[Dysphagia] "Aspiration tolerance"

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

 vstefans at george.ach.uams.edu wrote:

[[Trace or slightly more aspiration in someone with good lungs to start with 

and good oral hygeine and a good immune system, SURE...]]



Your sentence above illustrates the need for the clinician to weigh the entire situation, 

before making recommendations, and it makes the same point that I was.



I don't think anyone is advocating pouring food and fluid down the throats of someone who is

aspirating huge quantities.  But I have made people NPO in past years that I would never make 

NPO today. I don't have data either, but we've all seen plenty of patients (I work with 

adults) who have been chronic aspirators with no respiratory complications. We've also all 

seen patients who have become chronically dehydrated and malnourished as a result of our 

interventions. And we've seen patients made NPO who still got pneumonia. 



The important thing for the SLP to remember is that it's more than prandial aspiration that

causes pneumonia. When we get fixated on the trachea during a video and forget about the rest 

of the patient, that's when we can do a clinical disservice.



Pam Smith, Ph.D.

Bloomsburg University 

    
 -----Original Message-----
 From: vstefans at george.ach.uams.edu
 To: lobsterpam at aol.com
 Cc: dysphagia at b9.com; HAL9600 at aol.com
 Sent: Sat, 13 Jan 2007 11:23 PM
 Subject: Re: [Dysphagia] "Aspiration tolerance"
 
  EEEEEK!

Trace or slightly more aspiration in someone with good lungs to start with 
and good oral hygeine and a good immune system, SURE...

but the real question is how much for how long before clinically relevant 
and apparent damage begins to occur otherwise. Oh sure, my kids never gets 
sick - it's just "sinus" - doesn't everybody seem to catch everything from 
the other kids at school? - then we may end up with a major case of 
bronchiestasis, abscess, chronic oxygen requirement, etc.

I don't know how much data there is, maybe Irene can help, but I do know 
that in the bad old days when everyone thought it was fine for kids with 
CP to be badly malnourished and if they didn't choke they were eating just 
fine, their life span expectations were also pretty low - lots of kids 
just deteriorated as they hit their teenage years and people accepted it 
as unpreventable/natural course of condition.


Vikki Stefans, M.D., pediatric physiatrist (rehab doc for kids) at UAMS
and Arkansas Children's Hospital.  Working Mom of Sarah T. and Michael C.,
and wife of Henry Stefans. Every mom is a working mom!- OK, dads too.

On Tue, 9 Jan 2007 lobsterpam at aol.com wrote:

> 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.
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