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[Dysphagia] Dysphagia Digest, Vol 42, Issue 10
I did. Irene gave the details so I addressed her but replied to all.
Trudy
Trudy Lynch
Senior Speech Pathologist
Royal North Shore Hospital
St Leonards NSW 2065
Phone: (02) 9926 7741
Fax: (02) 9926 6568
>>> Vera Karger <vkargerslp at mac.com> 11/05/2007 9:47:19 >>>
Please respond to all.
Vera Karger, M.S., CCCS
Monroe, CT
vkargerslp at mac.com
On May 10, 2007, at 6:37 PM, Trudy Lynch wrote:
> Hi Irene,
> Thanks for your input into these discussions, they are very
> educational. Can you give more details about the Marek article you
> referred to (NEJM 2000)? I can't find it.
> Trudy
>
> Trudy Lynch
> Speech Pathologist
> Royal North Shore Hospital
> St Leonards NSW 2065
> Phone: (02) 9926 7741
> Fax: (02) 9926 6568
>
>>>> <dysphagia-request at dysphagia.com> 10/05/2007 23:37:14 >>>
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> Today's Topics:
>
> 1. logemann study (Wilma Clancy)
> 2. Logemann results (Irene Campbell-Taylor)
> 3. Re: Logemann Robbins results (Jai Gupta)
> 4. Logemann results and MBS (Irene Campbell-Taylor)
> 5. Re: Logemann results and MBS (Jai Gupta)
> 6. Results, research and opinion (Irene Campbell-Taylor)
> 7. Re: Results, research and opinion (Bill Connors)
> 8. Re: Logemann results and MBS (Shadd Lagrandeur)
> 9. Re: Logemann results and MBS (Irene Campbell-Taylor)
>
>
>
----------------------------------------------------------------------
>
> Message: 1
> Date: Wed, 09 May 2007 16:38:38 -0300
> From: "Wilma Clancy" <Wilma.Clancy at cdha.nshealth.ca>
> Subject: [Dysphagia] logemann study
> To: <dysphagia at dysphagia.com>
> Message-ID: <s641f920.077 at ngate01.cdha.nshealth.ca>
> Content-Type: text/plain; charset=US-ASCII
>
> I'd like to respond to the discussion regarding the Logemann study
> about
> aspiration of thick liquids. We must keep in mind that the
> participants
> in this study all had dementia, Parkinson's disease or Parkinson's
> disease with dementia. Therefore broad statements for all dysphagia
> patients are inappropriate.
>
> Furthermore, when you look at the definition of honey consistency in
> this trial of 3000 cP, we are in fact talking about what the
National
> Dysphagia Diet would call puree, not what most of us consider to be
> honey consistency as in the Novartis thickened liquids. When you
read
> the information with this in mind, we are talking about profoundly
> dysphagic patients not those that only aspirate thick liquids.
> Therefore, of course there is going to be more trouble with
pneumonia
> if
> the patient is aspirating puree rather than nectar consistency. I
am
> looking forward to reading this study. To my knowledge it has not
yet
> been published, (I recently did a search) but I have seen the
> presentation slides used by Dr. Logemann.
>
> Sincerely,
> Wilma Clancy
> Neurology Dietitian
>
>
> ------------------------------
>
> Message: 2
> Date: Wed, 9 May 2007 15:45:05 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley at yahoo.com>
> Subject: [Dysphagia] Logemann results
> To: Wilma.Clancy at cdha.nshealth.ca, dysphagia at b9.com
> Message-ID: <312708.71195.qm at web30212.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
> These are the patients most often found in LTC ? and the Parkinson?s
> with dementia is actually the parkinsonian stage of dementing
> illness. I
> don?t believe anyone has made general statements about all dysphagic
> patients ? simply that, contrary to popular belief, thickened
> fluids are
> aspirated, the thicker more than the thinner (as Perlman proved
years
> ago), and, as the authors say, it is probable that the lungs?
ciliary
> motion cannot clear the gum-based thickener used. If so, this would
> apply to all since lung function is not affected by dementing
illness.
> The importance of the findings is mainly to point out that the
almost
> universl belief that thickening prevents aspiration is false and
that
> dehydration is a constant danger.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 3
> Date: Thu, 10 May 2007 09:11:52 +1000
> From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
> Subject: Re: [Dysphagia] Logemann Robbins results
> To: <dysphagia at b9.com>
> Message-ID:
<88EEDD02C11B6A4182DD21E42394DCFE15556A at sesahs.nsw.gov.au>
> Content-Type: text/plain; charset=iso-8859-1
>
>
> Hi Everyone,
> Can anyone let me know if they observe pt aspirating on thickened
> fluid, will they prescribe thickened fluid? I think it common
clinical
> sense.. you won't....I really wonder if these patients can even
handle
> water or pureed food if they are aspirating on thickened
> consistency eg
> pudding consistency aspiration ..that is very severe dysphagia
..this
> person cannot live on water alone ..atleast I would keep the pt NBM,
> water sips for QOL if managed as per FWP and think of alternative
> feeding method. I think we tend to look for complex answers for time
> tested and simple clinical issue. We know that thickened fluid is
not
> good for all esp.. the randomised study by Dr Logemann etal last
> discussed showing clearly difference in PD, DAT etc...clearly
> demonstrated that. I really cannot understand why some people are so
> obsessed about not giving thickened fluid when there is clinical
> evidence on MBS's that it has some advantages in some cases..this is
> clinical fact..yes I agree we have !
