Irene Campbell-Taylor is correct that dysphagia can be a symptom of a wide variety of conditions; however, our article1 specifically discusses dysphagia as a result of central neurologic conditions, in this case stroke, and we do not think that the context would be misconstrued by our audience.
Campbell-Taylor hopes that by the term “overnight intravenous fluid administration” we actually meant hypodermoclysis, which she characterizes as “the long-term hydration method of choice.” Hypodermoclysis2 is a fine method of hydration that unfortunately has not yet caught on to a significant degree in Canadian hospitals, and it would have been a good choice for fluid administration. However, given the typical evolution of dysphagia, fluids may not be required for a prolonged period, so it was not necessary to choose a long-term method.
Campbell-Taylor also emphasizes that aspiration pneumonia must be differentiated from aspiration pneumonitis. Marik3 distinguished these 2 entities but noted that “some overlap exists.” When a patient presents to the emergency department with a history of stroke, dysphagia and bona fide infiltrates on radiography, as in the case described, we feel that antibiotics would be indicated, especially given the “sick” state (hyperglycemia, hypertension) exhibited by the case patient. We agree that it is bacteria in the saliva that usually cause pneumonia and that “scrupulous mouth care” is appropriate.
Finally, Campbell-Taylor states that our patient's pneumonia could not have been due to aspiration of saliva and disagrees with the management decision to withhold food by mouth. However, if significant dysphagia is noted by nursing, medical, or speech and language pathology staff members, and cognition is suspect, then “NPO” management is, in our opinion, clinically indicated.
Fred Saibil notes that many physicians have “remained completely unaware” of Heimlich's technique of swallowing retraining. We will be looking into this limited literature in the future.
Roy Preshaw notes that there is little evidence to support the use of tube feeding as a means to reduce the risk of aspiration pneumonia. As he points out, aspiration pneumonia occurs no matter what type of tube is inserted because oropharyngeal secretions, which may be colonized, are the culprits. However, tube feeding will improve nutrition and hydration status. It is unlikely that a research study will be undertaken to compare enteral nutrition with intravenous feeding, as Preshaw suggests, because stroke patients almost always have a functional gut and there is no justification for submitting them to the more complex method of parenteral nutrition. We certainly agree that there is a need for good randomized quality-of-life studies of stroke patients with dysphagia and are encouraged that our article has engendered such excellent discussion.
Hillel M. Finestone Associate Professor Division of Rehabilitation Medicine University of Ottawa Ottawa, Ont.