COVID-19 and dysphagia: practical guide to safe hospital care - number 1

ABSTRACT

The COVID-19 pandemic is associated with a new strain of coronavirus, SARS-Cov-2, which causes severe acute respiratory syndrome. This virus affects the upper respiratory tract and is transmitted mainly by droplets, sneezes and aerosols, so there is a high risk of transmission during the procedures of the speech therapist who works in the hospital environment. This article aims to describe the steps that can be taken by the speech therapist who attends bedside patients with dysphagia, to reduce the risk of cross-contamination in clinical practice during the COVID-19 pandemic.

Keywords:
Coronavirus; dysphagia; Covid-19; speech therapy; coronavirus infection

RESUMO

A pandemia da COVID-19 é associada com o novo tipo do coronavírus, o SARS-Cov-2, que causa síndrome respiratória aguda grave. Esse vírus afeta o trato respiratório superior e é transmitido, principalmente, por gotículas, espirros e aerossóis e, por isso, há um alto risco de transmissão durante os procedimentos do fonoaudiólogo que atua no ambiente hospitalar. O objetivo deste artigo foi descrever as iniciativas que podem ser adotadas pelo fonoaudiólogo que atende pacientes à beira do leito, com disfagia, visando diminuir o risco de contaminação cruzada na prática clínica durante a pandemia do SARS-CoV-2.

Palavras-chave:
Coronavírus; transtorno de deglutição; Covid-19; fonoaudiologia; infecção por coronavírus

Coronavirus is one of the main pathogens that target the human respiratory system. There are reports in the literature regarding human transmission of the coronavirus in health care settings and home environments⁽¹⁾. There is also evidence that the virus spreads mainly through sneezing, saliva droplets and aerosols ^(2,3)_. The common symptom of COVID-19 in critically ill patients is acute respiratory distress syndrome and most inpatients require respiratory support⁽⁴⁾_. A recent study⁽⁵⁾ on swallowing performance and safety at COVID-19 found during the first swallowing assessment, 19.8% of patients at levels on the ASHA 1-3 scale (when the individual is unable to swallow safely via oral and an alternative diet is necessary) and 53.5% of patients swallowed safely, but with diet restrictions and use of compensatory maneuvers. On the other hand, the study also suggests fewer rehabilitation sessions to return to safe oral feeding compared to critically ill patients in the ICU (without COVID-19), in addition to remaining intubated for longer.

The pace of the emerging COVID-19 literature and daily updates of national health policies and recommendations result in rapid change on topics of relevance to COVID-19. In this context, considering the evidence about a high risk of SARS-CoV-2 transmission during the procedures of the speech therapist inserted in the hospital environment, this article aimed to provide the current scientific evidence of the safe management of the speech therapist at the bedside during the current pandemic of COVID-19.

Personal protective equipment - PPE

• Speech therapists should prioritize the use of personal protective equipment, such as the N95 or PFF2 respirator (always perform a seal check when donning the mask), private hospital clothing, procedure gloves, protective glasses, face shild, cap and disposable aprons. Wash your hands with soap and water, according to standard precautionary measures, or rub your hands with 70% ethanol or 70% isopropanol⁽⁶), before and after contact with patients and surrounding environmental surfaces, as well as after removing PPE. One study demonstrates that SARS-CoV can be inactivated easily with many commonly used disinfectants ⁽⁷⁾. In addition, there is also evidence that rubbing hands with ethanol or isopropanol, both 70%, are generally effective against enveloped viruses, including SARS-CoV and MERS-CoV ⁽⁸⁾.

Speech therapy and COVID-19

• Speech therapy in patients with a negative viral load should be conducted with appropriate PPE. In the case of patients with suspected or confirmed COVID-19, care is not recommended, due to the risk of aerosol generation⁽⁹⁾. However, there are still controversies in the literature. We suggest that during the disease, care should be indicated only in cases of absolute necessity due to a significant deficit in swallowing, whose postponement of therapy imposes a greater risk of health problems and must prioritize measures that generate the least possible aerosols after agreement by the team and with use all appropriate personal protective equipment. It is necessary to define appropriate criteria to activate the speech therapy service and guide the best practices for hospital speech therapy assistance^(10,11). Priority should be given to minimum handling measures (adaptation procedures, compensations, guidelines and monitoring of swallowing) and the relevance of the speech-language assessment to the patient's condition should be analyzed. Patients with a history of risk of bronchoaspiration are eligible for speech-language assessment, such as: frail elderly, neurological disease, head and neck cancer, chronic lung disease, orotracheal intubation greater than 48 hours, and tracheostomy ^(12,13).

