Dysphagia in Patients With Severe Coronavirus Disease 2019-Potential Neurologic Etiologies

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.

Accuracy of the volume-viscosity swallow test for clinical screening of dysphagia in post COVID-19 patients

BACKGROUND & AIMS

Up to 30% of patients hospitalized for COVID-19 had oropharyngeal dysphagia, particularly those in the ICU. Many cases remained underdiagnosed due to difficulties in conducting instrumental evaluations during the pandemic. Consequently, screening tests were mandatory during this period.

OBJECTIVES

To evaluate the accuracy of the volume-viscosity swallow test (V-VST), compared to gold standard videofluoroscopy, for screening dysphagia in a post-COVID cohort of patients.

MATERIAL AND METHODS

We conducted a prospective single-center study involving 58 post-COVID adult patients with no previous history of dysphagia. Blinded raters performed the index V-VST upon admission and a standardized videofluoroscopy (VFSS, the reference test) within 72 h of patient intake. Oropharyngeal residue was considered a sign of impaired efficacy. Cough, decreased oxygen saturation, and voice changes were noted as signs of impaired safety. Accuracy, sensitivity, specificity, positive, and negative predictive values, and likelihood ratios were calculated for V-VST results and compared to the gold standard.

RESULTS

Patients (aged 59.98 (SD11.53) years) spent a mean of 46.98 (SD 28.43) days in ICU, 33.76 (SD34.88) days with tracheostomy, and 19.46 (SD13.26) days in the NeuroRehabilitation Unit. The V-VST showed the following properties, compared to VFSS: sensitivity 55.6%, specificity 62.9%, positive predictive value 44.5%, negative predictive value 37.1%, and accuracy 61.5%.

CONCLUSION

The V-VST showed mild accuracy, sensitivity, and specificity, compared to VFSS. Therefore, it should not be used as a stand-alone test for screening dysphagia in patients with a history of COVID.

Comparative Analysis of the Prevalence of Dysphagia in Patients with Mild COVID-19 and Those with Aspiration Pneumonia Alone: Findings of the Videofluoroscopic Swallowing Study

Background and Objectives: Patients recovering from mild coronavirus disease (COVID-19) reportedly have dysphagia or difficulty in swallowing. We compared the prevalence of dysphagia between patients diagnosed with mild COVID-19 and those diagnosed with aspiration pneumonia alone. Materials and Methods: A retrospective study was conducted from January 2020 to June 2023 in 160 patients referred for a videofluoroscopic swallowing study (VFSS) to assess for dysphagia. The cohort included 24 patients with mild COVID-19 and aspiration pneumonia, 30 with mild COVID-19 without aspiration pneumonia, and 106 with aspiration pneumonia alone. We reviewed the demographic data, comorbidities, and VFSS results using the penetration-aspiration scale (PAS) and functional dysphagia scale (FDS). Results: In a study comparing patients with mild COVID-19 (Group A) and those with aspiration pneumonia alone (Group B), no significant differences were observed in the baseline characteristics, including the prevalence of dysphagia-related comorbidities between the groups. Group A showed milder dysphagia, as evidenced by lower PAS and FDS scores, shorter oral and pharyngeal transit times (p = 0.001 and p = 0.003, respectively), and fewer residues in the vallecula and pyriform sinuses (p < 0.001 and p < 0.03, respectively). When Group A was subdivided into those with COVID-19 with (Group A1) and without aspiration pneumonia (Group A2), both subgroups outperformed Group B in terms of specific VFSS metrics, such as oral transit time (p = 0.01), pharyngeal transit time (p = 0.04 and p = 0.02, respectively), and residue in the vallecula (p = 0.04 and p = 0.02, respectively). However, Group B showed improved triggering of the pharyngeal swallowing reflex compared with Group A2 (p = 0.02). Conclusion: Mild COVID-19 patients showed less severe dysphagia than those with aspiration pneumonia alone. This finding was consistent across VFSS parameters, even when the COVID-19 group was subdivided based on the status of aspiration pneumonia.

[S1 guidelines for the management of postviral conditions using the example of post-COVID-19]

These S1 guidelines are an updated and expanded version of the S1 guidelines on long COVID differential diagnostic and management strategies. They summarize the state of knowledge on postviral conditions like long/post COVID at the time of writing. Due to the dynamic nature of knowledge development, they are intended to be "living guidelines". The focus is on practical applicability at the level of primary care, which is understood to be the appropriate place for initial access and for primary care and treatment. The guidelines provide recommendations on the course of treatment, differential diagnostics of the most common symptoms that can result from infections like with SARS-CoV-2, treatment options, patient management and care, reintegration and rehabilitation. The guidelines have been developed through an interdisciplinary and interprofessional process and provide recommendations on interfaces and possibilities for collaboration.

