Management of dysphagia

In the final section, "The case revisited," the authors state that "Mr. B's pneumonia is a strong indicator that aspiration occurred. His pneumonia is a probable sequela of aspirating saliva. Mr. B is not allowed to have anything by mouth when he is admitted to hospital."1 Finestone and [Linda Greene-Finestone] have missed the obvious at several levels. The patient's "pneumonia" on admission was certainly the result of aspiration but could not have been due to aspiration of saliva (bacterial pneumonia). The solution is not to give him nothing by mouth but instead to identify the real cause of the problem and ensure scrupulous mouth care while maintaining good nutrition and hydration. [Hillel M. Finestone] and Linda Greene-Finestone1 note that "if the risk of aspiration is high, enteral nutrition (tube feeding) should be provided." Unfortunately, there is little evidence to support the implication that enteral nutrition through a tube reduces the risk of aspiration pneumonia. Tube feeding does not afford protection against aspiration of oropharyngeal secretions, which may be colonized. The incidence of aspiration pneumonia is similar in subjects fed by nasogastric tube, gastrostomy or postpyloric tube.2-6 None of the cited studies compared the incidence of aspiration pneumonia among subjects receiving enteral nutrition with that among patients fed intravenously. [Irene 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.