Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Tracheostomy care of non-ventilated patients and COVID considerations: A scoping review of clinical practice guidelines and consensus statements

BACKGROUND

The purpose of this study is to examine and evaluate the existing clinical practice guidelines and consensus statements regarding tracheostomy care for non-mechanically ventilated patients.

METHODS

A systematic search of databases, and professional organisations was conducted from inception to 19 March 2023. Two appraisers evaluated each guideline using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers.

RESULTS

No specific clinical guidelines exist on airway management in non-mechanically ventilated patients. Of 6318 articles identified, we included 12 clinical practice guidelines, and 9 consensus statements, which were from China, the US, the UK, South Korea, Australia, France and Belgium. The AGREE II scores in six domains are (1) the scope and purpose, 70.30%; (2) stakeholder involvement, 37.61%; (3) rigor of development, 33.97%; (4) clarity of presentation, 68.16%; (5) applicability, 44.23% and (6) editorial independence, 40.06%. The overall quality of evidence was level B. The summarised recommendations for clinical practice encompass the following six areas: airway humidification, management of the trach cuff, management of inner cannula, tracheostoma care, tracheostomy suctioning and management and prevention of common post-operative complications.

CONCLUSIONS

The overall quality of the clinical guidelines on non-ventilated tracheostomy care was moderate, and further improvements are needed in domains of stakeholder involvement, applicability, clarity of presentation and editorial independence. Recommendations on non-ventilated tracheostomy care are often embedded in the guidelines on ventilated tracheostomy. Specific clinical guidelines are needed to provide a standardised approach to tracheostomy care for non-ventilated patients.

RELEVANCE TO CLINICAL PRACTICE

Patients with non-ventilated tracheostomy need specialised airway management. Improving patient outcomes requires standardised protocols, patient involvement, quality evaluation, and interdisciplinary approaches.

NO PATIENT OR PUBLIC CONTRIBUTION

The study reviewed clinical practice guidelines and consensus statements, therefore patient or public input was not needed.

The impact of COVID-19 on head and neck cancer patients: A review of speech valve complications and patient experience during the COVID-19 pandemic in the United Kingdom

PURPOSE

Surgical voice restoration (SVR) is associated with improved patient quality of life following laryngectomy. This study aims to determine the impact of the COVID-19 pandemic on patients with SVR and analyse the complications in this cohort of patients.

METHOD

A retrospective review of all patients with SVR at a single tertiary ear, nose, and throat (ENT) unit in the UK for 12 months during the COVID-19 pandemic, with comparison to the preceding 12 months. A survey was also administered to assess patients' experiences during the pandemic.

RESULT

Thirty-six patients were included in this study. During the pandemic period, 19.5% (n = 7) patients had significant complications, with five patients needing surgery to restore speech. In the 12 months pre-pandemic, 13.5% (n = 5) had significant complications, although none required surgery to restore speech. Six patients (19.4%) felt these complications were avoidable in normal circumstances. Further, 30.5% (n = 11) of patients reported a delay in seeking medical attention due to concerns about their vulnerability to COVID-19.

CONCLUSION

The COVID-19 pandemic has had an impact on many patients with SVR. This has resulted in a large proportion of patients experiencing delayed care, a loss of voice, a need for further surgical intervention, and negative impacts on their quality of life.

Enhancing Communication in Critically Ill Patients with a Tracheostomy: A Systematic Review of Evidence-Based Interventions and Outcomes

Background

Tracheostomy, a common procedure performed in intensive care units (ICU), is associated with communication impairment and affects patient well-being. While prior research has focused on physiological care, there is a need to address communication needs and quality of life (QOL). We aimed to evaluate how different types of communication devices affect QOL, speech intelligibility, voice quality, time to significant events, clinical response and tolerance, and healthcare utilization in patients undergoing tracheostomy.

Methods

Following PRISMA guidelines, a systematic review was conducted to assess studies from 2016 onwards. Eligible studies included adult ICU patients with a tracheostomy, comparing different types of communication devices. Data were extracted and synthesized to evaluate QOL, speech intelligibility, voice quality, time to significant events (initial communication device use, oral intake, decannulation), clinical response and tolerance, and healthcare utilization and facilitators/barriers to device implementation.

Results

Among 9,228 studies screened, 8 were included in the review. Various communication devices were employed, comprising both tracheostomy types and speaking valves, highlighting the multifaceted nature of interventions. Quality of life improvements were observed with voice restoration interventions, but challenges such as speech intelligibility impairments were noted. The median time for initial communication device usage post-intervention was 11.4 ± 5.56 days. The median duration of speech tolerance ranged between 30-60 minutes to 2-3 hours across different studies. Complications such as air trapping or breathing difficulties were reported in 15% of cases. Additionally, the median ICU length of stay post-intervention was 36.5 days. Key facilitators for device implementation included early intervention, while barriers ranged from service variability to physical intolerance issues.

Conclusion

Findings demonstrate that various types of communication devices can significantly enhance the quality of life, speech intelligibility, and voice quality for patients undergoing tracheostomy, aligning with the desired outcomes of improved clinical response and reduced healthcare utilization. The identification of facilitators and barriers to device implementation further informs clinical practice, suggesting a tailored, patient-centered approach is crucial for optimizing the benefits of communication devices in this population.

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.

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers

PURPOSE

Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage.

MATERIALS AND METHODS

Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews.

RESULTS

Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality.

CONCLUSIONS

Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

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.

Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do

Purpose of review

To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls.

Recent findings

Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity.

Summary

Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.

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.

COVID-19: Impact on the Musician and Returning to Singing; A Literature Review

OBJECTIVE

The purpose of this study was to review current literature of the impact of COVID-19 on musicians and returning to singing.

