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[Dysphagia] Logemann results and MBS
Shadd Lagrandeur <slagrandeur at lrgh.org> wrote:
One cannot help but extrapolate from the evidence provided during an
MBS....that is what we get paid to do. \
*** On the contrary. What one is paid to do is identify the cause of the problem - and saying, for example-that the patient had a stroke is insufficient, and thence formulate goals and management plans for the individual patient (emphasis on individual) with follow up. It has been shown over and over that VFSS does NOT duplicate a real meal. Indeed it cannot duplicate a real meal because of the situation and the materials provided. The VFSs is was only ever meant to identify the dynamics of the swallow and has been so demonstrated as far back as the late 1980's.
We know we get plenty of false negatives, however if a patient
silently aspirates thin barium during the MBS, you can safely extrapolate
that they aspirate thin fluids.
*** Absolutely not. There is no evidence to support such a conclusion. It depends on so many variables that such a homology is invalid.
If a patient keeps getting aspiration pneumonias despite our
interventions, then we try more interventions, put in a PEG tube, or let the
patient eat as they wish and die.
*** Is it really an accepted notion that aspiration leads inevitably to death? Nothing could be further from the truth. As repeatedly shown in the medical literature, the hazards of aspiration depend on four main variables, to be considered together:
What is being aspirated, how much, over how long a period and, most importantly, what is the patient's resistance/immune response. Please read Marek on Pneumonia and Pneumonitis, NEJM 2000 I believe. It explains this very clearly as well as the near drowning literature.
What are the practical implications of these discussions...no one has talked
about how this should actually change how we view, diagnose, treat, and make
recommendations for dysphagic patients.
*** I think the practical implications couldn't be clearer. What has been taken as received wisdom is often if not always wrong. Other means of gaining hydration are available - drinking water, hypodermoclysis, drinking in different positions etc. etc. These need to be learned and used more extensively.
In the end this is all evidence that despite our best attempts at prolonging
some of these people's unfortunate existences, nature still takes its
course!
*** Nature will always take its course. All we can do with respect to swallowing impairment is to try to improve or maintain nutrition and hydration for as long as possible in a manner that is comfortable, efficient and acceptable to the patient.
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com
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