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[Dysphagia] Logemann results and MBS
What one is paid to do is identify the cause of the problem
It's the physician's job to identify the cause of the problem. I believe
it's my job, with respect to swallowing, to provide a piece of the puzzle
and propose recommendations to limit the impact of that piece on the entire
puzzle.
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.
Wouldn't you agree that aspiration would point to poor dynamics? Why use
the test if there's nothing to be extrapolated from it? There are obviously
certain aspects that cannot be evaluated and a negative exam does not mean
that the patient doesn't aspirate. Give me a reason why I shouldn't think
that a patient aspirates regular liquids, when he/she aspirated barium? I
have received referrals for patients who have aspirated during a UGI that
did not aspirate during an MBS, and likely do not aspirate on a regular
basis. However these patients are often laying down or told to drink fast.
Dr. Logemann recommended avoiding honey thick (3000cp) liquids at all cause.
What about pudding that mixes with saliva, or pumpkin pie after it's been
thoroughly chewed. So basically if you're aspirating, you're better off
aspirating nectar rather than honey, but if you're eating a variety of
foods, aren't you bound to be swallowing something "honey thick"?
Shadd LaGrandeur, MA, CCC-SLP
LRGHealthcare Speech Pathology
Program Coordinator
603-527-2888
_____
From: Irene Campbell-Taylor [mailto:eripley at yahoo.com]
Sent: Thursday, May 10, 2007 09:37 AM
To: Shadd Lagrandeur; Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU; dysphagia at b9.com
Subject: RE: [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. \ <file:///\\at>
*** 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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