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Communications to the Editor |

Morale and Depression in Patients Treated Surgically for Intractable Aspiration FREE TO VIEW

Shinji Teramoto, MD, FCCP; Kaori Kon, MD; Yuji Iwasaki, MD
Author and Funding Information

Affiliations: Medical Research Center International University of Health and Welfare Tokyo, Japan Yotsugi Medical Center for the Severely Disabled, Tokyo, Japan,  Kumamoto University School of Medicine Kumamoto, Japan

Correspondence to: Shinji Teramoto, MD, FCCP, 3-35-14-305 Ikebukuro, Toshima-Ku, Tokyo, Japan 171-0014.



Chest. 2000;118(2):564-565. doi:10.1378/chest.118.2.564-a
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To the Editor:

In a recent issue of CHEST (November 1999), Takano and coworkers1 demonstrated that surgical therapy to prevent aspiration improved the depression and mood of patients with intractable aspiration and their families.

In principle, to prevent aspiration pneumonia, the alimentary routes are changed to enteral routes, requiring nasogastric tube feeding and gastrostomy.2 However, as suggested by Takano et al,1 the bypasses from stomach to nostrils by the tubes may contribute to the development of aspiration pneumonia.34 It has been reported that even a smaller size of nasogastric tube did not prevent or reduce microaspiration in patients receiving mechanical ventilation.4Because silent aspiration and swallowing disorders are very important elements in the pathogenesis of aspiration pneumonia and/or nosocomial pneumonia in patients with stroke and pulmonary disease,59 the prevention of aspiration is very important for the management of repetitive lower respiratory tract infections in patients with dysphagia. Because medical therapies and swallowing rehabilitation cannot always control the incidence of recurrent aspiration pneumonia in patients with dysphagia, laryngectomy and laryngotracheal separation could be choices for the management of intractable aspiration.

Although the efficacy of the surgical therapies has been determined conventionally in terms of physical condition and the rate of aspiration pneumonia, the variables of health-related quality of life (HRQOL), including morale, depression, mood, and energy, have not been assessed comprehensively, in either patients with dysphagia or their families. The therapeutic strategies to prevent aspiration are usually determined by the families, since the patients are often suffering from stroke, brain damage, and intellectual disabilities. The current study gives us very important information regarding the decision-making process for determining a therapeutic strategy for intractable aspiration.

Although Takano et al1 demonstrated that all their patients and families were satisfied with the surgical results, we do not think that mood and depression are always improved by the surgical procedures. In our experiences, the mothers of young adult patients with cerebral palsy and mental retardation experienced ambivalent moods. A 20-year-old woman with cerebral palsy and mental retardation was admitted to our hospital because of wheeze, cyanosis, fever, and dyspnea. She was intubated for the management of acute respiratory failure due to pneumonia. This was the second time she required mechanical ventilation in 1 year. Because of repetitive aspiration pneumonia, we persuaded her mother to permit us to perform laryngotracheal separation on her daughter. After the surgery, the patient did not experience serious respiratory tract infections. However, the mother was not completely happy. The self-depression score of the mother ranged from 50 to 60. Although she recognized the surgery as successful, the aphonia of her daughter was annoying to the mother.

Generally, we agree with the authors that laryngotracheal separation and laryngectomy are appropriate choices for prevention of aspiration pneumonia in selected patients with dysphagia. However, the variables of HRQOL are not always improved by these procedures in patients and their families. Because the HRQOL is affected by many factors, including social function, economic status, family members, and disease state, the satisfaction with or depression resulting from the surgical procedures is very complicated in patients with dysphagia. Many patients with dysphagia and their families may exhibit different emotions and HRQOL. The choices of laryngectomy or laryngotracheal separation for the treatment of recurrent aspiration pneumonia should be carefully considered in younger patients with dysphagia.

References

Takano, Y, Suga, M, Sakamoto, O, et al (1999) Satisfaction of patients treated surgically for intractable aspiration.Chest116,1251-1256
 
Finucane, TE, Bynum, JP Use of tube feeding to prevent aspiration pneumonia.Lancet1996;348,1421-1424
 
Rello, J, Sonora, R, Jubert, P, et al Pneumonia in intubated patients: role of respiratory airway care.Am J Respir Crit Care Med1996;154,111-115
 
Ferrer, M, Bauer, TT, Torres, A, et al Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients.Ann Intern Med1998;130,991-994
 
Farrell, Z, O’Neill, D Towards better screening and assessment of oropharyngeal swallow disorders in the general hospital.Lancet1999;354,355-356
 
Chan, ED, Welsh, CH Geriatric respiratory medicine.Chest1998;114,1704-1733
 
Teramoto, S, Matsuse, T, Fukuchi, Y, et al Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia [letter]. Lancet. 1999;;353 ,.:1243
 