Clinical examination for patients with dysphagia

• Oral inspection and handling of the mouth, tongue and oral mucosa should be avoided; in case of need to ensure adequate protection of the entire face and other care, it is recommended to avoid any type of stimulus that may trigger coughing and vomiting reflexes, including areas of the oral cavity, such as the base of the tongue, fauces, uvula, palate and wall pharynx⁽¹⁴⁾. A study showed a high viral load in the saliva of infected patients 25 days after the first symptoms⁽¹⁴⁾. These forms of transmission are important for hospital speech therapy practice, since many procedures performed by speech therapists require proximity to the patients' faces, in addition to contact with oral mucosa and body fluids, such as saliva and respiratory droplets⁽¹⁵⁾_.

• It is suggested to perform the swallowing assessment with multiple consistencies and disposable tools to define the safest and most adequate route of nutrition, considering the previous history, the current disease and the oropharyngeal performance, with provision and monitoring by the nursing team if applicable, to reduce multiple visits. In cases of extubation, the evaluation can be performed after 48 hours⁽¹⁰⁾. It is recommended to discard and not reuse the leftover food (with or without thickeners) used in the evaluation. One study suggests that SARS-CoV can be transmitted indirectly through contact of the mucosa, with a source of polluted water and food⁽¹⁶⁾_.

• Avoid cervical auscultation and if necessary use only the stethoscope available on the patient's bed. The stethoscope generates the possibility of spreading the virus and contamination of hospital devices, this can cause the contagion of health professionals and hospitalized patients⁽¹⁷⁾. It is important to consider the cleaning and disinfection of equipment surfaces that were used in patient care, using hospital-grade germicides. So far, what is known about the survival of SARS-CoV-2 is that it is more stable on plastic and stainless steel surfaces⁽¹⁸⁾.

Tracheostomy care and COVID-19

• In cases of tracheostomized patients and related procedures, such as endotracheal aspiration and deflation of the cuff, it is recommended to avoid this type of conduct due to the production of cough and “droplet sprays” of respiratory tract fluid, as they are potentially aerosol generators⁽¹⁹⁾. In a systematic review study, tracheostomy was considered as one of the procedures that generates the most aerosols⁽²⁰⁾. Cannulas without fenestra and with cuff are recommended, which should remain inflated until the COVID-19 test is negative⁽²¹⁾. However, an individual assessment must be made for each patient. The deflation of the cuff and associated procedures must occur only in a closed suction circuit, and in cases of absolute necessity, they must be performed after the quarantine period and isolation of the disease. Tube changes and cleaning should be avoided unless deemed urgent. The use of speaking valves should be weighed and discussed with the interprofessional team⁽²²⁾. Risk and benefits should be prioritized, taking into consideration benefits to airway management, phonation, and swallow physiology. Studies reinforce that during a sneeze or cough, these respiratory tract fluids with a viral load, usually larger than 5 mm in diameter, can be inhaled through microscopic aerosol particles⁽²³⁾. Another study suggests that SARS-CoV-2 can be transmitted through the air through aerosols formed during medical procedures⁽²⁴⁾. However, the route of transmission of the aerosol and the routes of transmission through feces and the mouth still need to be clarified⁽²⁴⁾_. There is still no evidence to support speech therapy in infected tracheostomy patients, in addition to the real impacts of these mechanisms on the transmission of SARS-CoV-2.

Complementary swallowing assessment and other strategies

• Complementary exams to assess swallowing and voice should be avoided⁽²⁵⁾. The evidence suggests that flexible pharyngolaryngological endoscopic evaluation and probably also swallowing video fluoroscopy are particularly at high risk of contamination for patients, speech therapists and otolaryngologists, in addition to the team involved in the procedure or equipment reprocessing⁽²⁶⁾.

• In the current scenario, we must consider the remote care as an alternative means of providing services, in a complementary way or in substitution to face-to-face treatments. One study⁽²⁷⁾ emphasize that the approach to assess dysphagia must be adapted to reduce the risk of possible viral exposure. Clinical history and virtual assessment of patients via call center, in addition to the use of validated questionnaires, can help in screening and selecting patients who need in-person assessment and diagnosis. On the other hand, there is still a gap in the evidence on the effectiveness of telerehabilitation in dysphagic patients when compared to face-to-face therapy⁽²⁸⁾. A flowchart depicting the practical guide to safe hospital care in COVID-19 is provided in Figure 1.

  

  Figure 1
  Flowchart of practical guide to safe hospital care in COVID-19
  

Finally, standard precautionary measures should be maintained for all patients without symptoms. We recommend the use of biosafety protocols and specific protection measures must be strictly followed during speech therapy sessions in the hospital environment. In addition, we suggest practical guidelines, such as screening and assessment of dysphagic patients, through validated and appropriate protocols for hospital speech therapy in patients with COVID-19.

• Study carried out at Departamento de Fonoaudiologia, Universidade Federal de Sergipe – UFS – São Cristóvão (SE), Brasil.
• Funding: None.

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Publication Dates

• Publication in this collection
  07 Dec 2020
• Date of issue
  2020

History

• Received
  13 July 2020
• Accepted
  24 Sept 2020