METHODS

A comprehensive search of peer-review articles was completed using PubMed, GoogleScholar, Scopus, and Web of Science. The search was completed using many key terms including voice, hoarseness, dysphonia, aphonia, cough, singers, and public speakers. The bibliography from each article found was searched to find additional articles. The search process revealed 56 peer-reviewed articles, 18 primary articles, ranging from the years 2019 to 2020.

CONCLUSION

COVID-19 has had a major impact on singers and other musicians worldwide. It can affect the voice and can lead to paresis/paralysis of laryngeal nerves to long-term changes in respiratory function. There is a risk from aerosolization/droplet formation transmission with singing, and with playing wind and brass instruments that can be mitigated by following COVID-19 guidelines. Ways to reduce possible transmission during singing and instrument play include virtual rehearsals or performances, mask-wearing, instrument covers, smaller choirs, performing outside, excellent ventilation being socially distanced, shorter rehearsals, regularly cleaning commonly touched surfaces and washing hands, avoiding contact with others, and temperature screening.

Impact of COVID-19 on People With Aphasia: Emerging Rehabilitation Needs

Purpose:The purpose of this article is to address an emerging issue in rehabilitation counseling: The effect of the COVID-19 pandemic on people with aphasia (PWA).

Method:Based upon a review of the literature this article provides an overview of (a) COVID-19 and emergent aphasia-related disability, (b) COVID-19 effects on stroke and aphasia services, (c) COVID-19 effects on mental health and employment of PWA.

Results:This review of the impact of COVID-19 on PWA highlights the increased and emerging needs for rehabilitation counseling services related to an anticipated increase in incidence of aphasia related to COVID-19 illness and secondary impact of medical care for this population.

Conclusion:The impact of COVID-19 on aphasia care in rehabilitation settings underscores the need for increased interprofessional education and collaboration to address the many gaps in aphasia care. Likewise, interdisciplinary research focused on rehabilitation outcomes in aphasia is needed to provide a foundation for evidence-based practice that conforms to the WHO-ICF framework.

Prevention of Tracheostomy-Related Pressure Injury: A Systematic Review and Meta-analysis

BACKGROUND

In the critical care environment, individuals who undergo tracheostomy are highly susceptible to tracheostomy-related pressure injuries.

OBJECTIVE

To evaluate the effectiveness of interventions to reduce tracheostomy-related pressure injury in the critical care setting.

METHODS

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units conducted to evaluate interventions to reduce tracheostomy-related pressure injury. Reviewers independently extracted data on study and patient characteristics, incidence of tracheostomy-related pressure injury, characteristics of the interventions, and outcomes. Study quality was assessed using the Cochrane Collaboration's risk-of-bias criteria.

RESULTS

Ten studies (2 randomized clinical trials, 5 quasi-experimental, 3 observational) involving 2023 critically ill adult and pediatric patients met eligibility criteria. The incidence of tracheostomy-related pressure injury was 17.0% before intervention and 3.5% after intervention, a 79% decrease. Pressure injury most commonly involved skin in the peristomal area and under tracheostomy ties and flanges. Interventions to mitigate risk of tracheostomy-related pressure injury included modifications to tracheostomy flange securement with foam collars, hydrophilic dressings, and extended-length tracheostomy tubes. Interventions were often investigated as part of care bundles, and there was limited standardization of interventions between studies. Meta-analysis supported the benefit of hydrophilic dressings under tracheostomy flanges for decreasing tracheostomy-related pressure injury.

CONCLUSIONS

Use of hydrophilic dressings and foam collars decreases the incidence of tracheostomy-related pressure injury in critically ill patients. Evidence regarding individual interventions is limited by lack of sensitive measurement tools and by use of bundled interventions. Further research is necessary to delineate optimal interventions for preventing tracheostomy-related pressure injury.

Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure

Objective

Aspiration is a common complication after tracheostomy in patients with acquired brain injury (ABI), resulting from impaired swallowing function, and which may lead to aspiration pneumonia. The Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valve (PMV) has been used to enable voice and reduce aspiration; however, its mechanism is unclear. This study aimed to investigate the mechanisms underlying the beneficial effects of PMV intervention on the prevention of aspiration.

Methods

A randomized, single-blinded, controlled study was designed in which 20 tracheostomized patients with aspiration following ABI were recruited and randomized into the PMV intervention and non-PMV intervention groups. Before and after the intervention, swallowing biomechanical characteristics were examined using video fluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). A three-dimensional (3D) upper airway anatomical reconstruction was made based on computed tomography scan data, followed by computational fluid dynamics (CFD) simulation analysis to detect subglottic pressure.

Results

The results showed that compared with the non-PMV intervention group, the velopharynx maximal pressure (VP-Max) and upper esophageal sphincter relaxation duration (UES-RD) increased significantly (P < 0.05), while the Penetration-Aspiration Scale (PAS) score decreased in the PMV intervention group (P < 0.05). Additionally, the subglottic pressure was successfully detected by CFD simulation analysis, and increased significantly after 2 weeks in the PMV intervention group compared to the non-PMV intervention group (P < 0.001), indicating that the subglottic pressure could be remodeled through PMV intervention.

Conclusion

Our findings demonstrated that PMV could improve VP-Max, UES-RD, and reduce aspiration in tracheostomized patients, and the putative mechanism may involve the subglottic pressure.

Clinical trial registration

[http://www.chictr.org.cn], identifier [ChiCTR1800018686].

