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[DYSPHAGIA] Adult with MR who is NPO with s/s of aspiration with saliva
Karen
There are several elements in this gentleman?s history
that are common in the population at large and even
more so in those with developmental disabilities (DD)
to the point of being almost typical.
There are several items that point to a virtually
certain GER:
He has severe DD and the incidence/prevalence of GER
in this adult population is approximately 85%.
He has scoliosis/kyphosis, both of which put excess
pressure on the stomach, exacerbating GER.
He has a chronic cough ? the most classic symptom of
GER. It is usually missed because, as in this case, it
seems to appear first after a viral infection. It is
then attributed to post-nasal drip when the
differential for chronic cough is 1) respiratory
infection, 2) post nasal drip and c) GER. The
medication for the sinusitis/rhinorrhea does not
appear to be having effect, leaving the most likely ?
GER.
He is on enteral feeding. The major hazards of PEG
feeding are reflux and aspiration pneumonia.
Severe reflux, as he almost certainly has, causes
sinusitis/otitis when it rises above the pharynx as it
tends to do during sleep.
Hypersalivation is also a sign of chronic GER.
One must be very careful with PEG feeding in such a
patient. Residuals must be checked regularly and, if
more than 75% of what was previously fed, all feeding
must be stopped until the stomach empties.
Gastroparesis is also a significant danger with such a
patient and little can be done as the typical
medications e.g. metoclopramide and domperidone cause
parkinsonism.
As he is already neurologically vulnerable,
scopolamine may cause severe side effects.
There is already pressure on the stomach from his
skeletal problem. Care must be taken to avoid any
extra pressure to diminish the risk of reflux.
Baclofen can be extremely hard on the gut and would
require careful administration and monitoring. As he
is reported to be spastic only at times, why is
baclofen being considered? He also has
cerebellar/brain stem impairment and it may not be
particularly useful.
Control of reflux in such a patient is very difficult.
The standard treatment is to raise the head of the bed
by about 25% but as he is scoliotic/kyphotic,
positioning will be difficult. Perhaps Occupational
Therapy could help here.
Adding fluid is likely to overfill the stomach,
further increasing the risk of reflux.
Hypodermoclysis would be the hydration method of
choice but I understand that Medicare won?t pay for
it.
This is a common but very difficult situation.
It is still possible to obtain cisapride in certain
locations. This is the most effective drug for the
treatment of reflux but one would have to determine
whether or not it was possible to obtain it in your
location. Without that, treatment is very difficult.
The PPIs such a Losec etc. we now know have
breakthrough production of acid during sleep and
really don?t prevent reflux ? they simply eliminate
the production of stomach acid so as to decrease the
risk of damage to the esophagus. Gaviscon q.i.d. is
sometimes effective and certainly the least hazardous
option.
Irene.
=====
www.dricampbell-taylor.com
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