Swallowing and Voice Outcomes in Patients Hospitalized With COVID-19: An Observational Cohort Study.

OBJECTIVE: To evaluate the presentations and outcomes of inpatients with coronavirus disease 2019 (COVID-19) presenting with dysphonia and dysphagia to investigate trends and inform potential pathways for ongoing care. DESIGN: Observational cohort study. SETTING: An inner-city National Health Service Hospital Trust in London, United Kingdom. PARTICIPANTS: All adult inpatients hospitalized with COVID-19 (N=164) who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months starting in April 2020. INTERVENTIONS: SLT assessment, advice, and therapy for dysphonia and dysphagia. MAIN OUTCOME MEASURES: Evidence of delirium, neurologic presentation, intubation, tracheostomy, and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy outcome measures were recorded for swallowing and tracheostomy pre- and post-SLT intervention and Grade Roughness Breathiness Asthenia Strain Scale for voice. RESULTS: Patients (N=164; 104 men) aged 56.8±16.7 years were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean, 15±6.6d), 13.4% had new neurologic impairment, and 69.5% were delirious. Individualized compensatory strategies were trialed in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice, but there was significant improvement in all during the study (P<.0001). On average, patients started some oral intake 2 days after initial SLT assessment (interquartile range [IQR], 0-8) and were eating and drinking normally on discharge, but 29.3% (n=29) of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. A total of 70.9% tracheostomized patients were decannulated, and the median time to decannulation was 19 days (IQR, 16-27). Among the 164 patients, 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice, and 7.8% required community follow-up for dysphagia. CONCLUSIONS: Inpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm, and a minority had new neurologic presentations. Patients typically improved with assessment that enabled treatment with individualized compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways.

Surface Electromyographic Biofeedback and the Effortful Swallow Exercise for Stroke-Related Dysphagia and in Healthy Ageing.

Dysphagia is common after stroke, leading to adverse outcome. The Effortful Swallow (ES) is recommended to improve swallowing but it is not known if dysphagic patients can increase muscle activity during the exercise or if age affects performance. Providing surface electromyographic (sEMG) biofeedback during dysphagia therapy may enhance exercise completion, but this has not been investigated and the technique's acceptability to patients is not known. Aims: To determine if age or post-stroke dysphagia affect the ability to increase submental muscle activity during the ES, if sEMG biofeedback improves ES performance and if sEMG is an acceptable addition to therapy. In a Phase I study submental sEMG amplitudes were measured from 15 people with dysphagia < 3 months post-stroke and 85 healthy participants aged 18-89 years during swallowing (NS) and when they performed the ES with and without sEMG biofeedback. Participant feedback was collected via questionnaire. Measurements were compared with repeated measures ANOVA and age effects were examined with linear regression. Both groups produced significantly greater muscle activity for the ES than NS (p < 0.001) and significantly increased activity with biofeedback (p < 0.001) with no effect of age. Participant feedback about sEMG was very positive; over 98% would be happy to use it regularly. The ES is a physiologically beneficial dysphagia exercise, increasing muscle activity during swallowing. sEMG biofeedback further enhances performance and is considered an acceptable technique by patients. These findings support the potential application of sEMG biofeedback and the ES in dysphagia therapy in stroke, justifying further investigation of patient outcome.

Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients.

PURPOSE: COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. METHODS: We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. RESULTS: At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. CONCLUSION: Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

Dysphagia in Duchenne muscular dystrophy assessed objectively by surface electromyography.

Objective swallowing assessment is indicated in the management of patients with Duchenne muscular dystrophy (DMD). Surface electromyography (sEMG) provides a non-invasive, objective method of quantifying muscle activity. It was hypothesised that the measurement of sEMG activity during swallowing would distinguish between preserved and disordered swallow function in DMD. This comparative study investigated the peak, duration, and relative timing of muscle activity during swallowing of four muscle groups: orbicularis oris, masseter, submental, and infrahyoid. The study included three groups of participants: Nine DMD patients with dysphagia (mean age = 21.7 ± 4.2 years), six DMD patients with preserved swallow function (21.0 ± 3.0 years), and 12 healthy controls (24.8 ± 3.1 years). Dysphagic DMD participants produced significantly higher normalised peak amplitude measurements than the healthy control group for masseter (61.77 vs. 5.07; p ≤ 0.01) and orbicularis oris muscles (71.87 vs. 26.22; p ≤ 0.05). Intrasubject variability for masseter peak amplitude was significantly greater for dysphagic DMD participants than the other groups (16.01 vs. 5.86 vs. 2.18; p ≤ 0.05). There were no differences in timing measurements between groups. Different characteristic sEMG waveforms were observed for the three groups. sEMG provides useful physiological information for the evaluation of swallowing in DMD patients, justifying further study.