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part II): Reliability and Validity in Healthy Elderly Individuals and Oral Cancer Patients

In our prior published study, we extracted evaluation items suitable for remote administration, and made a relatively simple Remote Examination of Deglutition (RED). This study aimed at verifying the reliability and validity of RED. The participants were 21 healthy elderly individuals and 72 postoperative oral cancer (OC) patients. OC patients underwent videofluoroscopic dysphagia examination, and severity was judged on the dysphagia severity scale (DSS). Reliability and validity of RED were examined in all participants under face-to-face conditions, in comparison with the Mann Assessment of Swallowing Ability (MASA). Reliability and validity of remote administration of RED were examined in 40 participants. ROC curves were used to find cut-off RED scores to predict aspiration and deglutition disorders. The Cronbach's alpha coefficient for the items was 0.882. There was a high correlation between the total score of RED and MASA in the face-to-face condition. When RED score was compared among different severity groups (DSS1-4, DSS5-6, and DSS7), the total and oral preparatory stage scores revealed significant group differences. The area under the curve (AUC) for aspiration based on the ROC curve was 0.913, with a sensitivity/specificity of 0.80/0.98. The AUC for deglutition disorders was 0.819, with a sensitivity/specificity of 0.74/0.67. In both face-to-face and remote conditions, the reliability of RED was good.The reliability and validity of RED were confirmed. RED has shown the potential to assess the likelihood of aspiration and deglutition disorders in OC patients remotely as an initial assessment tool.

A bibliometric analysis of linguistic research on COVID-19

Research on COVID-19 has drawn the attention of scholars around the world since the outbreak of the pandemic. Several literature reviews of research topics and themes based on scientometric indicators or bibliometric analyses have already been conducted. However, topics and themes in linguistic-specific research on COVID-19 remain under-studied. With the help of the CiteSpace software, the present study reviewed linguistic research published in SSCI and A&HCI journals to address the identified gap in the literature. The overall performance of the documents was described and document co-citations, keyword co-occurrence, and keyword clusters were visualized via CiteSpace. The main topic areas identified in the reviewed studies ranged from the influences of COVID-19 on language education, and speech-language pathology to crisis communication. The results of the study indicate not only that COVID-19-related linguistic research is topically limited but also that insufficient attention has been accorded by linguistic researchers to Conceptual Metaphor Theory, Critical Discourse Analysis, Pragmatics, and Corpus-based discourse analysis in exploring pandemic discourses and texts.

Quantification of Respirable Aerosol Particles from Speech and Language Therapy Exercises

INTRODUCTION

Voice assessment and treatment involve the manipulation of all the subsystems of voice production, and may lead to production of respirable aerosol particles that pose a greater risk of potential viral transmission via inhalation of respirable pathogens (eg, SARS-CoV-2) than quiet breathing or conversational speech.

OBJECTIVE

To characterise the production of respirable aerosol particles during a selection of voice assessment therapy tasks.

METHODS

We recruited 23 healthy adult participants (12 males, 11 females), 11 of whom were speech-language pathologists specialising in voice disorders. We used an aerodynamic and an optical particle sizer to measure the number concentration and particle size distributions of respirable aerosols generated during a variety of voice assessment and therapy tasks. The measurements were carried out in a laminar flow operating theatre, with a near-zero background aerosol concentration, allowing us to quantify the number concentration and size distributions of respirable aerosol particles produced from assessment/therapy tasks studied.

RESULTS

Aerosol number concentrations generated while performing assessment/therapy tasks were log-normally distributed among individuals with no significant differences between professionals (speech-language pathologists) and non-professionals or between males and females. Activities produced up to 32 times the aerosol number concentration of breathing and 24 times that of speech at 70-80 dBA. In terms of aerosol mass, activities produced up to 163 times the mass concentration of breathing and up to 36 times the mass concentration of speech. Voicing was a significant factor in aerosol production; aerosol number/mass concentrations generated during the voiced activities were 1.1-5 times higher than their unvoiced counterpart activities. Additionally, voiced activities produced bigger respirable aerosol particles than their unvoiced variants except the trills. Humming generated higher aerosol concentrations than sustained /a/, fricatives, speaking (70-80 dBA), and breathing. Oscillatory semi-occluded vocal tract exercises (SOVTEs) generated higher aerosol number/mass concentrations than the activities without oscillation. Water resistance therapy (WRT) generated the most aerosol of all activities, ∼10 times higher than speaking at 70-80 dBA and >30 times higher than breathing.

CONCLUSIONS

All activities generated more aerosol than breathing, although a sizeable minority were no different to speaking. Larger number concentrations and larger particle sizes appear to be generated by activities with higher suspected airflows, with the greatest involving intraoral pressure oscillation and/or an oscillating oral articulation (WRT or trilling).

Determining the Prevalence, Implementation Approaches, and Opinions of Above Cuff Vocalization: A Survey of Health Care Professionals

OBJECTIVE

To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs.

DESIGN

Observational, cross-sectional online survey.

SETTING

Critical care, acute, rehabilitation, long-term care, and community.

PARTICIPANTS

Health care professionals involved in tracheostomy care or weaning (N=243).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data.

RESULTS

The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%).

CONCLUSIONS

ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.

Tracheostomy care and communication during COVID-19: Global interprofessional perspectives

Objective

Investigate healthcare providers, caregivers, and patient perspectives on tracheostomy care barriers during COVID-19.

Study design

Cross-sectional anonymous survey

Setting

Global Tracheostomy Collaborative Learning Community

Methods

A 17-item questionnaire was electronically distributed, assessing demographic and occupational data; challenges in ten domains of tracheostomy care; and perceptions regarding knowledge and preparedness for navigating the COVID-19 pandemic.

