Introduction
Effect on Clinical Practice
Aerosol Generating Procedures
Well-Being
Dysphagia Management Innovations
Hospitalized Patients Presenting with Dysphagia
Acute Care (ICU Patients)
Author(s), Country, Study Type | N (% Male) | Age (in years) | Comorbidity/ Condition: %, Etiology | Laryngeal injuries | Hospital, ICU, Intubation, Mechanical Ventilation | Tracheostomy | Swallowing |
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Archer et al. [53] UK Prospective Cohort | 164 (63) Hospitalized and referred to SP | Mean = 57 SD = 17 | 34 Hypertension 29 Diabetes 23 Respiratory 13 BMI ≥ 30 10 CHD 9 Dementia 8 CKD 8 Cancer 4 Stroke 7 Other neurological | Endoscopies completed (n = 11) 5 Granulomas 3 Vocal cord palsy/paresis 3 Edema | Prevalence of Intubation 129/164 (79%) Intubation duration Mean = 15 days SD = 7 days | Tracheostomy placement 85/164 (52%) Time to Decannulation From trach insertion Median = 19 days IQR = 16, 27 days 71% decannulated within 2 months | 97% dysphagia before intervention 99 followed to hospital d/c: 31% with dysphagia |
Boggiano et al. [68] UK Retrospective cohort | 16 (69%) Hospitalized, referred to SP for FEES following intubation and/ or tracheostomy | Median = 56 IQR = 43–63 | 9 Hypertension 7 Diabetes 4 Obesity 3 Asthma 1 IHD 2 Hypercholesterolemia 2 Gout 2 Hypothyroidism 1 Cancer 4 Stroke 11 Other | Median 3 (IQR 2–4) laryngeal abnormalities; 63% clinically significant Edema 12 (75%) Abnormal movement 12 (75%) Atypical lesions 11 (69%) Erythema 6 (68%) Airway patency effecting tracheostomy weaning 8 (50%) | Days in ICU Median = 51 days Intubation Duration Median = 27 days | Tracheostomy placement 14 (88%) Time to Decannulation Median 34 days | FEES Signs of dysphagia 16 (100%) Aspiration 8 (50%) Silent aspiration 7 Targeted dysphagia therapy required 7 (44%) |
Dawson et al. [15] UK Prospective Cohort | 736 hospital admissions 720 (98%) admitted > 3 days 208 (29%) referred for swallowing assessment | Mean = 68 SD = 18 | - | 5 Vocal cord palsy Unquantified laryngeal edema Secretions with expectoration | ICU admissions Study-wide 204/720 (28%) intubated Referred to SLP 102/204 (50%) Intubation duration Oral ETT only Mean = 10 days SD = 6 days Oral ETT before tracheostomy placement Mean = 14 days SD = 4 days | Tracheostomy placement ICU admissions 82/204 (40%) Referred to SLP 82/102 (80%) | Oral Intake Started From oral extubation Mean = 5 days SD = 2 days From trach insertion Mean = 15 days SD = 7 days IDDSI Level ICU 2%: Level 7 33%: Levels 1–6 67%: NPO Ward 29%: Level 7 22%: NPO Hospital discharge 63%: Level 6/7 7%: NPO |
Dziewas et al. [106] Germany Prospective Case Series | 6 (100) Hospitalized, tracheostomized patients who survived ARDS and intubation | Median = 58 IQR = 52,60 | Comorbidity by Patient Patients 1, 2, 6 None Patient 3 Hypertension, CHD Patient 4 Hypothyroidism Patient 5 Morbid obesity, CHF, atrial fibrillation | 2 Unilateral vocal fold palsy 1 Bilateral vocal fold adductor paresis 1 irregular arytenoid cartilage movement | Duration of Mechanical Ventilation Median = 22 days IQR = 14, 30 days | Tracheostomy placement 6/6 (100%) Placement timing from oral intubation Median = 8 days IQR = 6, 9 Decannulation 3/6 (50%) Time to Decannulation Post-intubation Median = 38 days IQR = 28, 54 days | FEES 2 Silent aspiration 6 Reduced laryngeal sensation 3 Reduced spontaneous swallowing 3 Impaired secretion management 3 Pharyngeal weakness 1 Impaired oral control |
