[Dysphagia] Dysphagia Digest, Vol 38, Issue 10

[churcher at cheo.on.ca (Churcher, Elisabeth)]

Aspiration tolerance

At the Childrens Hospital of Eastern Ontario,  we  have observed otherwise healthy adolescents(no history of pneumonias or hospitalizations for respiratory problems) with cerebral palsy, spastic quadraplegia who have had back surgery for scoloisis.  They  almost always do poorly post surgery ( requiring prolonged ventilation, etc) because their lungs are in terrible condition because of damage from what we feel has been chronic aspiration over many years.  When they are fully recovered from their surgery we have done a  videofluoroscopy and  have always found they have aspiration.  In questioning the parents of how the adolescents fed prior surgery, they usually describe the children eating a puree or soft mechanical diet and indicate that there has usually been some coughing with feeding.  All these children have had some oral motor involvement and they all seem to be on the skinny side.

In following children from birth with spastic quadraplegic CP,  those who do not aspirate on feeding studies as babies frequently begin aspirating depending on the severity of the CP  usually after significant growth spurts.

With the pediatric population,  I do not recommend the continuation of oral feeding if aspiration has been identified on videofluoroscopy.  

Elisabeth Churcher
Occupatonal therapist

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Sent: Sunday, January 14, 2007 2:00 PM
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Subject: Dysphagia Digest, Vol 38, Issue 10


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Today's Topics:

   1. Re: "Aspiration tolerance" (Vikki Stefans)
   2. Re: "Aspiration tolerance" (lobsterpam at aol.com)
   3. esophageal course- last call for registrations (Speech Julie)
   4. Re: "Aspiration tolerance" (Jcarved at aol.com)


----------------------------------------------------------------------

Message: 1
Date: Sat, 13 Jan 2007 22:23:12 -0600 (CST)
From: Vikki Stefans <vstefans at george.ach.uams.edu>
Subject: Re: [Dysphagia] "Aspiration tolerance"
To: lobsterpam at aol.com
Cc: dysphagia at b9.com, HAL9600 at aol.com
Message-ID: <Pine.GSO.4.62.0701132216300.16446 at george.ach.uams.edu>
Content-Type: TEXT/PLAIN; charset=US-ASCII; format=flowed

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.


------------------------------

Message: 2
Date: Sat, 13 Jan 2007 23:37:24 -0500
From: lobsterpam at aol.com
Subject: Re: [Dysphagia] "Aspiration tolerance"
To: vstefans at george.ach.uams.edu
Cc: HAL9600 at aol.com, dysphagia at b9.com
Message-ID: <8C905ACD22B3A80-3F0-475A at FWM-D28.sysops.aol.com>
Content-Type: text/plain; charset="us-ascii"

 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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------------------------------

Message: 3
Date: Sun, 14 Jan 2007 10:20:34 -0500
From: "Speech Julie" <speechhuffman at nc.rr.com>
Subject: [Dysphagia] esophageal course- last call for registrations
To: "SID3VOICE for Karnell" <sid3voice at list.medicine.uiowa.edu>,
	<dysphagia at b9.com>
Message-ID: <004101c737ef$89c1f650$7301a8c0 at JulieWork>
Content-Type: text/plain; charset="iso-8859-1"

Registration is nearly closed for the below course.  If you are planning to 
attend and have and yet sent in your registration, please let me know so I 
can plan on you for handouts and lunch.  Julie



Raleigh, NC- January 19 & 20, 2007



Esophageal Dysphagia:  Applications for the Speech-Language Pathologist



This cutting-edge 2-day course is designed for the intermediate dysphagia 
therapist.  Gain valuable knowledge on esophageal disorders affecting the 
oropharyngeal stage of swallowing including laryngopharyngeal reflux (LPR) 
and GERD.  Dramatically improve your diagnostic ability and treatment 
planning by deciphering primary oropharyngeal versus esophageal dysphagia. 
Extensive clinical training for advanced interpretation of FEES and MBS to 
include implementation of the Reflux Finding Score (RFS) and esophageal 
sweep will be provided.  Affects of various enteral feeding methods and 
xerostomia will be discussed.  Course size limited.



Contact:  Julie Huffman (919) 784-4677 or huffro at nc.rr.com



------------------------------

Message: 4
Date: Sun, 14 Jan 2007 11:16:07 EST
From: Jcarved at aol.com
Subject: Re: [Dysphagia] "Aspiration tolerance"
To: vstefans at george.ach.uams.edu, LOBSTERPAM at aol.com
Cc: HAL9600 at aol.com, dysphagia at b9.com
Message-ID: <be7.c3ca9a8.32dbb147 at aol.com>
Content-Type: text/plain; charset="US-ASCII"

In a message dated 1/13/2007 10:18:39 PM Central Standard Time, 
vstefans at george.ach.uams.edu writes:


> I don't know how much data there is

We are collecting data in infants and young children at Children's Hospital 
of Wisconsin/Medical College - have presented preliminry data, but not 
published yet. When I say "we", this means physicians to include pulmonologists, 
gastroenterologists, and otolaryngologists for some as well as dietitians along 
with SLPs, etc.). We have been tracking now I think 12-15 patients from infants 
to some up to 18 months follow-up at this point. We are using a "dysphagia 
protocol" CT scan of chest with radiologists involved in establishing that 
protocol with our other physicians as baseline pulmonary objective data (obviously 
along with entire history and current pulmonary status) with normal findings on 
CT scan of chest and intermittent trace to minimal aspiration. Those meeting 
criteria have been (are) allowed to continue PO, not likely thickening either - 
with close clinical follow-up through our Feeding, Swallowing and Nutrition 
Center - not just pulmonary and feeding, but overall neurodevelopmental status, 
etc.  I can't go into all the details, but hopefully I have given enough to 
give you some idea of our tracking. So far all but 1 have continued to do well, 
repeat CT scan normal (not repeating often) and improved swallowing on VFSS - 
some we waited a year to retest if they were healthy, making developmental 
and feeding gains.... The one who was not kept totally PO ended up with a 
progressive severe neurologic diagnosis. We are not sure that the chest CT scan is 
the best measure, but for now that is what it is.

Clearly the big unanswered question continues to be - how much of what for 
how long can be aspirated and tolerated by an individual before chronic lung 
disease becomes problematic? We know that the rate of alveoli production is on a 
fairly steep curve during the first year and into the second year of life 
before it tapers off, and for some infants that young children that may be part of 
what helps as they reduce the aspiration with oral feeding over time.

The issues and questions are greater than can be handled via these kinds of 
messages, but a few comments..............

Thank you Vicky for emphasizing the concerns in the pediatric population.

joan arvedson


Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S, ASHA Fellow
Board Recognized Specialist in Swallowing and Swallowing Disorders
Program Coordinator, Feeding and Swallowing Services
Children's Hospital of Wisconsin-Milwaukee
PO Box 1997, Mail Station 785
Milwaukee, WI  53201

Clinical Professor, Dept. of Pediatrics
Medical College of Wisconsin-Milwaukee

Telephone: 414-266-6548

FAX: 414-266-6189


------------------------------

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End of Dysphagia Digest, Vol 38, Issue 10
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