Results

Respondents (n = 115) were from 20 countries, consisting of patients/caregivers (10.4%) and healthcare professionals (87.0%), including primarily otolaryngologists (20.9%), nurses (24.3%), speech-language pathologists (18.3%), respiratory therapists (11.3%), and other physicians (12.2%). The most common tracheostomy care problem was inability to communicate (33.9%), followed by mucus plugging and wound care. Need for information on how to manage cuffs and initiate speech trials was rated highly by most respondents, along with other technical and knowledge areas. Access to care and disposable supplies were also prominent concerns, reflecting competition between community needs for routine tracheostomy supplies and shortages in intensive care units. Integrated teamwork was reported in 40 to 67% of respondents, depending on geography. Forty percent of respondents reported concern regarding personal protective equipment (PPE), and 70% emphasized proper PPE use.

Conclusion

While safety concerns, centering on personal protective equipment and pandemic resources are prominent concerns in COVID-19 tracheostomy care, patient-centered concerns must also be prioritized. Communication and speech, adequate supplies, and care standards are critical considerations in tracheostomy. Stakeholders in tracheostomy care can partner to identify creative solutions for delays in restoring communication, supply disruptions, and reduced access to tracheostomy care in both inpatient and community settings.

[COVID-19-New challenges in dysphagia and respiratory therapy]

Coronavirus disease 2019 (COVID-19) can lead to severe disease courses with multiple organ involvement, respiratory and neurological functional impairments. Swallowing disorders (dysphagia) in this patient group can result from primary damage to the central and peripheral neuronal swallowing network but also from the frequently prolonged intensive care treatment and mechanical ventilation. Clinical observations indicate persistence of dysphagia in post-acute COVID-19 syndrome (long COVID), so that these patients probably also need long-term interventions for rehabilitation of safe and sufficient oral feeding. Therefore, structured disease-specific monitoring of dysphagia symptoms should be integrated into the treatment of COVID-19 patients and respiratory therapy should be an essential part of dysphagia management to re-establish cough effectiveness and breathing-swallowing coordination. Challenges arise from necessary adjustments to established treatment standards to prevent infections. Furthermore, the selection and intensity of therapeutic measures have to be adapted to the capacities and the specific pathophysiology of COVID-19 and long COVID patients to prevent further functional deterioration.

Clinical Experiences of People With a Laryngectomy During the SARS COVID-19 Pandemic

Purpose This study described the clinical experiences of patients with a total laryngectomy (TL) during the COVID-19 pandemic and identified changes in communication, tracheostoma care, and heat-moisture exchange (HME) use that were recommended or self-implemented. Method An online survey addressing the study aims was completed by 173 people with a TL who live in the United States. The survey was open from July 5 to August 10, 2020. Results In-person clinic visits, appointment cancellations, and contact from their speech-language pathologists (SLPs) were reported by 42%, 19%, and 54% of the TL respondents, respectively. At clinic visits, 78% were required to wear a mask over their nose/mouth, and 73% were required to wear a mask over their tracheostoma. Masks, gloves, and face shields worn by the SLP at these visits were reported by 84%, 82%, and 70% of the TL patients, respectively. Alaryngeal communication changes were recommended by the SLP for 7%-18% of TL patients, depending on their method of communication, whereas 43%-45% implemented changes on their own. Changes in tracheostoma care and HME use were recommended by the SLP for 27% and 21% of the TL respondents, respectively, whereas 54% and 47% made changes on their own. Conclusions Individuals with a TL will require in-person care even during a pandemic, as reflected in this study. Many had not been contacted by their SLP or otolaryngologist about TL guidelines that were becoming available. Notably, larger percentages of TL patients reported self-initiated changes to their communication, tracheostoma care, and HME use because of the pandemic than their SLP had advised. The types of communication changes varied in part, depending on the method of alaryngeal speech a respondent used. Supplemental Material https://doi.org/10.23641/asha.16807270.

Speech-language pathology approaches to neurorehabilitation in acute care during COVID-19: Capitalizing on neuroplasticity

Neurologic manifestations associated with a coronavirus disease 2019 (COVID‐19) diagnosis are common and often occur in severe and critically ill patients. In these patients, the neurologic symptoms are confounded by critical care conditions, such as acute respiratory distress syndrome (ARDS). Patients with dual diagnoses of COVID‐19 and neurologic changes such as myopathy, polyneuropathy, and stroke are likely at a higher risk of experiencing deficits with swallowing, communication, and/or cognition. Speech‐language pathologists are an integral part of both the critical care and neurologic disorders multi‐disciplinary teams, offering valuable contributions in the evaluation, treatment, and management of these areas. Patients in intensive care units (ICUs) who require mechanical ventilation often experience difficulty with communication and benefit from early speech‐language pathology intervention to identify the most efficient communication methods with the medical team and caregivers. Moreover, patients with neurologic manifestations may present with cognitive‐linguistic impairments such as aphasia, thereby increasing the need for communication‐based interventions. Difficulties with voice and swallowing after extubation are common, often requiring frequent treatment sessions, possibly persisting beyond ICU discharge. After leaving the ICU, patients with COVID‐19 often experience physical, cognitive, and mental health impairments collectively called post‐intensive care syndrome. This is often a lengthy road as they progress toward full recovery, requiring continued speech‐language pathology treatment after hospital discharge, capitalizing on the principles of neuroplasticity.

