[Dysphagia] nasal regurg. question

[pressmah at sjhmc.org (Pressman, Hilda)]

Thank you for your well thought out and, as usual, reasonable position.  It
is always a pleasure to read your postings.  Hilda Pressman

-----Original Message-----
From: Vikki Stefans [mailto:vstefans@george.ach.uams.edu]
Sent: Friday, April 30, 2004 7:36 PM
To: Nelson, Amy
Cc: 'dysphagia@b9.com'
Subject: Re: [Dysphagia] nasal regurg. question


Well, despite some comments very much against the reflexive or automatic
use of thickened liquids (which I would also oppose BTW) it could be worth
a try. Empirical treatment for reflux is a good start, but since that is
not enough it won't hurt to try using nectars, nutritional supplements,
soy drinks, etc. instead of thin liquids with meals.

Now Irene, before you electronically bite my head off :-) though I also
do not have true research data, I have patients, in and out, who are
healtheir in terms of lung function (inpatients who can't wean off the
vent until we modify the diet, other who don't need as much RT,
outpatients come back saying that now that they thicken they don't catch
anything that comes down the pike). My patients are younger ones and
perhaps are not as averse to drinking thicker liquids as some older
adults. I have not even come close to needing to put anyone on
hypodermoclysis yet, they are either getting adeqautely hydrated PO or
have a GT to fall back on. I have probably more children who take a little
soft or pureed by mouth and all of their liquids by tube.

I am looking forward to Dr. Logemann's research results, because I do
realize that "the plural of anecdote is not data!" (who said that by the
way???)  But you did once also admit that "the absence of evidence is not
evidence of absence."  I do worry at times that some of the less
experienced therapists may get the idea that thickening had no role and
should never be used. No treatment or technique applied indiscriminately
or mindlessly will work for everyone, of course, but thickeners do have a
role at least for some of my patients. And again, it can't be
overemphasized that the risk re thickened vs thin liquids is rarely if
ever the risk of catastrophic aspiration (I am very fed up with hearing
about people who think someone is going to isntatnly die if they get 10%
or so of a substance down the wrong pipe, and act accordingly) but more
chronic in nature. The risk of catastrophic aspiration is in the case of
trying to swallow something that needs chewed when you can't, chugging a
huge amount of fluid impulsively, of having a big bolus of pocketed food
fail to trigger a swallow and end up largely in the lungs. Or of course,
aspiration of emesis.

That said, I did lose one of my favorite patients with severe CP to lung
disease at age 19, and have another with bronchiectasis at age 8. Both had
been well medicated for reflux and just had the unfortunate "blessing" of
not overtly coughing and choking with their untreated (family refused,
just did their own version of chest PT after meals) and undetected
dysphagia, respectively.

I did have one teenager recently who hated thickener and whose problems
were relatively mild and improving, though real, and she was
immunosuppressed due to treatment for leukemia and had just gotten over a
rip-roaring sepsis and pneumonia. She was terribly "non-compliant" and our
S&LP on the case just about freaked when I said OK, lets do a water
protocol. But it worked out very well, under close inpatient supervision
anyways, and her dysphagia fortunately improved before she went home.

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 Thu, 22 Apr 2004, Nelson, Amy wrote:

> Hi everyone - I would really appreciate any input/ideas re: this man!  He
is
> in his late thirties and has a severe intellectual disability, is
> non-verbal, uses a few signs expressively & has a lot of diffiuclty
> following directions without a lot of support.  He has had a cleft palate
> repaired sometime in the past and has only a few teeth at the front of his
> mouth, which, coupled with poor self monitoring and generally poor oral
> control makes chewing pretty difficult!  He is currently on a soft diet,
> leaning towards minced/mashed with thin fluids - he does cough a few times
> per meal, but my main difficulty is that he is experiencing a fair bit of
> discomfort due to nasal regurgitation.  He won't cooperate for an MBS so I
> can't see what's actually going on, but this is what the clincial signs
are
> pointing to. I can't get a decent look inside his mouth and have requested
> an ENT consult to check on the integrity of his cleft repair which will
have
> to be done under GA, but I'm guessing that it's primarily a problem of
poor
> soft palate function...if this is the case, what can be done???  He
suffers
> from chronic rhinorrhea (treated with antihistamines) and rubs his nose
all
> the time and frequently holds onto it during meals.  He is currently being
> treated for helicobactar pilori and has a fairly persistant dry cough.  He
> wouldn't be able to follow directions to employ any compensatory strategy
or
> do any exercises and there's no way he would tolerate any orthodontic
> intervention...any other options???
> Thanks,
> Amy


The information contained in this message may be privileged and confidential
and protected from disclosure. If the reader of this message is not the
intended recipient, or an employee or agent responsible for delivering this
message to the intended recipient, you are hereby notified that any
dissemination, distribution or copying of this communication is strictly
prohibited. If you have received this communication in error, please notify
us immediately by replying to the message and deleting it from your
computer. Thank you. 

_______________________________________________
Dysphagia mailing list
Dysphagia@b9.com
http://lists.b9.com/mailman/listinfo/dysphagia