Grilli et al. [79] Italy Prospective Case Series | 41 (49%) Hospitalized | Median = 52 Range = 18–84 | Exclusions: previous neurological history & sarcopenia | Not reported | None required intubation | - | Post-acute phase of disease: 8 had dysphagia symptoms on Volume–Viscosity Test (VVST) 2 reported swallowing difficulties on Swallowing Disturbance Questionnaire (SDQ) 6-month follow-up: 6 / 8 resolved |
Lagier et al. [70] Belgium Retrospective Cross-sectional | 21 (67) Hospitalized patients who survived ARDS and intubation | Mean = 63 Range = 45–76 | 43 Hypertension 38 Obesity 33 Diabetes 24 OSA 29 Neurological 10 CHD | ICU Length of Stay Mean = 30 days Prevalence of Intubation 21/21 (100%) Intubation duration Mean = 17 days | VFSS Referred 0–14 days after ICU discharge 90% Dysphagia Primary/first swallow 6 Penetration 10 Aspiration 9 Silent Impairments 15 Pharyngeal delay 12 Tongue base retraction 9 Laryngeal closure 9 Oral control 7 Pharyngeal motility 5 Oral delay 3 Lip closure | ||
Laguna et al. [108] Spain Prospective Case Series | 232 (74) Admitted to ICU | Mean = 61 95%CI = 59, 62 | 39 Renal failure 35 Respiratory 18 Sepsis 18 Diabetes BMI Mean = 29 kg/m2 95%CI = 28, 30 | Hospital Length of Stay Mean = 27 days 95%CI = 26, 30 ICU Length of Stay Mean = 11 days 95%CI = 10, 12 Prevalence of Intubation 167/232 (72%) Duration of Mechanical Ventilation Mean = 14 days 95%CI = 11, 16 days Prevalence of ECMO 12/167 (7%) | Tracheostomy placement 67/167 (40%) | Completed mV-VST 93/110 (85%) survivors Dysphagia Study-wide 27/232 (12%) Post-extubation 25/167 (23%) | |
Lima et al. [55] Brazil Prospective Cohort | 101 (66) Hospitalized and referred to SP | Median = 53 SD = 16 | 45 Hypertension 41 Pulmonary 27 Diabetes 3 Neurological | Intubation duration Mean = 9 days SD = 8 days | ASHA NOMS 24-h post-extubation 20%: Levels 1–3 54%: Levels 4/5 ICU discharge 70%: Levels 6/7 | ||
Regan et al. [73] Dublin, Ireland Prospective Multi-site Cohort | 100 (69) Hospitalized and referred to SP | Mean = 62 Range 17–88 | 21 Respiratory disease 34% Cardiology 22 Diabetes 29 Obesity | No endoscopy reported 34 GRBAS 0 51 GRBAS 1–2 14 GRBAS 3 | Prevalence of Intubation 100% Intubation duration Median = 14 days IQR = 8–19.5 | Initial assessment (post-extubation) 59: FOIS Level 1–3 (tube dependent 31: FOIS 4–6 (modified) 10: FOIS 7 (regular diet) SLT Discharge 4: FOIS Level 1–3 18: FOIS 4–6 (modified) 73: FOIS 7 (regular diet) | |
Wang et al. [43] China Retrospective Case Series | 138 (54) Hospitalized patients | Median = 56 IQR = 42, 68 | 31 Hypertension 15 CHD 10 Diabetes 5 CVA 3 COPD | 17% Pharyngalgia 33% In ICU |
Author(s), Country, Study Type | N (% Male) | Age (in years) | Comorbidity/ Condition: %, Etiology | Laryngeal injuries | Hospital, ICU, Intubation, Mechanical Ventilation | Tracheostomy | Swallowing |
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Pownall S et al. [d] Sheffield, UK Retrospective cohort Unpublished data | 103 (63) Hospitalized patients referred to SP | Mean 77 Range 33–100 | 44 Respiratory 23 Dementia 22 Deconditioned 18 Cardiovascular 11 Stroke 67% no pre-existing dysphagia | Intubation duration Mean = 15 days | Duration of Tracheostomy Mean = 25 days[MB5] | FOIS Initial 11% Level 1 12% Level 7 Final 8% Level 1 12% Level 7 29% Resolved dysphagia 17% Modified diet Time: Assessment to Discharge Mean = 28 days | |