Tracheostomy for COVID-19: evolving best practice

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part I): Selection of Examination Items

In order to ensure appropriateness and feasibility of examination items for remote evaluation for deglutition disorders, a questionnaire based on the Delphi method was administered to 122 speech–language–hearing therapists (STs), and a set of examination items was selected. The participants were instructed to view a video recording of a remote assessment situation and answer a 30-item questionnaire. Of 19 items ensuring the appropriateness for deglutition disorders detection, 13 items ultimately met the consensus criteria for remote feasibility. Factor analysis extracted three factors: ‘oral observation,’ ‘overall evaluation,’ and ‘perceptual voice judgment.’ In free-text responses, “quality and stability of the voice that may be heard through the device” were the most common concerns, followed by “the need to correct of the camera angle, magnification, and targets that should be projected,” “concerns about the technical aspects of the assistants and their role in relation with the examiner/ST,” and “the need for palpation as well as visual confirmation.” The proposed 13-item examination is considered to capture the characteristics of deglutition disorders, while items that appeared difficult to implement remotely were excluded. The fact that some items could be influenced by the video calling experience when judging the feasibility of remote implementation, the acceptability of such items, is likely to increase in the future.

Ensuring communication access for all during the COVID-19 pandemic and beyond: supporting patients, providers, and caregivers in hospitals

The COVID-19 pandemic has revealed substantial gaps in communication access for patients across hospital settings. With the rise in positive cases globally, the need for communication enhancement strategies, including augmentative and alternative communication (AAC), has emerged as a critical need. Many resources exist that describe AAC assessment and intervention processes in the acute care setting; however, AAC service provision in the COVID-19 pandemic is fraught with many unanticipated challenges. Patients, providers, and caregivers have encountered significant communication strain both at the bedside and beyond hospital walls, resulting in a communication crisis induced by many COVID-19 related variables. This article describes the sequelae of symptoms a person with COVID-19 may experience, progression of communication needs, and evidence-based solutions to supporting communication access. Barriers related to the COVID-19 pandemic are outlined (e.g., evolving infection control practices, personal protective equipment requirements, visitor policies, and more) along with response recommendations to support communication enhancement efforts for people with and without COVID-19 benefiting from access to AAC.

The Impact of COVID-19 on Speech-Language Pathologists Engaged in Clinical Practices With Elevated Coronavirus Transmission Risk

Purpose This study assessed and described potential clinical practice changes secondary to COVID-19 that emerged as an early response to the pandemic for speech-language pathologists (SLPs) engaged in voice, alaryngeal, and swallowing activities that may increase the risk of virus transmission. Method SLPs from the United States and Canada (n = 665) who were engaged in clinical activities that might elevate the risk of COVID-19 exposure completed an online survey regarding their clinical practices. Topics assessed included potential clinical service modifications, COVID-19 testing and health, and potential financial impacts in the early time period of the pandemic. Results The percentage of SLPs completing the most endoscopic procedures prepandemic (≥ 10/week) was reduced from 39% of respondents to 3% due to the pandemic. Those who completed the most tracheoesophageal puncture voice prosthesis changes (≥ 5/week) reported a reduction in frequency from 24% to 6%. Twenty-five percent of SLPs reported that they were tested for COVID-19, and 6% reported a positive result. Descriptive statistics suggest that COVID-19 testing rates of SLPs, the percentage of SLPs experiencing a financial impact, and the percentage who were furloughed varied across SLP work setting. Conclusions These findings provide the first data characterizing the impact on COVID-19 on clinical practice for SLPs engaged in procedures such as endoscopy and laryngectomy care. The results indicate that, as frontline workers, SLPs were directly impacted in their practice patterns, personal health, safety, and financial security, and that these reported impacts occurred differently across SLP work settings.

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.

Clinical Manifestation, Evaluation, and Rehabilitative Strategy of Dysphagia Associated With COVID-19

ABSTRACT

Dysphagia is the difficulty in swallowing because of the presence of certain diseases; it particularly compromises the oral and/or pharyngeal stages. In severe acute respiratory syndrome coronavirus 2 infection, neuromuscular complications, prolonged bed rest, and endotracheal intubation target different levels of the swallowing network. Thus, critically ill patients are prone to dysphagia and aspiration pneumonia. In this review, we first discuss the possible cause and pathophysiology underlying dysphagia associated with coronavirus disease 2019, including cerebrovascular events, such as stroke, encephalomyelitis, encephalopathy, peripheral neuropathy, and myositis, that may lead to the dysphagia reported as a complication associated with the coronavirus disease 2019. Next, we present some recommendations for dysphagia evaluation with modifications that would allow a safe and comprehensive assessment based on available evidence to date, including critical considerations of the appropriate use of personal protective equipment and optimization individual's noninstrumental swallowing tasks evaluation, while preserving instrumental assessments for urgent cases only. Finally, we discuss a practical managing strategy for dysphagia rehabilitation to ensure safe and efficient practice in the risks of severe acute respiratory syndrome coronavirus 2 exposure, in which swallowing therapy using newer technology, such as telerehabilitation system or wearable device, would be considered as a useful option.

COVID-19 survivorship: How otolaryngologist-head and neck surgeons can restore quality of life after critical illness

Mortality from COVID-19 has obscured a subtler crisis – the swelling ranks of COVID-19 survivors. After critical illness, patients often suffer post-intensive care syndrome (PICS), which encompasses physical, cognitive, and/or mental health impairments that are often long-lasting barriers to resuming a meaningful life. Some deficits after COVID-19 critical illness will require otolaryngologic expertise for years after hospital discharge. There are roles for all subspecialties in preventing, diagnosing, or treating sequelae of COVID-19. Otolaryngologist leadership in multidisciplinary efforts ensures coordinated care. Timely tracheostomy, when indicated, may shorten the course of intensive care unit stay and thereby potentially reduce the impairments associated with PICS. Otolaryngologists can provide expertise in olfactory disorders; thrombotic sequelae of hearing loss and vertigo; and laryngotracheal injuries that impair speech, voice, swallowing, communication, and breathing. In the aftermath of severe COVID-19, otolaryngologists are poised to lead efforts in early identification and intervention for impairments affecting patients' quality of life.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