> to be vigilant and see that we are choosing the right pts and
weaning
> them out as quickly as possible back to normal fluid. ta
>
>
>
> Jai Gupta. M.Sc.(S.H.) CPSP MSPA
> Manager, Speech Pathology Department
> The Sutherland Hospital
> * Locked Bag 21, Taren Point NSW 2229 Australia
> * +612 9540 7111 page 594 or Direct +612 9540 7558
> *+612 9540 7717 *+61 0401 373 324
> <mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
>
> A Thought
>
> You see things; and you say, "Why?" But I dream things that never
> were;
> and I say, "Why not?" ...... George Bernard Shaw
>
>
>
>
>
>
>
>
>
> -----Original Message-----
> From: dysphagia-bounces at dysphagia.com
> [mailto:dysphagia-bounces at dysphagia.com]On Behalf Of Irene
> Campbell-Taylor
> Sent: Thursday, 10 May 2007 1:23 AM
> To: Cameron, Sharon (R3); dysphagia at b9.com
> Subject: Re: [Dysphagia] Logemann Robbins results
>
>
> The already existing literature seems to argue that not enough
> water is
> supplied and that even when patients drink all of the thickened
fluids
> given, they still do not ingest/absorb enough water.
> Among other articles see:
> Inadequate fluid intakes in dysphagic acute stroke
> K.WHELAN
> Department of Nutrition and Dietetics, Kings College London, UK.
> (Correspondence to: KW, Research Dietitian, Department of
> Nutrition and Dietetics, Kings College London,150 Stamford Street,
> London, SE19NN, UK)
> Clinical Nutrition (2001) 20(5): 423?428
>
>
> "Cameron, Sharon (R3)" <Sharon.Cameron at rvh.nb.ca> wrote: As a
> Dietitian on the list, unfortunately I have not been privy to the
> ASHA information.
>
> My question for those familiar with the research is a question about
> the
> dehydration associated with thickened fluids.
>
>
>
> Is it a question that the fluid is bound by and therefore not
> available
> to the body once thickened (more of a concern with gel thickeners)
or
> is
> it a question that once recommended, patients do not drink adequate
> quantities of thickened fluids ?
>
> Any info greatly appreciated
>
>
> Sharon Cameron
> Registered Dietitian
> Stan Cassidy Centre for Rehabilitation
> 800 Priestman Street
> Fredericton, NB E3B 0C7
> 506-452-5652
>
>
> -----Original Message-----
> From: dysphagia-bounces at dysphagia.com
> [mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
> Campbell-Taylor
> Sent: Wednesday, May 09, 2007 11:57 AM
> To: dysphagia at b9.com
> Subject: [Dysphagia] Logemann Robbins results
>
> For those who have difficulty with the links, the following is taken
> from the original presentation at ASHA 2006:
>
> Major Findings
> Long term results show that despite differential effect of
> interventions on immediate elimination of aspiration in
> videofluoroscopic suite (Part I findings)......the 3-month incidence
> of
> pneumonia was similar for chin down posture compared to thickened
> liquids
>
> ( This, of course, emphasises again that what is seen on VFSS is not
> necessarily what happens in real life.)
>
> Adverse Events Hospitalization
> Dehydration
> (Presumably hospitalization for pneumonia and/or effects of
> dehydration.)
> Dehydration No difference in measured parameters Subset: n=16
> Serum osmolality
> Sodium
> BUN (mg/dL)
> Serum creatine (mg/dL)
> Defined by primary physician
> Was more frequent in thickened liquid arms (6% vs. 2%, p<0.05)
>
> Current Clinical Notion
> "The thicker the liquid, the safer the swallow"
> *Not true in patients who aspirate thick liquids - worse health
> outcomes
>
>
>
>
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
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> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
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> ------------------------------
>
> Message: 4
> Date: Wed, 9 May 2007 17:27:24 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley at yahoo.com>
> Subject: [Dysphagia] Logemann results and MBS
> To: Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU, dysphagia at b9.com
> Message-ID: <427506.97784.qm at web30205.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
> "I really cannot understand why some people are so obsessed
about
> not giving
> thickened fluid when there is clinical evidence on MBS's that it has
> some
> advantages in some cases"
>
> The Logemann study showed clearly that what happened on VFSS was not
> replicated in real life. That is the point. Whether or not the VFSS
> shows aspiration of thickened fluids or not, the end result is the
> same.
