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Dr. David
Dr. David, Board Certified Physician
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Mom is in ICU with the result of improper dysphagia

Customer Question

Mom is in ICU with the result of improper dysphagia management. She had trouble breathing because of the secretions and was intubated Tuesday in the ER. Since then the IVU has weaned her twice and extubated; she does fine for about half a day (6 hrs) after
removal before suffering an event that requires reintubation. It is unclear whether it is a sudden onset of thick secretions coming up that she is not strong enough to dislodge on her own or more of a case of inflammation. They do apparently suction her out
but maybe not effectively. So, she goes for 5-8 hours off the vent just fine, with or without oxygen, and then suddenly becomes hypoxic. I would assume steroids for airway inflammation and mucus thinners, as she is used to with her home nebulizer, for secretions.
We do not know if either of these remedies has been tried or when. They seem to just see if she's going to be fine. That's not happening. How can this critical juncture post-extubation be eased? At 92, she is not a high priority and the doc seems to want us
to allow her to suffocate next time. She was alert and participatory, mostly. This last time she may have been too dopey to cough, even, which is always weak. Additional: would a mucus thinner that is not in mist form, such as a heavy-duty "Mucinex," be a
good idea, since the problem seems to be that 1) the mucus is so thick it can't be easily removed through their suction devices, and 2) besides her own dysphagia issues, on top of that she now has "intubation dysphagia," so she can't either swallow or cough
it up successfully? Or would perhaps a tracheotomy be a short-term solution, because it makes it easier to suction out deep mucus without re-intubation being the only remedy? They do not seem to do any postural adjustments while off the tube, such as put her
on her side so the whole airway isn't impinged upon. I do not know about PT such as percussion, etc. (you'd think there would be some kind of deep vibratory therapy to help dislodge this mucus.) I find it hard to believe that there is no remedy for choking
on your own phlegm What kind of specialist deals with this? In the elderly or even with just stroke patients or, say, veterans with traumatic brain injuries? Are any associated with hospitals around the SF Bay Area or Savramento/Stockton? They want to cease
re-intubation, which would mean death by choking the next time it happens. Mom was on a puréed diet with thickened liquids and did well with that. She fed herself and went on outings, etc. (see pic from 6/26 at aquarium). It was being given thin liquids in
bed by straw and recently reducing the nebulizer treatments to "on demand" that caused this incident, I'm pretty sure.
Submitted: 2 years ago.
Category: Medical
Expert:  Dr. David replied 2 years ago.
This is Dr. David
has she had a barium swallow study to see if she is aspirating on her feedings?
Customer: replied 2 years ago.
Yes. It shows clearly dysphagia due to vocal fold problems. Delayed closure, with some proportion of thin liquids inevitably going into her lungs instead of stomach.
I got her a course of VitalStim rehab therapy and it really helped. She was able to resume living as before in assisted living with puréed diet and nectar-thick liquids.
They did a swallow even this time that showed dysphagia again, but that was also after the first two day plus intubation, which I hear doesn't help the swallow mechanism.
Customer: replied 2 years ago.
I will need to call them soon. My hope is that they will just keep her on the vent until tomorrow, when I can see if there is a specialist available. Also because they are pushing to just let her expire next time they extubate her and she "fails" by clogging up after a few hours. There has been NO anti-inflammatory treatment and NO postural adjustment and NO systemic mucus-thinning medication so far. And she can't cough it up. What solutions might there be, then?
Nebulizer treatments are every four hours. Is that enough?
Is a trach a good short-term solution, just for better deep suctioning, or would that devise have too small a Camila to be any better than what they can use now, through the nose or in the intubation tube?
Is a water wash a good solution, with regular suctioning, short term, and what would be a longer-term solution u til I can get her to a SNF for rehab, care?
These are my kinds of questions. We've seen and done the pro-forma stuff and it has not been sufficient, so far, since she clogs up with thick deep mucus after a few hours off the vent, causing re-intubation.
Customer: replied 2 years ago.
I called. They are not planning to extubate her again overnight. She is alert and fine. On low dose presadex for anxiety. Low grade fever, @ 100. Continuous tube feeding of hi protein glucerna. Has lost maybe 4-5 lbs since beginning, from 103 to 98. Watching tv with company. Has a uti treated with vancomycin. BP under control. 48 hrs to culture for new bacteria. Before there was none, from lungs. Lungs clear unless there's a sudden lump of mucus that pools there until it comes up, for tries to without success. They always a manage to clear it, I guess, and x ray come back clear.Tomorrow is a regular week again. If they won't re-intubate her, that's a death sentence by default and suffocation, so I'd like to move her to a Snf with intense SLT,ASAP, on or off the vent.
What do you think?
Customer: replied 2 years ago.
Haven't heard anything from you except the q about barium swallow study.
Expert:  Dr. David replied 2 years ago.
sorry about the delay.
yes, I was suspecting that she was aspirating.
if she is aspirating that much, she needs to not be eating.
she needs a PEG tube placed and she needs to be placed on PEG feedings and enteric feedings through the PEG tube
that is why when she has been extubated before, she eats foods and it goes into her lungs and then she goes back needing to be intubated
she really needs to be NPO or nothing by mouth.
a tracheostomy will take away her ability to speak and can irritate her throat and cause her to cough as well
Customer: replied 2 years ago.
When extubated, she does not eat by mouth or any other way. The reason she chokes is that too-thick secretions pool after about five or six hours after the tube is taken out, and then at some point it starts to come up (maybe cilial action?) but she can't cough it out, because she is too weak and hasn't used her throat while intubated. So it becomes a clog and they re-intubate in order to both open up the airway again to prevent suffocation and to allow a suction tune to get down that far.They have done a bronchial wash that way, as well, perhaps to just get a culture but perhaps to also make it easier to get the mucus out.It isn't aspiration. It is a mucus plug from pooled self-generated secretions.While re-intubated, after the first such incident only, they started giving her liquid nutrition down the tube. That is basically protein-enhanced Glucerna. While that might be also a mucus producer, it happened before she was ever given nutrition, so it must be from the tube itself or some other reaction, not food or drink. She did fine with a puréed diet and thickened liquids. Only when she was given thin liquids in bed lying down with a straw did this occur, and that is why she is in the ICU.Is there a stronger agent for mucus dispersal or thinning than mucu-mist, given every four hours or so through the vent?Also, she has no problem breathing on her own, and they are leaving the air off in the vent much of the time (from 5:30 to 20:30 pm today). It's there for the choking (hypoxia) that happened twice some hours after they take the tube out. And, if it's out, they won't feed her.Why can't they put in a "clean-out" under the larynx that's closed most of the time but allows access for suction if needed? Sounds like a good idea, even if not possible for some reason.She wants to go out and do things, which doesn't seem like it would go with enteric feeding. And, she did fine with a dysphagia diet plus nebulizer every six hours or less.
Expert:  Dr. David replied 2 years ago.
yes, she should be on a scopolamine patch
also anti histamines like benadryl can help dry secretions
she can also try atrophine drops in her mouth to dry secretions as well.
she actually should be on all 3 of these agents.
talk to her ICU doctors about all of three of these agents to help dry up secretions.