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.

Prevalence and recovery of dysphonia in COVID-19 patients requiring intensive care treatment.

BACKGROUND: Dysphonia and laryngeal pathology are considerable issues in patients hospitalised with COVID-19 with prevalence rates cited between 29% and 79%. Most studies currently are limited to reporting single-institution data with many retrospective. OBJECTIVES: The aims of this study were to prospectively explore the following: (i) prevalence; (ii) treatment; and (iii) recovery pattern and outcomes for dysphonia, in patients with COVID-19 requiring intensive care unit (ICU) treatment. METHODS: Patients admitted to 26 ICUs over 12 months, diagnosed with COVID-19, treated for survival, and seen by speech-language pathology for clinical voice assessment were considered. Demographic, medical, speech-language pathology treatment, and voice outcome data (grade, roughness, breathiness, asthenia, strain [GRBAS]) were collected on initial consultation and continuously monitored throughout the hospital admission. FINDINGS: Two-hundred and thirty five participants (63% male, median age = 58 yrs) were recruited. Median mechanical ventilation duration and ICU and hospital lengths of stay (LOSs) were 16, 20, and 42 days, respectively. Dysphonia prevalence was 72% (170/235), with 22% (38/170) exhibiting profound impairment (GRBAS score = 3). Of those with dysphonia, rehabilitation was provided in 32% (54/170) cases, with dysphonia recovery by hospital discharge observed in 66% (112/170, median duration = 35 days [interquartile range = 21-61 days]). Twenty-five percent (n = 42) of patients underwent nasendoscopy: oedema (40%, 17/42), granuloma (31%, 13/42), and vocal fold palsy/paresis (26%, 11/42). Presence of dysphonia was inversely associated with the number of intubations (p = 0.002), intubation duration (p = 0.037), ICU LOS (p = 0.003), and hospital LOS (p = 0.009). Conversely, duration of dysphonia was positively associated with the number of intubations (p = 0.012), durations of intubation (p = 0.000), tracheostomy (p = 0.004), mechanical ventilation (p = 0.000), ICU LOS (p = 0.000), and hospital LOS (p = 0.000). More severe dysphonia was associated with younger age (p = 0.045). Proning was not associated with presence (p = 0.075), severity (p = 0.164), or duration (p = 0.738) of dysphonia. CONCLUSIONS: Dysphonia and laryngeal pathology are common in critically ill patients with COVID-19 and are associated with younger age and protracted recovery in those with longer critical care interventions.

Speech pathology assessment of dysphagia post endotracheal extubation: A service-model evaluation.

BACKGROUND: As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h. OBJECTIVES: The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU. RESULTS: There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU. CONCLUSION: The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility.

Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW.

BACKGROUND: The impact of COVID-19 on swallowing function is not well understood. Despite low hospital admission rates in Australia, the virus and subsequent treatment affects swallow function in those requiring intensive care unit (ICU) treatment. As such, the current pandemic provides a unique opportunity to describe swallowing function and outline dysphagia characteristics and trajectory of recovery for a series of cases across NSW. AIM: The aims of this study were to describe (i) physiological characteristics of swallowing dysfunction and (ii) pattern of swallowing recovery and outcomes, in ICU patients with COVID-19. METHODS: All patients admitted to 17 participating NSW Health ICU sites over a 12-month period (March 2020-March 2021), diagnosed with COVID-19, treated with the aim for survival, and seen by a speech pathologist for clinical swallowing examination during hospital admission were considered for inclusion. Demographic, critical care airway management, speech pathology treatment, and swallowing outcome data were collected. RESULTS: Twenty-seven patients (22 male; 5 female) with a median age of 65 years (interquartile range [IQR] = 15.5) were recruited. All required mechanical ventilation. Almost 90% of the total cohort had pre-existing comorbidities, with the two most frequently observed being diabetes (63%, 95% confidence interval = 44%-78%) and cardiac disease (59%, 95% confidence interval = 40%-75%) in origin. Prevalence of dysphagia was 93%, with the majority (44%) exhibiting profound dysphagia at the initial assessment. Median duration to initiate oral feeding was 38.5 days (IQR = 31.25) from ICU admission, and 33% received dysphagia rehabilitation. Dysphagia recovery was observed in 81% with a median duration of 44 days (IQR = 29). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU length of stay, and the duration to speech pathology assessment (p < 0.005), dysphagia severity (p < 0.002), commencing oral intake (p < 0.02), dysphagia recovery (p < 0.004), and enteral feeding (p < 0.024). CONCLUSION: COVID-19 considerably impacted swallowing function in the current study. Although many patients recovered within an acceptable timeframe, some experienced persistent severe dysphagia and a protracted recovery with dependence on enteral nutrition.