Obtaining Objective Clinical Measures During Telehealth Evaluations of Dysarthria

Purpose COVID-19 has shifted models of health care delivery, requiring the rapid adoption of telehealth, despite limited evidence and few resources to guide speech-language pathologists. Management of dysarthria presents specific challenges in the telehealth modality. Evaluations of dysarthria typically rely heavily on perceptual judgments, which are difficult to obtain via telehealth given a variety of technological factors such as inconsistencies in mouth-to-microphone distance, changes to acoustic properties based on device settings, and possible interruptions in connection that may cause video freezing. These factors limit the validity, reliability, and clinicians' certainty of perceptual speech ratings via telehealth. Thus, objective measures to supplement the assessment of dysarthria are essential. Method This tutorial outlines how to obtain objective measures in real time and from recordings of motor speech evaluations to support traditional perceptual ratings in telehealth evaluations of dysarthria. Objective measures include pause patterns, utterance length, speech rate, diadochokinetic rates, and overall speech severity. We demonstrate, through clinical case vignettes, how these measures were completed following three clinical telehealth evaluations of dysarthria conducted via Zoom during the COVID-19 pandemic. This tutorial describes how each of these objective measures were utilized, in combination with subjective perceptual analysis, to determine deviant speech characteristics and their etiology, develop a patient-specific treatment plan, and track change over time. Conclusion Utilizing objective measures as an adjunct to perceptual ratings for telehealth dysarthria evaluations is feasible under real-world pandemic conditions and can be used to enhance the quality and utility of these evaluations.

Telehealth for Dysphagia Across the Life Span: Using Contemporary Evidence and Expertise to Guide Clinical Practice During and After COVID-19

Purpose Our aim was to critically review recent literature on the use of telehealth for dysphagia during the COVID-19 pandemic and enhance this information in order to provide evidence- and practice-based clinical guidance during and after the pandemic. Method We conducted a rapid systematized review to identify telehealth adaptations during COVID-19, according to peer-reviewed articles published from January to August 2020. Of the 40 articles identified, 11 met the inclusion criteria. Full-text reviews were completed by three raters, followed by qualitative synthesis of the results and description of practical recommendations for the use of telehealth for dysphagia. Results Seven articles were guidelines articles, three were editorials, and one was a narrative review. One article focused on telehealth and dysphagia during COVID-19. The remaining 10 mentioned telehealth in varying degrees while focusing on dysphagia management during the pandemic. No articles discussed pediatrics in depth. The most common procedure for which telehealth was recommended was the clinical swallowing assessment (8/11), followed by therapy (7/11). Six articles characterized telehealth as a second-tier service delivery option. Only one article included brief guidance on telehealth-specific factors, such as legal safeguards, safety, privacy, infrastructure, and facilitators. Conclusions Literature published during the pandemic on telehealth for dysphagia is extremely limited and guarded in endorsing telehealth as an equivalent service delivery model. We have presented prepandemic and emerging current evidence for the safety and reliability of dysphagia telemanagement, in combination with practical guidelines to facilitate the safe adoption of telehealth during and after the pandemic.

COVID-19 and Speech-Language Pathology Clinical Practice of Voice and Upper Airway Disorders

Purpose Evaluation and management of voice and upper airway disorders in adults and children, by speech-language pathologists worldwide, have been significantly altered by the COVID-19 pandemic. Secondary to the pathogenic nature of the virus in the respiratory tract and upper airway, it is essential that speech-language pathologists who specialize in these disorders are knowledgeable of current practices to provide evidence-based care while minimizing viral transmission. Understanding how and when SARS-CoV-2 spreads is critical to the development of effective infection prevention within clinical practices. Method We established an evidence-based clinical practice guide for clinicians working with voice and upper airway through a comprehensive evaluation of peer-reviewed journals, non-peer-reviewed manuscripts on preprint servers, national health guidelines, and published and online consensus statements and emerging data. Emphasis was placed on risk mitigation for viral transmission via safe clinical practices, including evaluative procedures, therapy including telehealth, personal protective equipment, room, staffing, and distancing considerations. Results/Conclusions While knowledge relevant to viral transmission of SARS-CoV-2 is rapidly evolving, there is a paucity of literature specific to the evaluation and treatment of voice and upper airway disorders. Within these confines and given the potentially significant high risk of infection secondary to the nature of COVID-19, we summarize current considerations and recommend best practices that maximize risk mitigation whereby ensuring patient and provider safety.

Speech-Language Pathology and Audiology Care in the COVID-19 Era: Shared Experiences

Purpose

The COVID-19 pandemic has rapidly altered the global health-care system and stretched scarce resources to the limit. Resource limitations include personal protective equipment and medical devices; however, limited resources also include the more valuable health-care professional. Recent focus has been on the acute management of COVID-19. Still, there is a need to focus on the long-term rehabilitation of patients moving out of the acute treatment phase and into survivorship due to chronic respiratory concerns and other COVID-19 complications. Multidisciplinary, collaborative teams will support positive outcomes. Thus, speech-language pathologists too must carefully consider their role in patient care during a global pandemic. What makes the COVID-19 pandemic unique is the rapid minimally mitigated spread of the disease from close contact to most regions of the world. However, what appears to be true is a collective experience and common bond across regional borders.

Conclusions

Perhaps, this global pandemic may lead to a global partnership, a shared experience, and mutually dependent relationships. Global health is no longer “international service” or something that happens “over there”; global health is our reality.