McRae J [e] UCLH, UK Retrospective review Unpublished data | 26 out of 77 referral to SP in ICU (73) | Mean age: 56 years Median: 57.5 Range:28–69yrs | Not recorded Nil preadmission dysphagia | Vocal cord palsy 4 Laryngeal oedema 3 Vocal cord atrophy 2 Glottic gap 2 Granuloma 1 Vocal cord nodules 1 | Mean intubation time prior to trache tube: 17.2 days Median: 18 days Range: 3–33 days | Duration of Tracheostomy Mean: 23.3 days Median: 19 days Range: 7–53 days | Initial Assessment Clinical swallow assessment:100% Instrumental assessment: 42% (11/26) Discharge outcomes: IDDSI Level 0 and Level 7 100% Dysphonia 46% LOS: Mean: 47 days Median 43.5 days Range 22–116 days |
Wallace S et al. [a] Wythenshawe Hospital, UK Retrospective cohort Unpublished data | 45 (67) patients referred to SP in ICU | Median = 55 Range = 27–79 < 60 years 71% 60–79 years 27% > 80 years 2% | 27 Asthma 20 Diabetes 15 Reflux disease 15 Hypertension 15 CHD 7 High BMI 0 preadmission dysphagia | Prevalence of Intubation 43/45 (96%) Intubation duration Mean = 20.5 days Median = 18 days Range = 6–73 days | Tracheostomy Placement 25/45 (55%) Duration of Tracheostomy Mean 23 days Median = 13 days Range = 5–109 days 1 long-term | Assessment Initial 39 (87%) dysphagia FOIS—51% score 1 NBM, 36% score 2–6, 13% score normal 35 (77%) dysphonia Final 6 (13%) dysphagia FOIS—0 score 1 NBM, 8% score 2–6, 92% score 7 normal 12 (27%) dysphonia Initial TOMS Voice: 77% dysphonic (53% of whom scored 3 or less) Final TOMS Voice: 27% dysphonic (33% of whom scored 3 or less) Initial TOMS Swallow: 87% dysphagic (85% of whom scored 3 or less) Final TOMS Swallow: 13% dysphagic (10% score 4 mild 3% score 3 moderate | |
Wallace S et al. [a] Wythenshawe Hospital, UK Retrospective cohort Unpublished data | 85 (59) patients referred to SP not in ICU | Median = 85 Range = 55–100 < 60 years 5% 60–79 years 32% > 80 years 63% | 44 Dementia 19 COPD 16 Old CVA 14 Cancer 11 Parkinson’s disease 29 preadmission dysphagia | Assessment Initial 92% dysphagia 26% NPO Final 77% dysphagia 4% NPO | |||
[a] Robinson U et al. [b] Belfast H&SC Trust UK Retrospective cohort Unpublished data | 19 (68) patients referred to SP in ICU March–June 2020 | Median = 55 Range = 43–77 | 37 Cardiac 32 Diabetes 27 Respiratory 16 Neurological 5 Renal 11 None 0 preadmission dysphagia | Prevalence of Intubation 19/19 (100%) Intubation duration Median = 19 days Range = 8–52 days | Tracheostomy Placement 5/19 (26%) Duration of Tracheostomy Median = 14 days Range = 13–23 days | Assessment Initial FOIS < 7 14/18* (78%) Final FOIS < 7 8/17** (47%) NPO/Non-oral Feedings None *Data available for 18 out of 19 patients for initial FOIS **Data available for 17 out of 19 patients for final FOIS | |
Robinson U et al. [b] Belfast H&SC Trust UK Retrospective cohort Unpublished data | 30 (80) patients referred to SP in ICU Oct–Dec 2020 | Median = 64 Range = 42–83 | 30 Gastrointestinal 17 CHD 27 Respiratory 13 Diabetes 13 Renal 7 Neurological 13 None 0 preadmission dysphagia | Prevalence of Intubation 24/24*(100%) Intubation duration Median = 12 days Range = 2–42 days *data available for 24 only | Tracheostomy Placement 7/30 (23%) Duration of Tracheostomy Data available for 6/7 patients Median = 17 days Range = 8–45 days | Assessment Initial FOIS < 7 29/30 (97%) Final FOIS < 7 2/30 (7%) NPO/Non-oral Feedings None | |
Robinson U et al. [b] Belfast H&SC Trust UK Retrospective cohort Unpublished data | 92 (54) patients referred to SP not in ICU March–June 2020 | Median = 84 Range = 41–97 | Assessment Initial FOIS < 7 56/64* (88%) Final FOIS < 7 34/48** (79%) *Data available for 64 out of 92 patients only **44/92 patients died during hospital stay—final FOIS rating not collected for these patients therefore data only available for 48 patients | ||||
