Dysphagia Characteristics of Patients Post SARS-CoV-2 During Inpatient Rehabilitation

Dysphagia Prevalence and Outcomes Associated with the Evolution of COVID-19 and Its Variants in Critically Ill Patients

Data collected during the 2020-21 COVID-19 alpha wave indicated dysphagia prevalence rates up to 93%. Whilst many patients recovered during hospital admission, some experienced persistent dysphagia with protracted recovery. To explore (1) prevalence, (2) treatment, and (3) recovery patterns and outcomes for swallowing, in the ICU patient with Delta and subsequent variants of COVID-19. Prospective observational study. Patients admitted to 26 Intensive Care Units (ICUs) over 12 months, diagnosed with COVID-19, treated for survival and seen by Speech-Language Pathology (SLP) for clinical swallowing assessment were included. Demographic, medical, SLP treatment, and swallowing outcome data were collected. 235 participants (63% male, median age = 58 years) were recruited. Median mechanical ventilation was 16 days, and ICU and hospital length of stay (LOS) were 20 and 42 days, respectively. ICU-Acquired Weakness (54%) and delirium (49%) were frequently observed. Prevalence of dysphagia was 94% with the majority (45%) exhibiting profound dysphagia (Functional Oral Intake Scale = 1) at initial assessment. Median duration to initiate oral feeding was 19 days (IQR = 11-44 days) from ICU admission, and 24% received dysphagia rehabilitation. Dysphagia recovery by hospital discharge was observed in 71% (median duration = 30 days [IQR = 17-56 days]). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU LOS, and duration to SLP assessment (p = 0.000), dysphagia severity (p = 0.000), commencing oral intake (p = 0.000), dysphagia recovery (p < 0.01), and enteral feeding (p = 0.000). Whilst older participants had more severe dysphagia (p = 0.028), younger participants took longer to commence oral feeding (p = 0.047). Dysphagia remains highly prevalent in ICU COVID-19 patients. Whilst invasive ventilation duration is associated with swallowing outcomes, more evidence on dysphagia pathophysiology is required to guide rehabilitation.

Functional improvements of patients admitted to an inpatient rehabilitation facility after bilateral lung transplant due to severe COVID-19 pulmonary disease

BACKGROUND

Coronavirus disease (COVID-19) has introduced a new subset of patients with acute end-stage lung damage for which lung transplantation has been successfully performed.

OBJECTIVE

To describe the inpatient rehabilitation course of patients who underwent bilateral lung transplant due to severe COVID-19 pulmonary disease.

DESIGN

Retrospective chart review.

SETTING

Free-standing, academic, urban inpatient rehabilitation hospital.

PARTICIPANTS

Seventeen patients aged 28-67 years old (mean 53.9 ± 10.7) who developed COVID-19 respiratory failure and underwent bilateral lung transplant.

INTERVENTIONS

Patients participated in a comprehensive inpatient rehabilitation program including physical, occupational, and speech therapy tailored to the unique functional needs of each individual.

MAIN OUTCOME MEASURES

Primary outcome measures of functional improvements, include mobility and self-care scores on section GG of the Functional Abilities and Goals of the Improving Post-Acute Care Transformation Act, as defined as quality measures by the Centers for Medicare and Medicaid Services. Other functional measures included 6 minute walk test, Berg balance scale, Mann Assessment of Swallowing Ability (MASA), and Cognition and Memory Functional Independence Measure (FIM) scores. Wilcoxon signed rank sum test was used to evaluate statistical significance of change between admission and discharge scores.

RESULTS

Fourteen patients completed inpatient rehabilitation. Self-care (GG0130) mean score improved from 20.9 to 36.1. Mobility (GG0170) mean score improved from 30.7 to 70.7. Mean 6-minute walk distance improved from 174.1 to 467.6 feet. Mean Berg balance scores improved from 18.6/56 to 36.3/56. MASA scores improved from 171.3 to 182.3. All functional measures demonstrated statistically significant improvements with p value ≤ .008, except for cognition and memory FIM scores, which did not show a statistically significant difference. A majority (76%) of patients discharged home.

CONCLUSION

This new and unique patient population can successfully participate in a comprehensive inpatient rehabilitation program and achieve functional improvements despite medical complications.

Implications of COVID-19 in Airway and Swallowing Function

Objective

The acute treatment and complications of the novel COVID-19 virus have been well studied, but the implications of this novel virus for swallowing function continue to be investigated. The goal of this study is to retrospectively assess airway and swallowing outcomes for those patients who required intensive care unit(ICU)-level care for COVID-19 infection.

Study Design

Comparison of swallowing outcomes through diet change in COVID-19 patients in the Ochsner-Louisiana State University (LSU) Hospital ICU.

Setting

Ochsner-LSU Hospital (Shreveport, Louisiana).

Methods

A retrospective chart review was performed from March 2020 to May 2022 to identify patients with a primary diagnosis of COVID-19. Variables analyzed include age, gender, length of intubation, length of ventilation, airway interventions, use of extracorporeal membrane oxygenation, and diet prior to, during, and after hospitalization for COVID-19 infection.

Results

Two hundred and seven patients fit the inclusion criteria. There was a significant difference in discharge diet between those patients who were intubated and those who were not (P = .007). Thirty percent of patients were discharged on a different diet than their baseline with patients on a nonregular diet significantly more likely to discharge to a facility (P = .043). Negative vaccine status was associated with prolonged ICU stay, prolonged duration of intubation, and prolonged duration of ventilation.

Conclusion

COVID-19 continues to present novel challenges with new implications and outcomes being discovered in the third year of the pandemic. Further research is necessary to determine the most effective treatment approaches with respect to optimized speech and swallow outcomes.