> One cannot extrapolate from a VFSS as to what will happen during a
> meal
> with real food and liquid.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 5
> Date: Thu, 10 May 2007 11:10:47 +1000
> From: "Jai Gupta" <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
> Subject: Re: [Dysphagia] Logemann results and MBS
> To: <dysphagia at b9.com>
> Message-ID:
<88EEDD02C11B6A4182DD21E42394DCFE15556B at sesahs.nsw.gov.au>
> Content-Type: text/plain; charset="iso-8859-1"
>
>
> Hi
> I agree everyone has a right to opinion, and I still think the
> issue if
> thickened fluid goes over board at times. I don't think there is
> enough
> evidence to support that in real practice use of thickened fluid
> should
> be obsolete, we know FWP is not for all clients. With our current
> practice I think we are doing well. Unless we know (large scale
> multicentre studies or data) what is documented level on Asp
Pneumonia
> in pt seen with thickened fluid and those without thickened fluid,
we
> cannot ascertain if thickened fluid bad. It is a complex issue. We
> have
> started collecting data on Performance Indicator on how many pts
> develop
> Asp Pneumonia(AP) after Speech Pathology interventions and
preliminary
> data on multicenter study shows on 618 pt only 18 developed and
> some of
> these already had AP and some were end stage QOL and not compliant
and
> some had PEG so Pneumonitis rather then AP. We are hoping in future
we
> will get more accurate data. I still take the stand thickened fluid
is
> a!
> useful intervention strategy if used cautiously and skilfully and
as
> a mean to reach the goal of restoring normal/ adequate swallow.
> Ta
>
>
> Jai Gupta. M.Sc.(S.H.) CPSP MSPA
> Manager, Speech Pathology Department
> The Sutherland Hospital
> * Locked Bag 21, Taren Point NSW 2229 Australia
> * +612 9540 7111 page 594 or Direct +612 9540 7558
> *+612 9540 7717 *+61 0401 373 324
> mailto:Jai.Gupta @ <mailto:Jai.Gupta@ sesiahs.health.nsw.gov.au>
> sesiahs.health.nsw.gov.au
>
> A Thought
>
> You see things; and you say, "Why?" But I dream things that never
> were;
> and I say, "Why not?" ...... George Bernard Shaw
>
>
>
>
>
>
>
> -----Original Message-----
> From: Irene Campbell-Taylor [mailto:eripley at yahoo.com]
> Sent: Thursday, 10 May 2007 10:27 AM
> To: Jai Gupta; dysphagia at b9.com
> Subject: Logemann results and MBS
>
>
> "I really cannot understand why some people are so obsessed
about
> not giving
> thickened fluid when there is clinical evidence on MBS's that it has
> some
> advantages in some cases"
>
> The Logemann study showed clearly that what happened on VFSS was not
> replicated in real life. That is the point. Whether or not the VFSS
> shows aspiration of thickened fluids or not, the end result is the
> same.
> One cannot extrapolate from a VFSS as to what will happen during a
> meal
> with real food and liquid.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
>
> _____
>
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> NOTICE
>
> NB: *** Due to an organisational amalgamation, email addresses for
> recipients in this organisation have changed. Please update your
> contacts list with the details of the email addresses contained
> within.
>
> This email, and the files transmitted with it, are confidential and
> intended solely for the use of the individual or entity to whom
> they are
> addressed. If you are not the intended recipient, you are not
> permitted
> to distribute or use this email or any of its attachments in any
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> also request that you advise the sender of the incorrect addressing.
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> This email message has been virus-scanned. Although no computer
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> were detected, South Eastern Sydney and Illawarra Area Health
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> accept no liability for any consequential damage resulting from
email
> containing any computer viruses.
>
> ------------------------------
>
> Message: 6
> Date: Thu, 10 May 2007 05:17:58 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley at yahoo.com>
> Subject: [Dysphagia] Results, research and opinion
> To: dysphagia at b9.com, Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU
> Message-ID: <203362.9769.qm at web30202.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
> I find it difficult to express just how infuriating it is to be told
> that my "opinion" is interesting or that "everyone is entitled to an
> opinion". In life, yes. In science, no. Opinion, by definition, is
a
> personal belief without proof. I don't believe I have ever expressed
> "opnion without proof" unless so stated. When faced with proof, it
is
> mandatory that one examine it carefully and adjust accordingly if
> it is
> valid. An opinion, in medicine and a dollar (unless it's Starbucks)
> will
> get you a cup of coffee.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
>
> ------------------------------
>
> Message: 7
> Date: Thu, 10 May 2007 08:26:32 -0400
> From: "Bill Connors" <bill at aphasiatoolbox.com>
> Subject: Re: [Dysphagia] Results, research and opinion
> To: "'Irene Campbell-Taylor'" <eripley at yahoo.com>,
<dysphagia at b9.com>,
> <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>
> Message-ID: <200705101226.l4ACQNsm023308 at boa.b9.com>
> Content-Type: text/plain; charset="windows-1250"
>
> Good Morning Irene.
