Cassandra Kerr, MClSc, SLP
Grace Neubauer, MS, CCC-SLP
Stephanie Muñoz, MS, CCC-SLP
Erin Kamarunas, PhD, CCC-SLP
Meet our Team, here.
Here at TISLP we strive to provide SLPs with Evidence You Can Use to inform your clinical practice. We recognize that many of you are facing new constraints on the way you practice as a result of COVID-19. You may be limited by efforts to conserve personal protective equipment and to enforce strict infection control policies. You may be called on to use your knowledge and training to weigh the risks/benefits of our intervention in new ways. We are confident that you will continue to be a fierce advocate for your patients as you navigate this difficult situation.
To make this easier—and because we love connecting clinicians with science as efficiently as possible—we wanted to bring you the latest and most relevant research regarding COVID-19 and dysphagia.
The Bad News: Although it has been recommended that dysphagia screening should be mandatory for patients with critical COVID-19 post extubation, there is literally no research specifically addressing its impact on swallow function and safety.
The Good News: We can apply our existing knowledge related to dysphagia in the ICU to our current situation! To do this, we need to think critically about the symptoms of COVID-19 and the supportive therapies, and how those things might impact swallowing and aspiration risk.
With this in mind, here are some of the main considerations for increased risk of dysphagia and aspiration in patients with COVID-19:
We know that elevated respiratory rate (>25 breaths/min) and abnormal breath-swallow coordination are associated with increased risk of aspiration for both healthy and disordered populations (see here).
2) Respiratory Failure:
3) Cognitive Effects
Similarly to many of our typical patients in the ICU, patients with COVID-19 may develop neurological symptoms, such as delirium and altered level of consciousness, which can increase the risk for aspiration. And due to PPE shortages and/or staffing constraints, some of the normal supervision or assistance during meals might not be available, so paying attention to cognitive status in our assessment is as important as ever.
While many questions likely remain, we hope these considerations help you realize that the questions you are asking yourself with your patients with COVID-19 are the same questions you ask with any patient with respiratory compromise and altered mental status.
In the midst of this global pandemic, we acknowledge that research is limited and things are evolving rapidly. That is why we will be updating this post as new evidence becomes available. In the meantime, check out some of the resources we’ve found to be most helpful, below.
Also, these podcasts from the last month give some good perspectives:
Then for PPE issues:
If you have any questions on a COVID-19 and dysphagia that you haven’t found addressed elsewhere, please ask in the comments and we’ll let you know what we can find!
Take care, #MedSLPs.
Updates and Links, May 2020:
Bhatraju, P.K., Ghassemieh, B.J., Nichols, M., Kim, R., Jerome, K., Nalla, A.K., Greninger, A.L., Pipavath, S., Wurfel, M.M., Evans, L., Kritek, P.A., West, E., Luks, A., Gerbino, A., Dale, C.R., Goldman, J.D., O’Mahony, S., Mikacenic, C. (2020). Covid-19 in critically ill patients in the Seattle region—Case series. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2004500
Brodsky, M., Levy, M.J., Jedlanek, E., Pandlan, V., Blackford, B., Price, C. ,Cole, G., Hillel, A., Best, S., Akst, L. (2018). Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000003368
Brodsky, M., Nollet, J., Spronk, P., Gonzalez-Fernandez, M. (2020). Prevalence, pathophysiology, diagnostic modalities and treatment options for dysphagia in critically ill patients. American Journal of Physical Medicine and Rehabilitation. https://doi.org/10.1097/PHM.0000000000001440
Carda, S., Invernizzi, M., Bavikatte, G., Bensma ̈ıl, D., Bianchi, F, Deltombe, T… Molteni, F. (2020). The role of physical and rehabilitation medicine in the COVID-19 pandemic: the clinician’s view. Annals of Physical and Rehabilitation Medicine. https://doi.org/doi:10.1016/j.rehab.2020.04.001
Coghlan, K., Skoretz, S.A. (2017). Breathing and swallowing with high flow oxygen therapy. Perspectives of the ASHA Special Interest Groups. https://doi.org/10.1044/persp2.SIG13.74
Kangelaris, K.N., Ware, L.B., Wang, C.Y., Janz, D.R., Zhuo, H., Matthay, M., Calfee, C.S. (2016). Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000001359
Kim, M.J., Park, Y.H. ,Park, Y.S., Song, Y.H. (2015). Associations between prolonged intubation and developing post-extubation dysphagia and aspiration pneumonia in non-neurologic critically ill patients. Annals of Rehabilitation Medicine. https://doi.org/10.5535/arm.2015.39.5.763
Leder, S., Suiter, D., Warner, H.L. (2009). Answering orientation questions and following single-step verbal commands: Effect on aspiration status. Dysphagia. https://doi.org/10.1007/s00455-008-9204-x
Lee, J.M., Bae, W., Lee, Y.J., Cho, Y-J. (2014). The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000000122
Madison, M., Wimbish, T., Clark, B.J., Benson, A.B., Burnham, E.L., Williams, A., Moss, M. (2011). Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Critical Care. https://doi.org/10.1186/cc10472
Marvin, S., Thibeault, S., Ehlenbach, W.J. (2019). Post-extubation dysphagia: Does timing of evaluation matter? Dysphagia. https://doi.org/10.1007/s00455-018-9926-3
Richardson, S., Hirsch, J., Narasimhan, M. (2020). Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with Covid-19 in the New York city area. The Journal of the American Medical Association. https://doi.org/10.1001/jama.2020.6775
Steele, C., Cichero, J.A.Y. (2014). Physiological factors related to aspiration risk: A systematic review. Dysphagia. https://doi.org/10.1056/NEJMoa2004500
Vasilevskis, E.E., Han, J.H., Hughes, C.G., Ely, E.W. (2012). Epidemiology and risk factors for delirium across hospital setting. Best Practice & Research Clinical Anaesthesiology. https://doi.org/10.1016/j.bpa.2012.07.003
Wu, Y., Xu, X., Chen, Z., Duan, J., Hashimoto, K., Yang, L., Liu, C., Yang, C. (2020). Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain, Behavior, and Immunity. https://doi.org/10.1016/j.bbi.2020.03.031