Endogenous Endophthalmitis From Methicillin-Resistant Staphylococcus aureus Bacteremia Treated With Ceftaroline.

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia may lead to endogenous endophthalmitis (EE), an uncommon disease process described mainly in case series and case reports. It is considered an ophthalmologic emergency requiring prompt diagnosis and treatment with systemic intravenous and intravitreal antibiotics to improve mortality and prevent blindness. The management of MRSA EE represents a challenge, as there are no established guidelines for treatment or outcomes. In our case report, we demonstrate that ceftaroline may be considered as an alternative option to treat MRSA EE in lieu of vancomycin due to drug-induced rash, given the promising penetration of the blood brain barrier and low minimum inhibitory concentration (MIC) values for most Staphylococcus aureus isolates.

Glycopeptide Hypersensitivity and Adverse Reactions.

Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with ß-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.

Ablative fractional resurfacing for burn scar management affects the number and type of elective surgical reconstructive procedures, hospital admission patterns as well as length of stay.

BACKGROUND: Reconstructive surgery remains the main approach to address burn scar contractures. Ablative fractional resurfacing is an increasingly popular tool for severe burn scar management, but its effect on overall burns reconstructive case-mix, operating time and patterns of hospital admission have not been reported. METHODS: Retrospective analysis of hospital administrative data from September 2013 to June 2017 was performed evaluating these effects of ablative fractional CO2 laser (CO2-AFL). RESULTS: The total number of acute burn patients treated at CRGH increased substantially over this timeframe, resulting in 412 elective procedures including 82 before and 330 after introducing CO2-AFL. The proportion of traditional non-laser reconstructive procedures dropped considerably to 23.9% in about 2.5 years following CO2-AFL introduction. This change in approach had a profound effect on LOS with average LOS being 1.96days for non-laser and 0.36days for CO2-AFL-procedures (p<0.001). Anaesthetic times also decreased significantly, with median durations at 90min pre-laser and 64min post-laser introduction (p<0.001), and median anaesthetic times at 87min (non-AFL) and 57min (AFL procedures) (p<0.001). CONCLUSION: AFL profoundly affects elective reconstructive burn case mix with a replacement of conventional reconstructive operations in favour of AFL-procedures. This results in reductions of average LOS and anaesthetic times. Consequently, increased use of AFL in burn scar management could potentially reduce overall costs associated with burn scar reconstruction.

Ablative Fractional Resurfacing in Acute Care Management of Facial Burns: A New Approach to Minimize the Need for Acute Surgical Reconstruction.

Current evidence suggests awaiting for scars to fully mature before engaging surgical reconstruction unless acute indications to prevent secondary damage, such as microstomia and eyelid ectropion are apparent. To evaluate the efficacy of ablative fractional CO2 laser intervention early in the acute treatment of panfacial burn injury. A 39-year-old Asian male with 60% TBSA flame burns including panfacial involvement was developing microstomia and upper and lower eyelid ectropion early proceeding epithelialization. At 6-weeks postinjury, ablative fractional CO2 laser treatment was commenced while still in the intensive care unit, and subsequently delivered at regular intervals. Nonsurgical scar contracture management was provided concurrently as per site specific standard protocols. Measurements and photographic data relative to deficits in eye and mouth competence were obtained at rest, as well as maximal opening at baseline and routinely until scar stabilization was reached. The outcomes were subsequently compared with facial burn patient historical data within our facility. No significant difference was identified in the functional ROM for mouth and eye regions; treatment duration was, however, shorter and aesthetic outcomes were considered superior to their surgical reconstruction counterparts in the historical cohort. This case report reveals that early ablative fractional CO2 resurfacing treatment, coalesced with nonsurgical scar management is an efficacious interventional approach to abate contractures to the face, accelerates and enhances scar maturation processes and may alleviate the need for surgical scar reconstructions. Moreover, optimal aesthetic outcomes may be achieved compared with traditional reconstructive methods.

Dysphagia in older persons following severe burns: Burn location is irrelevant to risk of dysphagia and its complications in patients over 75 years.

