The Channel Sounds

My dad has Parkinson disease. There is a do-not-resuscitate directive on the refrigerator. My mother is his caretaker.

For now, Dad sits in his chair, leaning so far to the right that it looks as though he might just tumble out. His body can no longer hold him upright. The chair’s electronic components lift him to a standing position. He used to love electronic gadgets, though this is one he would not have wished for.

My dad has diminished cognition, vision, and hearing; his high-volume earphones play books on tape. Does he really follow the story? Or does he listen for our sake? If nothing else, it lets us believe he takes pleasure in the stories we play for him.

My dad has a Parkinson disease My mother is his caretaker, and she is often tired. The four rooms of their fastidious home are scattered now with the things that keep him going. Pill bottles and organizers line the new, almond Formica countertops: Stalevo for parkinsonism, Zoloft for depression, Seroquel for drug-induced psychosis, Miralax for constipation. Alarms remind my mother to measure his blood pressure and give the pills. At night, he wears foam-rubber booties to protect his heels from rubbing against the sheets and causing blisters. And there’s the stainless-steel walker; a hospital bed; and two wheelchairs, adorned with matching back and seat cushions, one for indoors and one for outdoors.

Researchers assessed the prognostic meaning of dyspnea in patients presenting for radionuclide stress testing. Based on their responses to questions about dyspnea and chest-pain symptoms, patients were classified into five groups: asymptomatic; non-anginal chest pain; a typical angina; typical angina; and dyspnea without chest pain. Over a 10-year period, nearly 18,000 patients at a Los Angeles medical center were enrolled. Patients with dyspnea were older than those with chest pain and had more comorbidities and classic risk factors, including left ventricular hypertrophy. During a mean follow-up of 2.7 years, rates of both death from any cause and death from cardiac causes were significantly (2 to 3 times) higher in patients with dyspnea than in any of the other groups, even than in patients with typical angina.

This finding held true in patients with and without known coronary disease. After controlling for numerous risk factors, dyspnea remained a significant independent predictor of death. An editorialist notes that diastolic dysfunction, which was not measured in this study, is known to decrease survival, even in the absence of heart failure. The editorialist cautions that “cardiac symptoms other than chest pain are of value in identifying patients . . . who should undergo functional testing.”

Any artificial airway increases the risk of aspiration. Potential complications of aspiration include hypoxemia, chemical pneumonities, pulmonary infection, mechanical pneumonities, pulmonary infection, mechanical obstruction, atelectasis, adscess, fibrosis, and respiratory distress syndrome; death also can result.

A speech therapies can perform a bedside swallowing evaluation to look for signs of aspiration; if necessary, videofluoroscopy can be performed. One recent study compared the realibility of the bedside colored dye test with that of videofluoroscopy for detecting aspiration in patients with tracheostomies. Both test indicated aspiration reliably, but the colored dye test had a high false-negative rate.

Silent aspiration (aspiration without the normal cough reflex) can occur. Moreover, the presence of dysphagia appears to have poor predictive value. In a study of 93 patients with neurologic disorders, silent aspiration occurred in 20% of patients who had no complaints of swallowing difficulties and in 49% of those with dysphhagia. Patients who require prolonged endotracheal intubation or tracheostomies tend to develop decreased sensation of the airway, and that too may increase the risk of the silent aspiration, as a  literature review conducted by Pannunzio has suggested.