Effects of face masks on acoustic analysis and speech perception: Implications for peri-pandemic protocols

Wearing face masks (alongside physical distancing) provides some protection against infection from COVID-19. Face masks can also change how people communicate and subsequently affect speech signal quality. This study investigated how three common face mask types (N95, surgical, and cloth) affected acoustic analysis of speech and perceived intelligibility in healthy subjects. Acoustic measures of timing, frequency, perturbation, and power spectral density were measured. Speech intelligibility and word and sentence accuracy were also examined using the Assessment of Intelligibility of Dysarthric Speech. Mask type impacted the power distribution in frequencies above 3 kHz for the N95 mask, and above 5 kHz in surgical and cloth masks. Measures of timing and spectral tilt mainly differed with N95 mask use. Cepstral and harmonics to noise ratios remained unchanged across mask type. No differences were observed across conditions for word or sentence intelligibility measures; however, accuracy of word and sentence translations were affected by all masks. Data presented in this study show that face masks change the speech signal, but some specific acoustic features remain largely unaffected (e.g., measures of voice quality) irrespective of mask type. Outcomes have bearing on how future speech studies are run when personal protective equipment is worn.

Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience

OBJECTIVES

As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.

RESULTS

During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status.

CONCLUSION

Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.

A Consensus Statement for the Management and Rehabilitation of Communication and Swallowing Function in the ICU: A Global Response to COVID-19

Objective

To identify core practices for workforce management of communication and swallowing functions in coronavirus disease 2019 (COVID-19) positive patients within the intensive care unit (ICU).

Design

A modified Delphi methodology was used, with 3 electronic voting rounds. AGREE II and an adapted COVID-19 survey framework from physiotherapy were used to develop survey statements. Sixty-six statements pertaining to workforce planning and management of communication and swallowing function in the ICU were included.

Setting

Electronic modified Delphi process.

Participants

Speech-language pathologists (SLPs) (N=35) from 6 continents representing 12 countries.

Interventions

Not applicable.

Main Outcome Measures

The main outcome was consensus agreement, defined a priori as ≥70% of participants with a mean Likert score ≥7.0 (11-point scale: 0=strongly disagree, 10=strongly agree). Prioritization rank order of statements in a fourth round was also conducted.

Results

SLPs with a median of 15 years of ICU experience, working primarily in clinical (54%), academic (29%), or managerial positions (17%), completed all voting rounds. After the third round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance.

Conclusions

A set of global consensus statements to facilitate planning and delivery of rehabilitative care for patients admitted to the ICU during the COVID-19 pandemic were agreed by an international expert SLP group. Statements focused on considerations for workforce preparation, resourcing and training, and the management of communication and swallowing functions. These statements support and provide direction for all members of the rehabilitation team to use for patients admitted to the ICU during a global pandemic.

How COVID-19 Patients Were Moved to Speak: A Rehabilitation Interdisciplinary Case Series

Background

Up to 36% of patients admitted to the ICU for COVID-19 require tracheostomy. While the literature recommends the use of multidisciplinary teams in the management of patients with tracheostomy for other diseases, little is known on the collaborative administration of physical therapy and speech language pathology services in the COVID-19 population.

Purpose

We sought to determine the outcomes of a collaboration between physical therapy (PT) and speech language pathology (SLP) in the treatment of patients who underwent tracheostomy placement as part of their treatment for COVID-19 at our facility.

Methods

We conducted a retrospective case series on patients with COVID-19 who had a tracheostomy. We included patients who had undergone mechanical ventilation for 14 days or longer, had a surgical tracheostomy, been discharged from intensive care to a medical unit, and received PT and SLP referrals. We compiled retrospective data from electronic medical records, analyzing days from tracheostomy to achievement of PT and SLP functional milestones, including mobility, communication, and swallowing. Of six critically ill patients with COVID-19 who had tracheostomy placement at our facility, three met inclusion criteria: patient 1, a 33-year-old woman; patient 2, an 84-year-old man; and patient 3, an 81-year-old man. For all patients, PT interventions focused on breathing mechanics, secretion clearance, posture, sitting balance, and upper and lower extremity strengthening. SLP interventions focused on cognitive reorganization, verbal and nonverbal communication, secretion management, and swallowing function. Intensity and duration of the sessions were adapted according to patient response and level of fatigue.

Results

We found that time to tracheostomy from intubation for the three patients was 23 days, 20 days, and 24 days, respectively. Time from tracheostomy insertion to weaning from ventilator was 9 days for patient 1, and 5 days for patient 2 and patient 3. Regarding time to achieve functional PT and SLP milestones, all patients achieved upright sitting with PT prior to achieving initial SLP milestone of voicing with finger occlusion. Variations in progression to swallowing trials were patient specific and due to respiratory instability, cognitive deficits, and limitations in production of an effortful swallow. Patient participation in therapy sessions improved following establishment of oral verbal communication.

Conclusion

Interdisciplinary cooperation and synchronized implementation of PT and SLP interventions in three COVID-19 patients following prolonged intubation facilitated participation in treatment and achievement of functional milestones. Further study is warranted.

Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach

PURPOSE

Critical care nurses caring for patients with a tracheostomy are at high risk because of the predilection of SARS-CoV-2 for respiratory and mucosal surfaces. This review identifies patient-centered practices that ensure safety and reduce risk of infection transmission to health care workers during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Consensus statements, guidelines, institutional recommendations, and scientific literature on COVID-19 and previous outbreaks were reviewed. A global interdisciplinary team analyzed and prioritized findings via electronic communications and video conferences to develop consensus recommendations.

