The SLP Role in the Rehab of COVID19
This truly is not that new, it is actually what we do!
The COVID19 virus moves down the respiratory tract, through the mouth, nose, throat, and lungs. The lower airway has more ACE2 receptors than the rest of the respiratory tract, therefore COVID-19 is more likely to go deeper than more common viruses like the common cold. Speech-language pathologists who work with people with dysphagia need to be ready! We are entering a new era and increased area specialty of iatrogenic dysphagia. This is difficulty swallowing caused by a medical treatment or treatments, such as prolonged intubation and/or traumatic intubation.
On March 30, 2020, Bhatraju, et al. (2020) reported on 24 critically ill people in the Seattle area, showing that 75%* needed mechanical ventilation. The earliest that an individual was extubated (removal of the breathing tube) was 8 days. (We have heard anecdotal reports of people requiring up to 14 days). Bhatraju commented on how a typical indicator of age did not seem to matter, as the age range of those intubated was 18 to 88 years. A multivariable analysis in the Marvin, et al. (2018) study showed that age (>65) was significantly associated with SILENT aspiration. We must keep in mind that age may be a risk factor for post extubation dysphagia during the COVID recovery process and we should be more cautious regarding the risk for silent aspiration in those with COVID over 65? But doing dysphagia evaluations without a Modified Barium Swallow Study, how do you really know for sure?
What are the pattern of deficits with post-extubation cases?
There is not one standard protocol to resource for exactly how and when to evaluate this population of patients who were extubated after requiring intubation and ventilation for 48 hours or more. They are all different and it is dependent on the patient’s current and past medical history. The length of intubation can vary from 4 days to 4 weeks. This applies to all patients 18 to 88. One thing remains the same though, speech pathologists should be consulted on these patients after extubation. During the COVID crisis the CDC guidelines came out with the recommendations to avoid any endoscopic procedures and this included FEES due to the high risk of infection spread. It is our job to educate our physicians on post extubation dysphagia considerations, and to delay at least 24 - 48 hours before a bedside assessment, given the likelihood and enhanced risk for laryngeal sensory deficits and damage. NG tubes should remain in place upon extubation for proper access to adequate fluid intake and critical medications required for anyone with many comorbidities.
We must use critical thinking in the bedside evaluation, being keenly aware that this is subjective and we educate with nurses and physicians on these limitations. You may have to initiate modified diets and thickened liquids with these patients. The recent trend in dysphagia thinking the last few years............”If we can’t definitively rule out aspiration of thickened liquids, isn’t it safer to aspirate water?” We need to recognize the severity of this risk with COVID19 on the respiratory system. You may have to change your mindset and this is the time to be somewhat conservative with diet texture recommendations and consider the patient’s comorbidities (as you always should) and their overall current medical status.
What to expect from post extubation on the aerodigestive tract and cognition
- Aphonic, the inability to produce sound
- Increased and unmanaged secretions
- A patient who is hypotensive prior to intubation is at high risk of further hemodynamic decompensation or cardiac arrest during the peri-intubation period
- Overall weakness - myopathy/polyneuropathy (muscle weakness/paresis in people who are critically ill)
- High risk for silent aspiration- like stroke, head and neck cancer, History of COPD, advanced liver disease, and sepsis prior trach, or those with suspected vocal fold trauma post extubation that doesn’t resolve. None of this has changed
- Hypoxia - There should be use of Non-rebreather masks (plus or minus nasal cannula), as opposed to high flow nasal cannula or BIPAP- in efforts to create a seal during oxygen delivery and reduce aerosol generation.
- Desaturating and increased effort of breathing when eating and drinking by altering respiratory/swallow coordination which elevates the risk of aspiration.
- Pneumonia in COVID-19 occurs when parts of the lung consolidate and collapse.
- Delirium- Altered mental status is common in the setting of metabolic disarray from poor nutrition and hydration, ICU type delirium, lethargy from the COVID infection. The elderly dementia patients with comorbidities are a population at the highest of risk.
- Stroke: There are increased reports about the questionable neurological consequences of COVID19 resulting in stroke, as well as recrudescence of old stroke symptoms in setting of the infection.
- Head and Neck Cancer:
- Total laryngectomees are not immune from COVID19. Most of our involvement here requires much education to nursing/medical staff on total laryngectomee considerations including stoma care.
- Trachs: Tracheostomizing patients after significantly prolonged intubation is common in the field. Post trach care and SLP intervention for the evaluation and treatment is within the scope of our practice not just today but always.
- Medication side-effects
- Poor oral care
- Not to mention, the quality of life issues as well as the mental health issues related to the critical illness that results in various mental and physical stress levels including isolation that is on a whole new level with facility lock-downs.
Evaluating and treating COVID19 patients is truly no different than treating other cases. We are still using clinical judgement, critical thinking skills, educating, advocating and communicating with medical teams- as we always have done. But in other ways- our practice has drastically changed to accommodate the COVID19 situation. We can rely heavily on our bedside skills or use the proper instrumental assessment during this time, MBSS. We will start seeing COVID patients being admitted to acute rehab and skilled nursing. We are still faced with the same challenges as we always have been: NPO vs pleasure feeds, trial feeds? Aspiration vs malnutrition/dehydration risk? Every patient is unique- we still make appropriate recommendations on a case by case basis. But there has NEVER been a more critical time to keep their respiratory status as strong and uncompromised as possible, considering the effect of COVID 19 if someone does becomes infected.
Call DiagnosTEX at 817-514-6271 to help you properly diagnose your recovering COVID patients.
This has been a challenging experience so far for all in the healthcare field, from PPE to caseloads. In these COVID times, the challenge for clinicians is the word “objectively.” Thorough clinicians can make solid clinical judgments based on good chart reviews, detailed discussions with medical team/family, and bedside swallowing evaluations that include a cranial nerve exam. Yet as it has always been, a bedside exam cannot objectively and completely evaluate the oropharyngeal swallow or 100 % rule-out aspiration.
An MBSS is still a very important evaluation for dysphagia patients to have at this time. The instrumental evaluation provides direct lateral and AP viewing of cervical spine, soft tissue abnormalities, detection and visualization of the depth of aspiration, stage transition, and biomechanics of all stages of the swallow through the lower esophagus. The most comprehensive imaging of the swallow available. As a physician-based medical practice, DiagnosTEX is proud to stand with you in caring for patients during the COVID 19 outbreak. Although many hospitals are limiting appointments for non-urgent procedures, safe oral intake is never 'elective.' Evaluation of at-risk patients is required to maintain safe PO feeding and decreasing the risk of life-threatening situations (such as aspiration, pneumonia, dehydration and malnutrition). We want you to feel confident in our dedication to the quality, safety, and oversight of infection control during this COVID 19 event when these patients come to you for rehab.