Teramoto, S, Matsuse, T, Ouchi, Y Foreign body aspiration into the lower airways may not be unusual in older adults [letter].Chest1998;113,1733-1734
 
Teramoto, S, Matsuse, T, Ouchi, Y Clinical significance of cough as a defense mechanism or as a symptom in elderly patients with aspiration and diffuse aspiration bronchiolitis [letter].Chest1999;115,602-603
 
Katayama, F, Miura, H, Sunaoshi, W, et al Successful total laryngectomy in three cases with severe motor and intellectual disabilities syndrome for the management of repetitive lower respiratory tract infections.No To Hattatsu1999;31,415-421
 
To the Editor:

Teramoto et al present some interesting arguments concerning our article in CHEST in November 1999.1 As they point out, direct, face-to-face communication with patients and their families is very important, especially for younger patients (for example, their patient with cerebral palsy). However, we should consider not only medical indications but also other factors, such as psychosocial, economical, and patient’s individual status, when we select the surgical therapy for intractable aspiration.

Previously, four important factors were proposed in a practical approach to ethical decisions,2 namely: (1) medical indication; (2) patient’s preference; (3) quality of life (QOL); and (4) contextual features. All of the patients in our study fulfilled the medical indication for surgical therapy because of severe intractable aspiration. In addition, informed written consent to loss of speech was received from each patient, and each patient decided his or her own therapy. Furthermore, there were no problems with contextual features. We think that patients and their families were not satisfied with surgical therapy alone to improve patients’ QOL, unless the other three factors were also fulfilled. These four factors are related to each other, and a patient’s satisfaction leads to the family’s satisfaction.

We believe that a patient’s desire for oral intake of food and the ability to taste food are the most important factors when making a decision about surgical therapy.1 Therefore, a decision to use surgical therapy for the treatment of intractable aspiration should be considered carefully, according to the various conditions of each patient, especially in the case of younger patients.

In conclusion, our studies show that the patient’s QOL improves very well if we select the cases suitable for surgical therapy.

References
Takano, Y, Suga, M, Sakamoto, O, et al Satisfaction of patients treated surgically for intractable aspiration.Chest1999;116,1251-1256
 
Jonsen, AR, Siegler, M, Winslade, WJ Introduction. Jonsen, AR Siegler, M Winslade, WJ eds.Clinical ethics: a practical approach to ethical decisions in clinical medicine 3rd ed.1992,1-12 McGraw-Hill. New York, NY:
 

Figures

Tables

References

Takano, Y, Suga, M, Sakamoto, O, et al (1999) Satisfaction of patients treated surgically for intractable aspiration.Chest116,1251-1256
 
Finucane, TE, Bynum, JP Use of tube feeding to prevent aspiration pneumonia.Lancet1996;348,1421-1424
 
Rello, J, Sonora, R, Jubert, P, et al Pneumonia in intubated patients: role of respiratory airway care.Am J Respir Crit Care Med1996;154,111-115
 
Ferrer, M, Bauer, TT, Torres, A, et al Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients.Ann Intern Med1998;130,991-994
 
Farrell, Z, O’Neill, D Towards better screening and assessment of oropharyngeal swallow disorders in the general hospital.Lancet1999;354,355-356
 
Chan, ED, Welsh, CH Geriatric respiratory medicine.Chest1998;114,1704-1733
 
Teramoto, S, Matsuse, T, Fukuchi, Y, et al Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia [letter]. Lancet. 1999;;353 ,.:1243
 
Teramoto, S, Matsuse, T, Ouchi, Y Foreign body aspiration into the lower airways may not be unusual in older adults [letter].Chest1998;113,1733-1734
 
Teramoto, S, Matsuse, T, Ouchi, Y Clinical significance of cough as a defense mechanism or as a symptom in elderly patients with aspiration and diffuse aspiration bronchiolitis [letter].Chest1999;115,602-603
 
Katayama, F, Miura, H, Sunaoshi, W, et al Successful total laryngectomy in three cases with severe motor and intellectual disabilities syndrome for the management of repetitive lower respiratory tract infections.No To Hattatsu1999;31,415-421
 
Takano, Y, Suga, M, Sakamoto, O, et al Satisfaction of patients treated surgically for intractable aspiration.Chest1999;116,1251-1256
 
Jonsen, AR, Siegler, M, Winslade, WJ Introduction. Jonsen, AR Siegler, M Winslade, WJ eds.Clinical ethics: a practical approach to ethical decisions in clinical medicine 3rd ed.1992,1-12 McGraw-Hill. New York, NY:
 
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