BACKGROUND: Management of burns in older persons is complex with evidence indicating advanced age is associated with elevated risk for morbidity and mortality. Dysphagia and its sequelae may further increase this risk. AIMS: (1) Determine the prevalence, and (2) identify risk factors for dysphagia in patients admitted with severe burn injury over 75 years. METHODS: All patients >75 years admitted to Concord Repatriation General Hospital with severe burn injury over a 4-year period (2013-2017) were assessed for dysphagia on presentation and continually monitored throughout their admission. Burn injury, demographic and nutritional data were captured and analysed for association with and predictive value for dysphagia. RESULTS: Sixty-six patients (35 male; 31 female) aged 75-96 years (median 82 years) were recruited. Dysphagia was identified in 46.97% during their hospital admission. Dysphagia was significantly associated with burn size, pre-existing cognitive impairment, mechanical ventilation, duration of enteral feeding, hospital length of stay, in-hospital complications and mortality. No association was identified between burn location, burn mechanism, surgery and dysphagia. Burn size and Malnutrition Screening Tool score were found to be independent predictors for dysphagia. CONCLUSIONS: Dysphagia prevalence is high in older persons with burns and is associated with increased morbidity and mortality, regardless of burn location.

Intensive swallowing and orofacial contracture rehabilitation after severe burn: A pilot study and literature review.

BACKGROUND: Dysphagia following severe burns can be significant and protracted, yet there is little evidence describing the rehabilitation principles, process or outcomes. PURPOSE: Outline current evidence and detail the clinical outcomes of two cases who underwent a multifaceted intensive treatment programme aimed at rehabilitating dysphagia by strengthening swallow function and minimising orofacial contractures after severe head and neck burns. METHODS: Two men (54 and 18 years) with full-thickness head and neck burns and inhalation injury underwent intensive orofacial scar management and dysphagia rehabilitation. Therapy was prescribed, consisting of scar stretching, splinting and pharyngeal swallow tasks. Horizontal and vertical range of movement (HROM; VROM), physiological swallow features, functional swallowing outcomes and related distress, were collected at baseline and routinely until dysphagia resolution and scar stabilisation. RESULTS: At presentation, both cases demonstrated severely reduced HROM and VROM, profound dysphagia and moderate dysphagia related distress. Therapy adherence was high. Resolution of dysphagia to full oral diet, nil physiological swallowing impairment, and nil dysphagia related distress was achieved by 222 and 77 days post injury respectively. VROM and HROM achieved normal range by 237 and 204 days. CONCLUSION: Active rehabilitation achieved full functional outcomes for swallowing and orofacial range of movement. A protracted duration of therapy can be anticipated in this complex population.

Orofacial Contracture Management: Current Patterns of Clinical Practice in Australian and New Zealand Adult Burn Units.

Burn injury to the face can lead to scarring and contractures that may impair oral competence for articulation, feeding, airway intubation access, oral/dental hygiene, aesthetics, and facial expression. Although a range of therapy interventions has been discussed for preventing contracture formation, there is minimal information on current practice patterns. This research examined patterns of clinical practice for orofacial burns management during a 4-year period to determine the nature and extent of clinical consistency in current care. Allied health clinicians involved in orofacial contracture management in Australia and New Zealand were surveyed at two time points (2010 and 2014). Twenty and 23 clinicians, respectively, across a range of allied health professions completed the surveys. Both surveys revealed multiple allied health disciplines, predominantly occupational therapy, speech language pathology, and physiotherapy, were involved orofacial burn management. A high degree of variation was observed across clinical practices in the 2010 survey. In the 2014 survey, although, greater consistency in practice patterns was observed with more clinicians commencing intervention earlier, with greater treatment intensity observed and more treatment modalities being used. Furthermore, in 2014, there was an increased use of assessment tools and clinical indicators to guide patient treatment. Agreement regarding clinical practice pathways for orofacial contracture rehabilitation is still emerging, and treatment continues to be predominantly guided by clinical experience. There is an urgent need for treatment efficacy research utilizing validated outcome measure tools to inform clinical consensus and practice guidelines.

The speech-language pathologist's role in multidisciplinary burn care: An international perspective.

PURPOSE: To explore international practices of speech-language pathology (SLP) within burn care in order to provide direction for education, training and clinical practice of the burns multidisciplinary team (MDT). METHOD(S): A 17-item online survey was designed by two SLPs experienced in burn care with a range of dichotomous, multiple choice and open-ended response questions investigating the availability and scope of practice for SLPs associated with burn units. The survey was distributed via professional burn association gatekeepers. All quantitative data gathered were analysed using descriptive statistics and qualitative data were analysed using content analysis. RESULT(S): A total of 240 health professionals, from 6 different continents (37 countries) participated within the study. All continents reported access to SLP services. Referral criteria for SLP were largely uniform across continents. The most dominant area of SLP practice was assessment and management of dysphagia, which was conducted in concert with other members of the MDT. CONCLUSION: SLP has an international presence within burn care that is currently still emerging.

Impaired laryngopharyngeal sensitivity in patients with COPD: the association with swallow function.