[Neurointensive care medicine and COVID-19]

This review article summarizes important findings on the interfaces between the coronavirus disease 2019 (COVID-19) pandemic and neurology with an emphasis of the implications for neurointensive care medicine. More specifically, the prevalence, pathomechanisms and impact of neurological manifestations are reported. The most common neurological manifestations of critically ill COVID-19 patients are cerebrovascular complications, encephalopathies and intensive care unit-acquired weakness (ICUAW). A relevant direct pathophysiological effect by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) itself has not yet been established with certainty. In fact, indirect systemic inflammatory processes triggered by the viral infection and side effects of intensive care treatment are much more likely to cause the reported sequelae. The impact of the pandemic on patients with neurological disorders and neurointensive care medicine is far-reaching but not yet sufficiently studied.

[The Respiratory Therapist in Neurology An Evolving Specialization in Germany]

In Germany, nurses, physiotherapists and speech and language therapists follow a qualifying training for about 1,5 years to become respiratory therapists (RTs). With respect to neurological illness, RTs diagnose and treat disorders of respiration, cough and swallowing as well as a retention of tracheobronchial secretions. There is an increasing demand for RTs in neurology, in neurointensive care and in neurological and neurosurgical early rehabilitation. The certification of specialized centers for weaning in neurological and neurosurgical early rehabilitation was introduced by the German Society for Neurorehabilitation (DGNR) in 2021. As a certification criterion it includes the employment of a respiratory therapists. In neurological organizations treating critically and severely ill patients, RTs work at an important interdisciplinary intersection of physicians, nurses and therapists. RTs are qualified to train teams, patients and family caregivers and to establish care structures for critically and severely ill neurological patients. Due to the complexity of neurological illnesses RTs working in neurological institutions need specific qualification. Specific training for RTs in neurology and neurorehabilitation might improve care for critically and severely ill neurological patients. Further professionalization of RT in Germany requires standardizing curricula, a professional society for RTs and, finally, academization.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

An International Commentary on Dysphagia and Dysphonia During the COVID-19 Pandemic

COVID-19 has had an impact globally with millions infected, high mortality, significant economic ramifications, travel restrictions, national lockdowns, overloaded healthcare systems, effects on healthcare workers' health and well-being, and large amounts of funding diverted into rapid vaccine development and implementation. Patients with COVID-19, especially those who become severely ill, have frequently developed dysphagia and dysphonia. Health professionals working in the field have needed to learn about this new disease while managing these patients with enhanced personal protective equipment. Emerging research suggests differences in the clinical symptoms and journey to recovery for patients with COVID-19 in comparison to other intensive care populations. New insights from outpatient clinics also suggest distinct presentations of dysphagia and dysphonia in people after COVID-19 who were not hospitalized or severely ill. This international expert panel provides commentary on the impact of the pandemic on speech pathologists and our current understanding of dysphagia and dysphonia in patients with COVID-19, from acute illness to long-term recovery. This narrative review provides a unique, comprehensive critical appraisal of published peer-reviewed primary data as well as emerging previously unpublished, original primary data from across the globe, including clinical symptoms, trajectory, and prognosis. We conclude with our international expert opinion on what we have learnt and where we need to go next as this pandemic continues across the globe.

[Guideline S1: Long COVID: Diagnostics and treatment strategies]

This guideline comprises the state of science at the time of the editorial deadline. In view of the high turnover of knowledge the guideline is designed as a living guideline. The main objective was to provide a tool for the use in primary care, being considered well suited as a first point of entry and for the provision of care. The guideline gives recommendations on the differential diagnosis of symptoms following SARS-CoV‑2 infection, on their therapeutic options, as well as for guidance and care of the patients concerned. It also offers advice concerning return to daily life and rehabilitation. Long COVID being a very variable condition, we chose an interdisciplinary approach.

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

Eine COVID-19-Erkrankung kann zu schweren Krankheitsverläufen mit multiplen Organbeteiligungen und respiratorischen und neurologischen Funktionseinschränkungen führen. Schluckstörungen (Dysphagien) können in dieser Patientengruppe durch primäre Schädigungen des zentralen und peripheren neuronalen Netzwerkes der Schluckfunktion entstehen, aber auch bedingt durch die häufig längere intensivmedizinische Behandlung und Beatmung. Erste klinische Befunde zeigen persistierende Dysphagien im Rahmen des Post-COVID-Syndroms („Long-COVID“), sodass die Patienten auch längerfristige Maßnahmen zur Rehabilitation einer sicheren und suffizienten oralen Nahrungsaufnahme benötigen. Daher sollte in die Behandlung von COVID-19-Patienten ein strukturiertes erkrankungsspezifisches Monitoring in Bezug auf Dysphagiesymptome integriert werden, und atemtherapeutische Maßnahmen zur Regulation von Husteneffektivität und Atem-Schluck-Koordination sollten auch bei diesen Patienten essenzieller Bestandteil des Dysphagiemanagements sein. Herausforderungen ergeben sich dabei einerseits durch die erforderlichen Anpassungen etablierter Behandlungsstandards an den Infektionsschutz. Zudem müssen Auswahl und Durchführungsintensität therapeutischer Maßnahmen an die Kapazitäten und die spezifische Pathophysiologie der COVID-19- und Long-COVID-Patienten angepasst werden, um weitere funktionelle Verschlechterungen zu vermindern.