Safe management of laryngectomized patients during the COVID-19 pandemic

Masks and respirators for prevention of respiratory infections: a state of the science review

SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.

Perceptions and practices of people with a total laryngectomy during COVID-19 pandemic: A mixed methods analysis

PURPOSE

People with a total laryngectomy (PTL) confront safety threats related to altered airway anatomy and risk of adverse events is amplified during healthcare crises, as exemplified by COVID-19 pandemic. Understanding these challenges, how they are navigated by PTL, and what resources can be deployed to alleviate risk can improve interprofessional care by speech-language pathologists (SLPs), otolaryngologists, and other professionals.

MATERIALS AND METHODS

An online survey was disseminated to PTL in the United States during the COVID-19 pandemic, querying participants about safety concerns and sources of information accessed to address care. Descriptive statistics and Chi-square were used to analyze information sources consumed by tracheoesophageal, esophageal, and electrolaryngeal speakers. Content analysis was completed to identify themes and quantify responses by subtheme.

RESULTS

Among 173 respondent PTL, tracheoesophageal speakers preferentially sought otolaryngologist input, whereas esophageal and electrolaryngeal speakers more often chose SLPs (p < .01). Overall, tracheoesophageal speakers had more SLP or otolaryngologist contact. Many PTL reported stringent handwashing, neck cleaning, and hygienic risk mitigation strategies. Six themes emerged in content analysis involving risk of infection/transmission, heightened vigilance, changes to alaryngeal communication, modified tracheostoma coverage, diagnostic testing, and risk from comorbid conditions. Limited provider contact suggested pandemic barriers to healthcare access.

CONCLUSIONS

PTL have a range of laryngectomy-specific needs and concerns, and type of alaryngeal communication was associated with source of information sought. Collaborations among healthcare professionals need to be optimized to improve patient navigation and overall access to specialized care.

Usage of Heat and Moisture Exchange Devices, Virtual Visits, Masking, and Vaccinations Among People With a Laryngectomy During COVID-19

PURPOSE

This study described the COVID-19 risk mitigation actions of people with a total laryngectomy (TL) during the pandemic.

METHOD

An online survey was completed by 215 people with a TL who lived in the United States. The survey was open from December 1, 2021, to January 15, 2022.

RESULTS

There was a significant increase in frequency of heat and moisture exchange (HME) device use during the pandemic compared with pre-COVID-19. Frequency of HME use was significantly greater for those who were vaccinated and those who had at least one clinical visit with their speech-language pathologist (SLP). The use of virtual visits increased from 9% pre-COVID-19 to 37% during the pandemic. Seventy percent of respondents were "satisfied" or "very satisfied" with virtual visits and 51% judged them "as good as in-person." Eighty percent were vaccinated for COVID-19 and 75% received a booster. One third reported that they did not wear mask over the face or over the tracheostoma. Twenty percent had tested positive for COVID-19 with 70% of these people requiring hospitalization.

CONCLUSIONS

HME use and virtual SLP visits increased during the pandemic and the vaccination rate was high among this group of respondents. Overall, there were still large percentages of people with a TL who were not using an HME, not vaccinated, and did not wear a mask. SLPs should consider reaching out directly to their TL caseload, particularly those not yet seen during the pandemic, to support uptake of COVID-19 mitigation activities specific to people with a TL as the pandemic persists.

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations

In the past, the use of face masks in western countries was essentially limited to occupational health. Now, because of the COVID-19 pandemic, mask-wearing has been recommended as a public health intervention. As potential side effects and some contraindications are emerging, we reviewed the literature to assess the impact of them in daily life on patient safety and to provide appropriate guidelines and recommendations. We performed a systematic review of studies investigating physiological impact, safety, and risk of masks in predefined categories of patients, which have been published in peer-reviewed journals with no time and language restrictions. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. Wearing a N95 respirator is more associated with worse side effects than wearing a surgical mask with the following complications: breathing difficulties (reduced FiO₂, SpO₂^, PaO₂ increased ETCO₂, PaCO₂), psychiatric symptoms (panic attacks, anxiety) and skin reactions. These complications are related to the duration of use and/or disease severity. Difficulties in communication is another issue to be considered especially with young children, older person and people with hearing impairments. Even if benefits of wearing face masks exceed the discomfort, it is recommended to take an "air break" after 1-2 h consecutively of mask-wearing. However, well-designed prospective studies are needed. The COVID-19 pandemic could represent a unique opportunity for collecting large amount of real-world data.

Shielding, hospital admission and mortality among 1216 people with total laryngectomy in the UK during the COVID-19 pandemic: A cross-sectional survey from the first national lockdown

BACKGROUND

People with a total laryngectomy (PTL) rely on a permanent opening in their neck (stoma) to breathe. This altered anatomy may increase susceptibility to contracting and transmitting SARS-CoV-2.

AIMS

To report on (1) the frequency and characteristics of PTL who tested positive for COVID-19, (2) the receipt of advice regarding shielding and patient self-reports of shielding, (3) hospital admissions and length of stay, and (4) mortality rates in this group during the first UK national lockdown.

