Brief Answer:
Urgent Supportive care and Replacements with absent swallowing in elderly

Detailed Answer:
Hello,

Welcome to Health Care Magic.

Thanks for writing.

I am Dr.Saddiq ul Abidin. I have read your question completely, I understand your concern and will try to help you in best way possible.

From the kind of details and summary, you have put in the "Medications tried" section , it appears that you have been through alot already, as far as the work up and management is concerned, regarding your wives issues, so I would not go into much details and queries regarding the onset of her illness, and the kind of tests and therapeutic measure she has uinderg one by now.

But based on the symptoms you have described, which she is experiencing right now, it seems that her bulbar palsy has caused her, to be unable to swallow or drink foods, the way health individuals can, so it is evident by the facts you mentioned, that she might be under nourished, and is not getting her required calorie requirements, needed per day by an adult body.

Also that, the decreased intake of fluids are contributing to a decreased turgor and lost skin tone. I don't know whether have she developed symptoms like sunken eyes or decreased urinary output? or not? but she is already on the verge of developing complications of dehydration and kidney damage if not corrected promptly.

Also that her essential vitamins, protein energy and mineral requirements are likely to be getting compromised, which needs replacements at its own with supplements and multi-vitamin medications.

If she is continuously getting a compromised intake through mouth, she can have an Naso- gastric tube placed as an alternative, so that meshed up foods or semi solids, diluted in fluids can be given, via that tube and her essential needs can be met temporarily.

She might need Intra-vascular fluid replacements with Dextrose or saline waters. All these needs, can be met in your rural set up in a local GP Clinic, or some nearby rural health facility. Your GP might need to see status of her electrolytes and kidney function tests, so that fluid replacements can be based on those.

For more long standing purposes PEG intubation through skin directly into stomach might be needed, if gag or swallowing reflexes are completely lost and temporary tubes cant be kept for long standing purposes, owing to increased risks of infections.

After managing these urgent needs of her supportive treatment, you can pursue with the plans to visit UCSF, to see a neurologist to get a detailed evaluation of your wife and based on the detailed history and work up next steps of management can be decided.

I hope this answered your question.If you have more queries I am happy to answer. Otherwise rate before closing the discussion

Regrads.

Dr.Saddiq ul Abidin
M.B.B.S(Licensed Family Physician)
Resident Medicine.

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Brief Answer:
HBOT precautions and SLP as part of supportive management options

Detailed Answer:
Thanks for sharing the details and keeping me apprised of the situation. Well, based on the new information, you have shared there are certain issues, which need to be discussed separately.

The role of HBOT in neural conditions is still not proven, and mostly is taken out as experimental modality, offered to the patients. So before going through all such procedures, you need to bear these facts in mind.

Now, since she is on PEG tube, so the question of undergoing HBOT with PEG tube comes. The only absolute and strict contradiction to HBOT is; pneumothorax (air around lungs, pressing the lungs already). Other conditions, are considered to be relative contraindications. This means in short, that in the case of your wife, risks should be weighed with benefits, by the treating doctor, before making her go through the whole procedure. Also the access of PEG tube should be sealed off completely and around site of insertion, there shouldn't be enough scars or deficient tissue, which can let high pressure gas fill into the stomach. So with strict precautions, yes she may undergo that, but final verdict will be of treating doctor, who has already been treating her.

Now regarding her inability to push the piston. As it is related to involve, the muscles of palate and throat along with blowing off air from lungs, so a synchrony between all these has to be there, which is at the moment deficient in your wife, owing to the nature of the disease. But it will improve gradually with a continuous usage.

As far as, rest of the options are concerned, A proper speech learning pathologist can guide in a sophisticated way, with all the methods, whether, psycho-stimulating, motivational, electrical or mechanical devices and other methods involved, and you need to discuss them in detail and have regular sessions with.

Thanks for your patience. Hoping your wife a better recovery and fast treatment outcome, as you are already leaving no stone unturned, to get her back to a normal life and your efforts are commendable. Kindly rate me before closing the discussion. For that purpose, you can visit my profile here and can write a feedback here: http://doctor.healthcaremagic.com/doctors/dr-saddiq-ulabidin/70164
Regards.

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