[Dysphagia] Disagreement

[eripley at yahoo.com (Irene Campbell-Taylor)]

There may be no disagreement at all ? it probably is aspiration pneumonia BUT caused by aspiration of saliva (the usual cause) not food or fluid.  The patient is going to aspirate saliva chronically and there is nothing that can be done about it except get on the physician?s case about having mouth care done properly. Any such discussion must, of course, be accompanied by evidence of which there is, thankfully, a great deal.  When the situation is explained to the family i.e. it is vitally important to maintain nutrition and hydration so that the patient has a chance of resisting the possible infection caused by the aspiration of saliva, things change. The question of unsuspected pneumonitis followed by a bacterial superinfection has to be addressed with the physicians as this is a common scenario in patients with diabetes, PD, GERD etc. etc. There is an excellent article by Dr Tom Marrie that makes the points very well. The abstract is:
   
  Pneumonia in the long-term-care facility.

Marrie TJ. Infect Control Hosp Epidemiol. 2002 Mar;23(3):159-64

Walter C. Mackenzie Health Sciences Center, Edmonton, Alberta, Canada.

Pneumonia is a common infection among residents of long-term-care facilities (LTCFs), with an incidence of 1.2 episodes per 1,000 patient-days. This rate is believed to be six- to tenfold higher than the rate of pneumonia among elderly individuals living in the community. The risk factors for pneumonia among residents of LTCFs are profound disability, bedridden state, urinary incontinence, difficulty swallowing, malnutrition, tube feedings, contractures, and use of benzodiazepines and anticholinergic medications. An elevated respiratory rate is often an early clue to pneumonia in this group of patients. Staphylococcus aureus (including methicillin-resistant S. aureus) and aerobic gram-negative bacilli (including multidrug-resistant isolates) are more frequent causes of pneumonia in this setting than in the community. Criteria have been developed that help identify patients for treatment in their LTCFs.
   
  In addition, see:
  DePaso WJ Aspiration pneumonia. Clin Chest Med, 12:269-84.1991.  
   
  The clinical presentation and course of chemical pneumonitis after inhalation of gastric contents ranges from mild and self-limited to severe and life-threatening, depending on the nature of the aspirate and the underlying condition of the host. Unless there is witnessed inhalation of vomit, diagnosis is difficult and requires a high index of suspicion in a patient who has risk factors for aspiration. The sudden onset of an illness characterized by dyspnea, cyanosis, and low-grade fever associated with diffuse rales, hypoxemia, and alveolar infiltrates in lower lung lobes should suggest aspiration of stomach contents. Bacteria usually play no role in the initial lung injury, and antibiotics should be withheld until there is evidence of superinfection, usually caused by aspiration of saliva. Preventive measures should be employed in patients at high risk for  aspiration of reflux or vomitus. Patients with unexplained chronic respiratory syndromes should be evaluated for
 gastric regurgitation.


Dr I Campbell-Taylor
Clinical Neuroscientist
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