[A case of serious aspiration pneumonia associated with multiple cerebral infarctions and Alzheimer's disease followed by hospital and home care service team].

A 81-year-old man, who had been diagnosed in multiple cerebral infarction and Alzheimer's disease, was followed up in his local clinic since 1997. He had been bedridden before admission, but could eat. He was admitted with severe aspiration pneumonia in December 1999. Since severe dementia and dysphagia were noted after admission, he was examined to find out whether or not he could swallow while the treatment of his pneumonia was conducted at the same time. The water swallowing test indicated a risk of aspiration, thus, percutaneous endoscopic gastrostomy was performed on January 26, 2000 after the completion of the treatment for pneumonia. Although the patient's condition was complicated by aspiration pneumonia, enteral feeding through the gastric fistula gradually became successful, and he was discharged in June 2000. His family physician followed him up by visiting at home to examine and observe his general physical condition including consciousness, vital signs, skin and respiration, while taking measures in cooperation with the local health care visiting nurse. The patient, thereafter, was repeatedly admitted and discharged because of exacerbation and remission of symptoms, including coughing, sputum and fever, probably caused by aspiration pneumonia. When he was admitted in December 2001, which was his sixth admission, since there were troubles with the infusion tube and frequent gastroesophageal reflux, the gastric fistula management was judged to be a great burden on the patient. In January 2002, the gastrostomy tube was removed and the patients, whose alimentation was managed using intra-venous hyperalimentation (IVH), was discharged. Besides periodic visits by his family physician, a 24-hour house visit system was introduced to control his IVH and deal with his family members' anxiety. His general condition, thereafter, has not markedly changed. The patient has continuously received medical treatment for 14 months after being discharged and his condition is stable.

[The usefulness of the water swallowing test and videofluorography in swallowing rehabilitation in patients with cerebrovascular disease].

It has been suggested that videofluorography (VF) is useful in the diagnosis of aspiration. The aim of this study was to investigate the usefulness of the water swallowing test and VF in swallowing rehabilitation in patients with cerebrovascular disease. Fifteen patients (mean age 72.9 +/- 2.3 years) were examined. The swallowing abnormality was assessed by the water swallowing test and VF. Patients with abnormal swallowing function on the water swallowing test (Group A, n = 4) showed aspiration and silent aspiration into the trachea on VF. However, patients suspected of dysphagia on the water swallowing test (Group B, n = 11) could swallow, demonstrating the disappearance of silent aspiration, with pooling of barium in the piriform sinus on VF. All patients in Group A could not ingest any food by mouth and received percutaneous endoscopic gastrostomy or intermittent oro-esophageal tube feeding. The swallowing function in Group B improved after swallowing rehabilitation. All patients in Group B could ingest food by mouth. These findings suggest that the water swallowing test is useful for quantitative assessment of swallowing disorder and for deciding on therapy of swallowing function.

[A case of chronic obstructive pulmonary disease (COPD) followed by pulmonary rehabilition].

We report a 75-year-old woman with chronic obstructive pulmonary disease (COPD) suffering from cough, sputum, high-grade fever and dyspnea on effort. Her chest radiograph revealed an infiltrative shadow in the right lower lung field and her laboratory data showed marked inflammatory changes. Her arterial blood gas analysis showed marked hypoxemia and hypercapnia. After her laboratory data and general condition improved, we performed pulmonary rehabilitation for the patient for about 6 weeks. The program consisted of pursed lip breathing, diaphragmatic breathing, muscle stretch gymnastics, and walking. The 6-minute walking test distance increased from 170 m to 280 m. The minimum SpO2 during the 6-minute walking test increased from 88% to 91%. (O2 3 L/m) After discharge, she continued to receive home care from a visiting nurse specialized in respiratory medicine and 24 hour-monitoring of O2-compliance at home. She has not experienced acute exacerbation or re-hospitalization for 1 year. We conclude that home care service is effective to maintain stable conditions such as state of breathing, SpO2, vital signs, and activities of daily living for elderly COPD outpatients.