Robinson U et al. [b] Belfast H&SC Trust UK Retrospective cohort Unpublished data | 89 (N/A) patients referred to SP not in ICU Oct–Dec 2020 | Mean = 81 Range = 60–101 | 17 Gastrointestinal 45 Cardiology 31 Respiratory 12 Renal 30 Dementia 45 Other Neurological 21 Diabetes 34 preadmission dysphagia | Assessment Initial FOIS < 7 68/80* (85%) Final FOIS < 7 47/61** (77%) *Data available for 80 out of 89 patients only **19/89 patients died during the hospital episode. FOIS ratings not collected for these patients therefore data available for 61 patients | |||
Gillivan-Murphy P et al. [f] Mater Hospital Dublin Retrospective cohort Unpublished data | 68 (51) in-patients referred to SP during hospital stay March–June 2020 | Median = 75 Range = 43–97 | 63 Cardiology 28 COPD 25 Diabetes 25 Mental Disorder 18 Dementia 13 Intellectual Disability 1 None | Prevalence of Intubation 15/68 (22%) Intubation duration Median = 7.5 Range = 3–19 | Tracheostomy Placement 5/68 (7%) Duration of Tracheostomy Median = 23 Range = 18–78 | Assessment FOIS < 7 54/64* (84%) *Data available for 64 out of 68 patients IDDSI Liquids ≥ Level 1 23/50** (46%) ** Data available for 50 out of 68 patients IDDSI Food < 7 31/49*** (63%) Data available for 49 out of 68 patients |
Acute Care (Non-ICU Patients)
Inpatient Rehabilitation
Implications on Long-Term Care
Outpatient Clinics
Variable | Previously hospitalized patients | Non-hospitalized patients | ||||
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Naunheim et al. [109] Prospective post-discharge follow-up—recent discharge (n = 20) | Neeval et al. [90] Retrospective case series outpatients (n:24) | Rouhani et al. [69] Prospective post-discharge follow-up—average 54-day post-discharge (n = 41) | Ratcliffe et al. [c] Retrospective ENT outpatient follow-up (original data—unpublished) (n = 24) | Wallace et al. [a] Retrospective post-ICU outpatient follow-up (original data—unpublished) (n = 45) | Ratcliffe et al. [c] Retrospective ENT outpatient (original data—unpublished) (n = 21) | |
Sex M:F (% Male) | 15:5 (75%) | 12:12 50% | 28:13 (70%) | 16:8 (67%) | 30:15 (67%) | 7:14 (33%) |
Age Mean (range) | 59 (32–77) | 50 (20–81) | 56 (32–77) | 56 (30–76) | 55 (27–79) | 48 (21–71) |
Hospital journey | 13 intubated (65%); 9 tracheostomy (45%) | 20 (83%) hospitalized; 18 (75%) intubated | 41 intubated (100%); 41 tracheostomy (100%) | 24 intubated (100%); 21 tracheostomy (88%) | 43 intubated (96%); 25 tracheostomy (56%) | - |
Vocal fold pathologies (endoscopy, stroboscopy) | 8 (40%) unilateral vocal fold immobility 3 (15%) posterior glottic stenosis 2 (10%) subglottic stenosis 2 2 (10%) granulation tissue or edema 2 (10%) LPR 2 (10%) posterior glottic diastasis 1 (5%) MTD | 50% vocal fold movement impairment 39% early glottic injury 22% subglottic/ glottic stenosis 17% posterior glottic stenosis | 3 (7%) unilateral vocal fold palsy 2 (4%) subglottic stenosis 1 (2%) ecchymosis right vocal fold palsy 1 (2%) bilateral vocal fold palsy | 12 (50%) vocal fold palsy 6 (25%) granuloma 4 (17%) subglottic stenosis 2 (8%) arytenoid prolapse 2 (8%) oedema 2 (8%) hypofunction 1 (4%) MTD | 1 (2%) glottic stenosis | 10 (47%) NAD 9 (43%) MTD 2 (10%) reflux 1 (5%) vocal fold nodules 1 (5%) vocal fold pre-nodules |
Breathing | 7 (35%) self-reported breathing issues; 29% if not intubated | 17 (70%) dyspnea 3 cough 3 respiratory distress 4 stridor | 9 (22.5%) fixed upper airway obstruction on spirometry | 15 (63%) self-reported breathing issues 6 (25%) chronic cough | - | 17 (81%) breathing pattern disorder 11 (52%) chronic cough |