>
> Good Lord Irene. I remember when I used to say, "That and a DIME
> will
> get
> you a cup of coffee." If I didn't feel so young you might make me
> feel
> old
> :-)
>
> And by the way, could you ever have imagined years a go that you
would
> have
> been paying 2 bucks for a cup of Joe?
>
> Bill Connors
> The Aphasia Center of Innovative Treatment
> bill at aphasiatoolbox.com
>
> -----Original Message-----
> From: dysphagia-bounces at dysphagia.com
> [mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
> Campbell-Taylor
> Sent: Thursday, May 10, 2007 8:18 AM
> To: dysphagia at b9.com; Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU
> Subject: [Dysphagia] Results, research and opinion
>
> I find it difficult to express just how infuriating it is to be told
> that my
> "opinion" is interesting or that "everyone is entitled to an
opinion".
> In
> life, yes. In science, no. Opinion, by definition, is a personal
> belief
> without proof. I don't believe I have ever expressed "opnion without
> proof"
> unless so stated. When faced with proof, it is mandatory that one
> examine it
> carefully and adjust accordingly if it is valid. An opinion, in
> medicine and
> a dollar (unless it's Starbucks)will get you a cup of coffee.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
> Dysphagia at dysphagia.com
> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
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>
>
> ------------------------------
>
> Message: 8
> Date: Thu, 10 May 2007 08:36:54 -0400
> From: "Shadd Lagrandeur" <slagrandeur at lrgh.org>
> Subject: Re: [Dysphagia] Logemann results and MBS
> To: "'Irene Campbell-Taylor'" <eripley at yahoo.com>,
> <Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU>, <dysphagia at b9.com>
> Message-ID: <000601c792ff$e3e1cb90$7d06a8c0 at practice.lrgh.org>
> Content-Type: text/plain; charset="us-ascii"
>
>
> " Whether or not the VFSS shows aspiration of thickened fluids or
not,
> the
> end result is the same. One cannot extrapolate from a VFSS as to
what
> will
> happen during a meal with real food and liquid."
>
> One cannot help but extrapolate from the evidence provided during an
> MBS....that is what we get paid to do. What actions should we take,
> otherwise? 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. If patients are aspirating thin
> liquids
> during the exam, and thick liquids at home, then they are obviously
> unsafe
> for PO. 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.
>
> 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.
>
> 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!
>
> Shadd LaGrandeur, MA, CCC-SLP
> LRGHealthcare Speech Pathology
> Program Coordinator
> 603-527-2888
>
> -----Original Message-----
> From: dysphagia-bounces at dysphagia.com
> [mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Irene
> Campbell-Taylor
> Sent: Wednesday, May 09, 2007 08:27 PM
> To: Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU; dysphagia at b9.com
> Subject: [Dysphagia] Logemann results and MBS
>
> "I really cannot understand why some people are so obsessed
about
> not
> giving
> thickened fluid when there is clinical evidence on MBS's that it has
> some
> advantages in some cases"
>
> The Logemann study showed clearly that what happened on VFSS was not
> replicated in real life. That is the point. Whether or not the VFSS
> shows
> aspiration of thickened fluids or not, the end result is the same.
One
> cannot extrapolate from a VFSS as to what will happen during a meal
> with
> real food and liquid.
>
> Dr I Campbell-Taylor
> Clinical Neuroscientist
> Exclusive Distributor:
> www.interactivetherapy.com
> _______________________________________________
> Dysphagia mail list: Normal and disordered swallowing information
> Dysphagia at dysphagia.com
> Manage subscription: http://lists.b9.com/mailman/listinfo/dysphagia
> Visit the new Dysphagia Web Forum: http://dysphagia.com/forum
>
>
>
>
>
>
> ------------------------------
>
> Message: 9
> Date: Thu, 10 May 2007 06:37:08 -0700 (PDT)
> From: Irene Campbell-Taylor <eripley at yahoo.com>
> Subject: Re: [Dysphagia] Logemann results and MBS
> To: Shadd Lagrandeur <slagrandeur at lrgh.org>,
> Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU, dysphagia at b9.com
> Message-ID: <21227.26492.qm at web30214.mail.mud.yahoo.com>
> Content-Type: text/plain; charset=iso-8859-1
>
>
>
> 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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> End of Dysphagia Digest, Vol 42, Issue 10
> *****************************************
>
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