RESULTS

Aerosol-generating procedures are commonly performed by nurses and other health care workers, most notably during suctioning, tracheostomy tube changes, and stoma care. Patient repositioning, readjusting circuits, administering nebulized medications, and patient transport also present risks. Standard personal protective equipment includes an N95/FFP3 mask with or without surgical masks, gloves, goggles, and gown when performing aerosol-generating procedures for patients with known or suspected COVID-19. Viral testing of bronchial aspirate via tracheostomy may inform care providers when determining the protective equipment required. The need for protocols to reduce risk of transmission of infection to nurses and other health care workers is evident.

CONCLUSION

Critical care nurses and multidisciplinary teams often care for patients with a tracheostomy who are known or suspected to have COVID-19. Appropriate care of these patients relies on safeguarding the health care team. The practices described in this review may greatly reduce risk of infectious transmission.

Respiratory Particle Emission During Voice Assessment and Therapy Tasks in a Single Subject

Introduction

SARS-CoV-2 is transmitted via respiratory particles. Respiratory particle emission is impacted by manner of breathing and voicing, as well as intersubject variability. Assessment and treatment of voice disorders may include tasks that increase respiratory particle emission beyond typical breathing and speaking. This could increase the risk of disease transmission via respiratory particles.

Methods

Respiratory particle emission was measured during a single-subject, repeated measures clinical simulation of acoustic and aerodynamic assessment and voice therapy tasks. An optical particle sizer was used to measure particle count (1–10 μm in diameter). Assessment and therapy tasks were completed in three conditions: (1) 15 cm from the device, (2) 1 m from the device, and (3) 1 m from the device with the subject wearing a surgical mask.

Results

Condition 1 generated the highest particle count, with a median of 5.1 (13) additional particles above baseline, which was statistically significant (U = 381.5, P= 0.002). In condition 1, therapy and acoustic tasks combined produced more particles compared to the baseline and speech tasks, with a median difference of 6.5 additional particles per time point (U = 309.0, P= 0.002). This difference was not significant for conditions 2 and 3. Peak particle generation occurred in specific phonatory tasks, which was most pronounced in condition 1. Voice therapy tasks during condition 1 generated the highest peaks of normalized total particles with classical singing and expiratory muscle strength training. There was a significant difference in the amount of particle generation between condition 1 and 2, with a median difference of 5.2 particles (U = 461.0, P= 0.002). The particle count difference between conditions 2 and 3 was 2.1 (U = 282.0, P= 0.292), and this difference was not significant. The normalized total particles were assessed over time for each condition. For all conditions, there was no significant accumulation of particles.

Conclusions

For a single subject, production of voice assessment and therapy tasks combined resulted in an increased number of respiratory particles compared to speech and baseline (1–10 μm). EMST and classical singing generated the greatest concentration of particles. Respiratory particle counts were higher at 15 cm from the particle sizer compared to 1 m from the particle sizer, suggesting that physical distancing may reduce immediate clinician exposure to respiratory particles. Particle concentration did not accumulate over time.

What Now for Rehabilitation Specialists? Coronavirus Disease 2019 Questions and Answers

Recognizing a need for more guidance on the coronavirus disease 2019 (COVID-19) pandemic, members of the Archives of Physical Medicine and Rehabilitation Editorial Board invited several clinicians with early experience managing the disease to collaborate on a document to help guide rehabilitation clinicians in the community. This consensus document is written in a “question and answer” format and contains information on the following items: common manifestations of the disease; rehabilitation recommendations in the acute hospital setting, recommendations for inpatient rehabilitation and special considerations. These suggestions are intended for use by rehabilitation clinicians in the inpatient setting caring for patients with confirmed or suspected COVID-19. The text represents the authors’ best judgment at the time it was written. However, our knowledge of COVID-19 is growing rapidly. The reader should take advantage of the most up-to-date information when making clinical decisions.

Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community

OBJECTIVES

To report experience with a global multidisciplinary tracheostomy e-learning initiative.

METHODS

An international multidisciplinary panel of experts convened to build a virtual learning community for tracheostomy care, comprising a web-based platform, five distance learning (interactive webinar) sessions, and professional discourse over 12 months. Structured pre- and post-webinar surveys were disseminated to global participants including otolaryngologists, intensivists, nurses, allied health professionals, and patients/caregivers. Data were collected on audio-visual fidelity, demographics, and pre- and post-tutorial assessments regarding experience and skill acquisition. Participants reported confidence levels for NICU, pediatric, adult, and family care, as well as technical skills, communication, learning, assessment, and subdomains.

RESULTS

Participants from 197 institutions in 22 countries engaged in the virtual education platform, including otolaryngologists, speech pathologists, respiratory therapists, specialist nurses, patients, and caregivers. Significant improvements were reported in communication (P < .0001), clinical assessments (P < .0001), and clinical governance (P < .0001), with positive impact on pediatric decannulation (P = .0008), adult decannulation (P = .04), and quality improvement (P < .0001). Respondents reported enhanced readiness to integrate knowledge into practice. Barriers included time zones, internet bandwidth, and perceived difficulty of direct clinical translation of highly technical skills. Participants rated the implementation highly in terms of length, ability for discussion, satisfaction, applicability to professional practice, and expertise of discussants (median scores: 4, 4, 4, 4 and 5 out of 5).

CONCLUSIONS

Virtual learning has dominated the education landscape during COVID-19 pandemic, but few data are available on its effectiveness. This study demonstrated feasibility of virtual learning for disseminating best practices in tracheostomy, engaging a diverse, multidisciplinary audience. Learning of complex technical skills proved a hurdle, however, suggesting need for hands-on experience for technical mastery. While interactive videoconferencing via webinar affords an engaging and scalable strategy for sharing knowledge, further investigation is needed on clinical outcomes to define effective strategies for experiential online learning and virtual in-service simulations.