Dysphagia in Duchenne muscular dystrophy assessed by validated questionnaire.

BACKGROUND: Duchenne muscular dystrophy (DMD) leads to progressive muscular weakness and death, most typically from respiratory complications. Dysphagia is common in DMD; however, the most appropriate swallowing assessments have not been universally agreed and the symptoms of dysphagia remain under-reported. AIMS: To investigate symptoms of dysphagia in DMD and to determine the potential of the validated Sydney Swallow Questionnaire (SSQ) to diagnose dysphagia in this patient group. METHODS & PROCEDURES: Three participant groups completed the SSQ and the results were compared: nine DMD participants with dysphagia, six DMD participants without dysphagia and 12 healthy controls. OUTCOMES & RESULTS: The questionnaire scores for dysphagic DMD participants were significantly higher than for non-dysphagic DMD participants (p = 0.039) and for healthy controls (p ≤ 0.001). The diagnostic ability of the questionnaire was good for detecting dysphagia in participants with DMD (receiver operating characteristic (ROC) area under the curve = 0.89, p = 0.013), with a cut-off score of 224.5 (13.2%) giving a sensitivity of 0.78 and a specificity of 0.83 for determining dysphagia. Dysphagic participants rated time to eat a meal, swallowing hard food, swallowing thick liquids and needing to cough up or spit during meals with the highest severity of all questionnaire items. Results of the questionnaire by item are presented to inform the clinician of the symptoms of dysphagia in DMD. CONCLUSIONS & IMPLICATIONS: DMD leads to pervasive symptoms of dysphagia. The simple SSQ is a clinically informative assessment tool for patients with DMD.

Thirst Interventions in Adult Acute Care-What Are the Recommended Management Options and How Effective Are They?: A Systematic Review.

PURPOSE: The aim of this study was to review the scope and quality of evidence for thirst treatment in adult acute care. METHODS: A systematic review was completed by 2 independent reviewers using MEDLINE, PubMed, BNI, EMBASE, EMCARE, and CINAHL databases and additional hand searching in June 2020. Interventions to relieve thirst for inpatients receiving acute care were included. Evidence was appraised against the levels of evidence for therapeutic studies, and a risk-of-bias assessment was completed for included studies. Outcomes are presented via narrative synthesis. Meta-analysis was planned. RESULTS: Four studies (out of 844) were eligible reporting thirst outcomes from 611 critical care patients. Meta-analysis could not be completed because a priori criteria were not met. Two randomized controlled trials represented the highest level of evidence. Thirst assessment was completed via a self-reported scale in all reviewed works. Interventions included cold water sprays or swabs, menthol lip moisturizer, and use of humidification. Three works demonstrate reduced thirst scores; all interventions in these studies exploit cooling effects to the oropharynx with the aim of preabsorptive satiation of thirst. A humidified oxygen circuit showed a neutral response when compared with a nonhumidified circuit. CONCLUSIONS: There is a limited but growing evidence base related to thirst treatment in the acute setting. Studies using a "bundle" of topical interventions incorporating cooling and menthol treatments showed positive effects in reducing symptom burden. Work to explore the scope of application for thirst treatment for patients unable to self-report, consideration of sustained effects, and a study of individual versus combined effects of bundle elements would be welcomed as the evidence base continues to develop.

Role of speech and language therapy in managing dysphagia and dysphonia in lung cancer.

A 75-year-old person was referred to speech and language therapy for voice rehabilitation following diagnosis of unilateral vocal cord palsy, secondary to relapsed non-small-cell lung cancer. On assessment, the patient presented with moderate-severe dysphonia. In addition, they presented with moderate pharyngeal stage dysphagia with risk of silent aspiration, which was successfully managed using a simple head turn strategy. This presentation is not atypical for patients who have disease in the upper chest or mediastinum and an increase in awareness and anticipation of such symptoms, with timely referral to appropriate specialist services, could help prevent complications associated with dysphagia, such as aspiration pneumonia and worse quality of life.