Pneumonia and its Discontents

I anxiously began last night to read a book just published (6/6/16) – and, like W.C. Fields with the Bible, I was looking for loopholes. MULTIPLE SCLEROSIS: Coping with Complications (Archway Publications) is Dr. Barry Farr’s perspective on his 24-year dialogue with the disease. Farr is Professor Emeritus of Internal Medicine, with specialties in infectious disease and epidemiology, at the University of Virginia. I was a year behind Barry Farr at our Mississippi Delta high school, and was sponsored by him into a social fraternity at the University of Mississippi back in the day.  Farr has done pivotal research and published on such topics as surveillance of Methacillin-resistant Staphylococcus Aureus (MRSA), alternating air pressure wheelchair cushions, and the use of silver-coated urinary catheters by hospital patients . 

                                                                                                                                                                                                                                                                                                                                                                                                                                The Society for Healthcare Epidemiology of America (SHEA), has since 2006 awarded the “Barry Farr Award” to the author of the most outstanding paper published each year in their house journal, Infection Control and Hospital Epidemiology. So, this author has serious chops for clinical observation and research methodology, and he has applied them to present to the reader, strategies to help the MS survivor increase her/his quality of life. But, why am I looking for loopholes in Farr's narrative?

In Chapter 31, "Preventing Pneumonia", Farr says that a treatment for dysphagia that involves exercise lends little to any prevention effort: "There doesn't yet seem to be consistent evidence from randomized trials documenting significantly lower rates after swallowing exercises" (p. 252). He is taking food out of the mouths of my grand dogs, might be my stereotypical statement on this issue. That's right, my child has dogs. Yet to date, there is no evidence that exercise based treatment makes a significant difference in the bodily impairment; that is, the efficiency of swallowing for persons with MS. Exercise may instead, make a difference in phenomena that impact the swallow. One example of a correlated phenomenon is the cough. As Farr comments at the beginning of this chapter, "Vigorous coughing in a patient already suffering severe pain....also makes the pain worse with each cough" (p. 247).

 

Speech-language pathology would argue that exercise-based rehabilitation of speech and swallowing impairments, holds some promise. For example, expiratory muscle strength training (EMST) is a treatment modality enjoying a lot of research interest, and that may hold promise for increased cough control (Sapienza and Troche, 2012, pp. 56-57). Cough suppression therapy may also contribute to increased success with non-pharmacological management of the condition (Chamberlain, Garrod and Birring, 2013).

But Farr leaves some valuable observations as well, about how his attention to his posture; his rate per swallow; his sustaining attention on the swallowing act, rather than switching focus to and from his social connections at mealtimes; and heightened interest in oral care, with emphasis on flossing - all these strategies implemented, raise the odds for success in pneumonia prevention. Some of these strategies are discussed in refereed journals (Langmore and colleagues, Dysphagia, 1998), and others are reported anecdotally by clinical 'grunts on the line' like this writer. 

I joked earlier that Dr. Farr's comments about speech-language pathology were impacting my livelihood. That really is not a worry of mine. Earlier in my career, I felt doctors were casting aspersions on the field to such a degree - something need be done. One of my prized possessions is a handwritten letter from the late Oliver Sacks; it was his response to my rather heavyhanded critique of his piece "Recalled to Life" in The New Yorker (10/31/2005). Aphasia, treated by MUSIC THERAPY?? I calmed down after receiving Sacks' thoughts on the matter. All is forgiven, Brother Barry. Good job. 

SELECTED REFERENCES: 

1. Sapienza, Christine M., and Troche, Michelle S.  RESPIRATORY MUSCLE STRENGTH TRAINING: Theory and Practice. San Diego: Plural Publishing, 2012.

2. Chamberlain, Sarah, Garrod, Rachel and Birring, Surinder S., "Cough Suppression Therapy: Does It Work?", PULMONARY PHARMACOLOGY AND THERAPEUTICS, 26 (5), March 2013, 1-4.

3. Langmore, Susan E., et al. "Predictors of Aspiration Pneumonia: How Important Is Dysphagia?", DYSPHAGIA, 13 (1998), 69-81.