METHODS & PROCEDURES

This is a cross-sectional survey and case note review. National Health Service (NHS) centres providing care to PTL were invited to participate via the Royal College of Speech and Language Therapists' (RCSLT) Head & Neck Clinical Excellence Networks and through social media. PTL were reviewed by their speech and language therapist either in person or via telehealth between 30 March and 30 September 2020. Data were collected within the time frame covered by the Control of Patient Information (COPI) notice issued for COVID-19 and included information on COVID-19 testing, shielding, hospital admissions, length of stay and deaths. Information was submitted to the lead NHS site using a custom designed data-capture worksheet. Analysis was performed using descriptive statistics, including proportions and frequency counts. Pearson's Chi squared tests were used to compare categorical data using a 5% significance level.

OUTCOMES & RESULTS

Data were obtained from 1216 PTL from 26 centres across the UK. A total of 81% were male; mean age was 70 years (28-97 years). Of the total group, 12% received a COVID-19 test. A total of 24 (2% of total sample) tested positive for COVID-19. Almost one-third of PTL (32%) received a government letter or were advised to shield by a healthcare professional. During the data collection time frame, 12% had a hospital admission (n = 151) with a median length of stay of 1 day (1-133 days), interquartile range (IQR) = 17 days. A total of 20 of these admissions (13%) had tested positive for COVID-19 with a median length of stay of 26 days, IQR = 49 days. The overall mortality was 4% (41 patients), with eight deaths occurring within 28 days of testing positive for COVID-19.

CONCLUSIONS & IMPLICATIONS

This study highlighted the lack of routine national data for neck-breathers with which to compare the current findings. Greater testing in the community is necessary to understand the prevalence of COVID-19 in PTL and if this group is indeed more susceptible. The potential for nasopharyngeal and tracheal aspirates to show differing results when testing for COVID-19 in neck-breathers requires further investigation.

WHAT THIS PAPER ADDS

What is already known on the subject? People with total laryngectomy (PTL) have an altered anatomy for breathing and speaking. The presence of a neck stoma poses an additional virus entry point aside from the nose, mouth and conjunctiva. This could increase the susceptibility to COVID-19 for PTL. What this paper adds? This is the first national audit to provide data on shielding, hospital admissions and mortality for patients with total laryngectomy in the UK over the pandemic. The overall mortality in PTL over the first lockdown did not appear to be higher than the "best case" estimates from previous years. However, one in three PTL who acquired COVID-19 and were admitted to hospital, died within 28 days of testing positive. These findings are relevant to the current care and management of PTL over the pandemic but also highlights important knowledge gaps. What are the potential or actual clinical implications of this work? This study highlights gaps in the collection of baseline information on hospital admissions, length of stay and mortality for people with laryngectomy in the UK, restricting comparisons between the current data and historical data. The need for further research on whether neck-breathers should be tested via both nasopharyngeal and tracheal aspirates is important not just currently, but also in case of any future respiratory epidemics.

Self-care and clinical management of persons with laryngectomy during COVID-19 pandemic: a narrative review

Objective

To summarize guidelines on self-care and clinical management of persons with laryngectomy during the COVID-19 pandemic.

Method

Articles published in electronic databases—PubMed, Scopus, Web of Science, and CINHAL with the compliant keywords—were scouted from December 2019 to November 2020. All original articles, letters to editors, reviews, and consensus statements were reviewed and included.

Results

In all, 20 articles that had information pertaining to self-care of persons with laryngectomy or guidelines for clinicians working with this population were identified. Four of the included studies were case reports of persons with laryngectomy who contracted the COVID-19 virus. One of the included articles was a cohort study that explored the use of telerehabilitation in persons with laryngectomy.

Conclusion

The hallmarks of preventative strategies for persons with laryngectomy during the COVID-19 pandemic are as follows: physical distancing, use of a three-ply mask or surgical mask to cover the mouth and nose, and use of Heat Moisture Exchange (HME) device over stoma in addition to covering it with a surgical mask or laryngectomy bib. Telerehabilitation, not a preference with this population prior to the pandemic, has gained popularity and acceptance during the COVID-19 situation. The reports of COVID-positive persons with laryngectomy have indicated contrary findings from the tracheal and nasal swabs, necessitating compulsory inclusion of both nasal and tracheal swabs.

Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review

IMPORTANCE

The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries.

OBSERVATIONS

From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis.

CONCLUSIONS AND RELEVANCE

Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.

Tracheoesophageal voice prosthesis management in laryngectomy patients during the COVID-19 pandemic

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncology patients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers is deferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent procedures may be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses, such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center's approach to managing this unique patient population.

Tracheostomy care during COVID 19 pandemic in a head and neck oncology unit

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Aerosol Generating Procedures (AGP) and interventions are challenging during COVID-19.

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During Emergencies AGP poses a major threat to health care workers and other patients.

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Minimisation of aerosolisation is best achieved by techniques such as closed suctioning and enhanced use of HME.