Is Postextubation Dysphagia Underestimated in the Era of COVID-19? A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the incidence rate of postextubation dysphagia (PED) in patients with COVID-19, as well as relative factors potentially influencing the clinical course of dysphagia.

DATA SOURCES

Six databases including PubMed, MEDLINE, Embase, ScienceDirect, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched with no restriction on the language.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Data were extracted and cross-examined among 3 of the authors. The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of the PED incidence rate. Subgroup analyses, sensitivity analyses, and metaregression were also performed to identify the heterogeneity among the studies.

RESULTS

A total of 594 patients were enrolled and analyzed from the 10 eligible studies. The weighted incidence of PED in patients with COVID-19 was 66.5% (95% CI: 49.7%-79.9%). Age was the potential factor influencing the incidence rate after heterogeneity was adjusted by the metaregression analysis.

CONCLUSION

Compared to the current evidence reporting only 41% of the non-COVID patients experienced PED, our study further disclosed that a higher 66.5% of COVID-19 patients suffered from PED, which deserves global physicians' attention. With the association between COVID-19 and dysphagia having been more clearly understood, future clinicians are suggested to identify intubated patients' risk factors earlier to strengthen PED care programs in the era of COVID-19.

Implementation of a free water protocol at a long term acute care hospital

This feasibility study aimed to trial a Free Water Protocol (FWP) for patients with thin liquid dysphagia in the Long-Term Acute Care Hospital (LTACH) setting. Patients with dysphagia are often prescribed thickened liquids to avoid or mitigate aspiration. While this clinical intervention can minimize the risk of aspiration pneumonia (PNA), it is generally not well received by patients. As such, the goal of this study was to determine if patients who knowingly aspirate thin liquids can safely tolerate thin liquid water, and if so, to what degree of benefit. The study assessed for adverse events, fluid intake, hydration status, quality of life, and overall swallow function outcomes. These measurements were taken over a 7 day trial period using inventories, lab work, clinical judgment, and observation. Ten participants were enrolled in this study with 9 having sufficient data for analysis (n = 9). No adverse events related to the FWP were observed, and patients saw improved total fluid intake (P = 0.0074), swallow-related quality of life (P = 0.0273), and overall swallow function (P = 0.0002). The results in this feasibility study allowed for the hospital wide implementation of the FWP and laid out the groundwork for future studies looking at longitudinal effects of a FWP.

Prevalence of oropharyngeal dysphagia and risk of mortality among hospitalized COVID-19 patients: A meta-analysis

Background

Post-extubation and neurologic complications in COVID-19 patients have been shown to cause oropharyngeal dysphagia (OD). We performed the first meta-analysis to explore and estimate the pooled prevalence of OD, risk of mortality, and associated factors among hospitalized COVID-19 patients.

Methods

We searched Scopus, PubMed, Embase, CINAHL, WHO COVID-19 database, and Web of Science for literature on dysphagia in COVID-19 patients. We used the generalized linear mixed model (GLMM) to determine the prevalence estimates of OD in the R software and the DerSimonian-Lard random-effects model in the Comprehensive Meta-Analysis software to explore the risk of mortality and associated factors of OD, presented as odds ratios (ORs) and corresponding 95% confidence intervals (CIs). We used Cochran's Q, τ², and the I² statistic to assess heterogeneity and conducted a moderator analysis to identify moderator variables.

Results

We included eighteen studies with a total of 2055 participants from the 910 studies retrieved from electronic databases. The prevalence of OD among hospitalized COVID-19 patients was estimated at 35% (95% CI = 21-52; low certainty of evidence) associated with a high risk of mortality (OR = 6.41; 95% CI = 1.48-27.7; moderate certainty of evidence). Intubation (OR = 16.3; 95% CI = 7.10-37.3; high certainty of evidence), use of tracheostomies (OR = 8.09; 95% CI = 3.05-21.5; high certainty of evidence), and proning (OR = 4.97; 95% CI = 1.34-18.5; high certainty of evidence) among hospitalized COVID-19 patients were highly associated with developing OD. The prevalence of OD was higher among hospitalized COVID-19 patients who were admitted in intensive care units (ICU), intubated, and mechanically ventilated.

Conclusions

The prevalence of OD among hospitalized COVID-19 patients is estimated at 35% associated with a high risk of mortality. OD assessment among hospitalized COVID-19 patients who are managed in an ICU, prone position, intubated, and mechanical ventilated deserves more attention.

Registration

PROSPERO CRD42022337597.

Current opinion of presentation of dysphagia and dysphonia in patients with coronavirus disease 2019

PURPOSE OF REVIEW

Dysphagia and dysphonia are common presentations of both acute and long coronavirus disease 2019 (COVID-19). The majority of peer-reviewed publications in 2020 and early 2021 were expert guidance and consensus statements to support dysphagia management in multidisciplinary teams while protecting clinicians and patients from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. This review discusses dysphagia and dysphonia primary data published in 2021-2022, focusing on patient presentations, pathophysiology, and evidence for interventions.

RECENT FINDINGS

Clinicians and researchers amassed knowledge of the cross-system presentation of dysphagia and dysphonia in patients with COVID-19, from severe disease requiring ICU stays to those with mild-to-moderate disease presenting to outpatient clinics. Pre-COVID-19 health status, hospitalization experience, presence of neurological symptoms, and impact of the virus to the upper aerodigestive and respiratory system need consideration in patient management. Long-term dysphagia and dysphonia manifested from COVID-19 require otolaryngologist and speech-language pathologist input.

SUMMARY

Changes in immunity through population vaccination and variations in COVID-19 from SARS-CoV-2 mutations means prevalence data are challenging to interpret. However, there is no doubt of the presence of long-term dysphagia and dysphonia in our clinics. Long-term dysphagia and dysphonia are complex and a multidisciplinary team with a tailored approach for each patient is required.