Research indicates that patients with Chronic Obstructive Pulmonary Disease (COPD) have increased aspiration risk. Several factors may pre-dispose a patient to aspiration including a reduction in laryngopharyngeal sensitivity (LPS). Reduced LPS has been associated with increased aspiration risk in pathologies including stroke; however, this has not been examined in COPD. This study aims to explore possible associations between LPS and swallowing function in COPD patients, and determine whether a LPS predictive value may be used as a method of evaluating dysphagia risk in this patient population. Twenty participants with COPD underwent LPS discrimination testing, respiratory function testing, self-reporting swallowing questionnaire, clinical swallowing examination, and fibre-optic endoscopic evaluation of swallowing (FEES). Participants with COPD demonstrated impaired LPS defined by elevated laryngeal adductor reflex thresholds and high incidence of pharyngeal residue on FEES. Positive correlations were identified between their clinical swallowing examination and FEES results for the presence of laryngeal penetration/aspiration (p < 0.04), vallecular residue (p < 0.01), and piriform residue (p < 0.01). In conclusion, COPD patients have reduced laryngopharyngeal mechanosensitivity and impaired swallowing function characterized primarily by pharyngeal stasis. The combination of these deficits may place patients with COPD at increased aspiration risk due to lack of detection of pharyngeal residue and subsequent inhalation of pharyngeal contents.

The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity.

Patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of aspiration secondary to impaired swallow function. One possible cause of this impairment is a reduction in laryngopharyngeal sensitivity. The relationship between COPD and laryngopharyngeal sensitivity has not been previously determined. We conducted a study to investigate the effect of COPD on laryngopharyngeal sensitivity by using laryngopharyngeal sensory discrimination testing (LPSDT). Our study population was made up of 20 adults (mean age: 71.7 yr) with clinically proven COPD and 11 healthy, age-matched controls. All 31 subjects underwent LPSDT with the use of an air-pulse stimulator via a nasendoscope. The threshold of laryngopharyngeal sensation was evaluated by measuring the amount of air pressure required to elicit the laryngeal adductor reflex (LAR). We found that the patients with COPD had a significantly higher LAR threshold than did the controls (p< 0.001). We conclude that patients with COPD have significantly less mechanosensitivity in the laryngopharynx. This sensory change may place patients with COPD at increased risk for aspiration.

Rehabilitation of speech and swallowing after burns reconstructive surgery of the lips and nose.

Rehabilitation of speech and swallowing postburns reconstructive surgery has not been previously described in detail in the literature. Severe facial burn injury requiring subsequent reconstructive surgery may result in complications including circumoral contracture and aesthetic and functional irregularities. These complications may manifest as facial and labial sensation deficits, poor oral access for intubation and oral/dental hygiene, and inadequate oral competence causing chronic drooling and poor articulation. This report describes the physical rehabilitation of a patient with full-thickness burns to the nose, lips, mouth, and chin following electrical burn injury. The severity of injury sustained placed the patient at high risk for microstomia, dysphagia, and speech disorder. A multidisciplinary team approach was used to coordinate the planning of reconstructive procedures, facilitate patient recovery, and optimize functional and aesthetic outcomes. Speech pathology intervention aimed to 1) facilitate safe transition from nonoral to oral intake, 2) improve articulation and speech intelligibility, and 3) minimize oral contracture development. At 6 months postinjury, the patient can safely tolerate a soft diet, demonstrate speech clarity at preinjury level, and has recovered functional oral range of movement. Rehabilitation of speech and swallowing is an essential factor to consider when planning postburn reconstructive procedures.

Management of dysphagia in toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS).

Toxic epidermal necrolysis (TEN) is a rare and potentially fatal skin disorder, precipitated by severe allergic drug reaction, and is one of a spectrum of conditions, which includes Stevens-Johnson syndrome (SJS). Mucosal involvement is common, resulting in extreme pain on swallowing and poor oral intake. The aim of this study was to describe swallow function in TEN and SJS and define the role of Speech Pathology in management. The Burns Unit database was reviewed for patients that presented over a five-year period with TEN and SJS. Diagnosis of TEN and SJS was confirmed by skin biopsy. Information specific to swallow function, treatment approaches, and adequacy of oral intake was collected. Fourteen patients' medical records were studied: eight TEN, two TEN/SJS spectrum, and four SJS. The majority had mucosal involvement causing odynophagia, poor oral intake, an ability to tolerate fluids more easily than solids, and increased aspiration risk. These symptoms were confirmed by Speech Pathology swallowing assessment. Severe mucosal involvement resulting in odynophagia, dysphagia, and poor oral intake is common in TEN and SJS. The speech pathologist is able to assess swallow function and provide recommendations to promote safe oral intake, minimize odynophagia, and facilitate nutritional input critical to optimizing recovery.