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:
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Dyspnea:

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).

• Ask yourself: Is your patient short of breath? Is their respiratory rate >25 breaths/min? If the answer is yes, then risk for dysphagia and subsequent aspiration is elevated.

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Respiratory Failure:

1. High flow oxygen therapy: We don’t know a lot about the effect of high flow oxygen therapy on swallowing function and safety (yet!), but some expert clinicians and researchers caution that high flow O2 may increase the risk of dysphagia and aspiration, especially for higher flow rates (for a good overview of the research, see Breathing and Swallowing With High Flow Oxygen Therapy). But that doesn’t mean “high flow = no go”. It means we must consider the patient's underlying condition and assess aspiration risk and dysphagia management on a case by case basis.
2. Intubation: Current data shows that a majority of COVID-19 patients admitted to the ICU require mechanical ventilation (see here and here). As SLPs, we know that critical illness and intubation can increase the risk of dysphagia (for a good overview of the research, see Prevalence, Pathophysiology, Diagnostic Modalities and Treatment Options for Dysphagia in Critically Ill Patients), and that longer intubations may result in worse outcomes (see here and here). While there is a growing body of research on post-extubation dysphagia, there is still no consensus for when or how to assess these patients. But here’s some food for thought: based on the results of this study, (and our review of it, here) Marvin et al. suggested that although some patients may be safe to start an oral diet within a few hours after extubation, delaying the assessment by 24 hours may allow patients to return to a less restrictive diet.​​ Ask yourself: Was my patient intubated? If the answer is yes, then risk for dysphagia and aspiration is elevated. And if they were intubated for more than a week, then the clinical signs of dysphagia may be more severe.

A quick side note: We know there has been some conversation regarding the potential impact of prone positioning during mechanical ventilation (vs. traditional supine positioning) on swallowing safety. Unfortunately, there is no research on this at this time, but if you want to hear some expert clinicians in our field discuss proning (risk of laryngeal injury; the role of the SLP), check out the additional resources at the bottom of this page.

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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.

Ask yourself:

• Can my patient answer specific orientation questions and follow single-step commands? If the answer is no, then risk for aspiration is elevated (see here).
• Will my patient be able to follow compensatory swallow strategies without assistance or supervision during meals (because of limited PPE)? If the answer is no, then this will inform your dysphagia management plan. 
• See our Ask TISLP on cognition, too!

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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. ​
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Additional resources

• If you’re looking for a comprehensive review of the research related to COVID-19 and dysphagia, Karen Sheffler, MS, CCC-SLP, BCS-S did that, and it's amazing! Her post brings together the relevant research on characteristics of COVID-19, how the symptoms and supportive therapies might affect swallowing and aspiration risk, and expert opinions on practice issues in the face of limited imaging and PPE. Seriously, if you want a comprehensive discussion, it’s the best we’ve found. 
• A video by Luis F. Riquelme, Ph.D., CCC-SLP, BCS-S of the National Foundation of Swallowing Disorders regarding the role of SLP in this pandemic.
• The National Foundation of Swallowing Disorders’ list of international guidelines and resources, compiled by Rinki Varindani Desai, MS, CCC-SLP.
• The Dysphagia Research Society's COVID-19 Resource Page is also excellent for keeping up-to-date.
• For guidance on using telehealth for dysphagia management check out this website by Georgia Malandraki, PhD, CCC-SLP, BCS-S. 
• See this and this, for information on aerosol-generating procedures, from RCLT.
• Then also see this Zoom call, Dysphagia Service Delivery Considerations in Healthcare Settings, presented by ASHA Special Interest Group 13 (Swallowing and Swallowing Disorders). Some topics include: the SLP’s changing role, direct v. indirect assessment, telepractice, and the value of a clinical swallow exam.
• And here's a really good presentation on managing dysphagia in the ICU.

Also, these podcasts from the last month give some good perspectives:  

• Down the Hatch—The Swallowing Podcast: COVID Era and SLP dysphagia therapy: Listen to nine experts discuss their opinions about the “essential-ness” of SLP intervention in a variety of settings and across the country.
• The Swallow Your Pride Podcast:
  • At the Table with Martin Brodsky and Paula Leslie, A Conversation on COVID-19: Another perspective about how SLPs are adapting their practice. Speakers discuss prioritization and triage. Some discussion about cognitive changes and effects of proning resulting in possible laryngeal injury.
  • A Dive into Decision Making and Delivery of Care with Kelsey Day, M.S., CCC-SLP: A discussion around dysphagia management considerations and suggestions for COVID-19 patients, including SLPs role in proning patients and documentation tips.
• Speech Uncensored: SPECIAL COVID Convo with Brooke Richardson, MS, CCC-SLP More discussion about our role with COVID patients, including significant limitation of MBS and FEES. Check out a list of resources that Brooke compiled, here.

Then for PPE issues: 

• Due to PPE shortages across the country, you may face difficult decisions in how to prioritize your caseload. George Barnes MS, CCC-SLP, aka Dysphagia Dude, provides some advice about making these decisions here, posted on the Dysphagia Cafe website.
• ASHA has provided us some guidance about recommended PPE in relation to COVID-19 that can serve as a good resource to figure out what equipment you will need.

In the midst of this global pandemic, we acknowledge that research is limited and things are evolving rapidly. We’ll continue to provide updates on COVID and dysphagia every single month. 

​Take care, Med SLPs.
 

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 [open access]
 
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 [open access]

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  [available to ASHA SIG members]
 
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  [open access]
 
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  [open access]
 
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  [open access]
 
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 [open access]
 
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  [open access]
 
Vasilevskis, E.E., Han, J.H., Hughes, C.G., Ely, E.W. (2012). Epidemiology and risk factors for delrium 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

Written by:
Cassandra Kerr, MClSc, SLP
Grace Neubauer, MS, CCC-SLP
Stephanie Muñoz, MS, CCC-SLP

​Edited by:
Erin Kamarunas, PhD, CCC-SLP