Voice | 12 (60%) self-reported dysphonia; 43% if not intubated | 19 (79%) dysphonia 14 patient completed VRQOL: median 73 (28–100) | 22/41 (53.7%) abnormal GRBAS 5/38 (13.2%) VHI: score > 11 (range 12–35) | 19 (79%) dysphonia (classified by SP perceptual assessment) | 13 (29%) self-reported dysphonia (telehealth by ICU outreach team, 4–6-week post-discharge home, standard triage questions) | 19 (90%) dysphonia (classified by SP perceptual assessment) |
Swallowing | 6 (30%) self-reported dysphagia: 14% if not intubated 2 (10%) globus: 29% if not intubated 2 (10%) pain: 29% if not intubated | 6 (25%) dysphagia | 12/40 (30%) EAT-10 score > 2 (range 4–33) 34/41 (82.9%) FOIS 7; 3/41 (7.3%) FOIS 6; 2/41 (4.9%) FOIS 5; 2/41 (4.9%) FOIS 3 | 14 (58%) self-reported dysphagia 11 (46%) globus | 9 (20%) self-reported dysphagia (telehealth by ICU outreach team, 4–6-week post-discharge home, standard triage questions) | 3 (14%) self-reported dysphagia 16 (76%) globus |
Non-hospitalized Outpatient Presentations
The Future
Red flags/risk factors for dysphagia | Justification/evidence | |
---|---|---|
Medical history | Pre-existing dysphagia | Prevalence of pre-existing dysphagia general population is reported at 16% [55] Comorbidities of COVID-19 make likelihood of pre-existing dysphagia greater |
High BMI | Increased risk of reflux-related laryngeal injury Potential for complex and prolonged tracheostomy wean [110] | |
Increased age | Higher likelihood of prolonged hospitalization and dysphagia [48] Higher likelihood of swallow decompensation, pre-morbid dysphagia, multiple comorbidities, frailty [111] | |
Previous neurological disease / disorder | Pre-morbid dysphagia / dysphonia / laryngeal pathology [64] | |
Chronic respiratory disease / asthma / COPD | Known relationship between COPD and silent aspiration [111] Desynchrony of respiration and swallowing [113] | |
Hospitalization experience | Acute Respiratory Distress Syndrome (ARDS) | Strongly associated with dysphagia, aspiration pneumonia, malnutrition [59] |
Prolonged ICU stay | Immobility/ Muscle loss/ deconditioning [65] Sepsis [114] Polyneuropathy [65] | |
Prolonged intubation (incl. larger endotracheal tube > 8.0) | High risk of laryngeal injury both early and later, including paralysis, edema, stridor, and stenosis [61, 62, 96] Risk of disuse atrophy [116] | |
Tracheostomy insertion | ||
Patient complaints / concerns | Complaints of swallowing difficulties | Altered sensation, fatigue, weakness, breathlessness |
Complaints of persistent altered taste/smell & /or reflux & /or gastric issues | Increase risk of nutrition issues secondary to reduced interest in food & reduced intake | |
Disturbance in voice quality following infection | High risk of laryngeal injury both early and later, including paralysis, edema, stridor, and stenosis [61, 62, 97, 116] Risk of disuse atrophy [116] Vagus nerve impairment Signification associations between severity of dysphonia, dysphagia, and cough Dysphonic COVID-19 patients are more symptomatic than non-dysphonic individuals [97] | |
Ongoing fatigue on discharge | ||
Ongoing shortness of breath on discharge | Incoordination of breathing–swallowing mechanism | |
Occupational risk | Required to talk for prolonged periods of time with face mask Stigma Chronic fatigue, anxiety, depression | Known to lead to increase volume and increase risk of vocal pathology [117] High levels of anxiety & depression in long COVID [104] |