Cambridge Memorial Hospital, 
 700 Coronation Blvd., 
 Cambridge, Ontario. 
 N1R 3G2 
 Telephone: 519 ? 621 - 2330 ext 1126/Pager 1104 
 Fax: 519 - 740 ? 4978 Attention Nancy Burnett 3BN 
 Email: nburnett at cmh.org  
  -----Original Message----- 
 From: dysphagia-bounces at b9.com [SMTP:dysphagia-bounces at b9.com] On Behalf Of lobsterpam at aol.com 
 Sent:  January 9, 2007 7:29 AM 
 To:  HAL9600 at aol.com; dysphagia at b9.com 
 Subject:  Re: [Dysphagia] "Aspiration tolerance"   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 decision!  s. 
   
  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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