The Impact of COVID-19 on Swallowing and Airway Management in ICU Patients: A Retrospective Study

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In March 2020, the world witnessed the emergence of the coronavirus pandemic, which brought about unprecedented changes in our understanding of infectious diseases.

The virus responsible for this global crisis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a wide range of health challenges.

While COVID-19 is commonly associated with upper respiratory symptoms, it can also lead to severe multisystem infections, with varying degrees of impact on patients’ lives. The severity of COVID-19 can range from mild symptoms to life-threatening complications, with certain demographics being more susceptible to severe outcomes.

The COVID-19 landscape is characterized by 80% of patients experiencing mild symptoms, including fever, fatigue, dry cough, myalgia, dyspnea, and sputum production. However, approximately 15% of patients develop severe disease marked by significant lung changes on imaging, and 5% become critically ill.

The elderly, particularly those over 80 years of age, and individuals with underlying comorbidities face a higher risk of mortality. As a result, many COVID-19 patients are admitted to intensive care units (ICUs) due to acute respiratory failure, necessitating the development of comprehensive protocols for airway management.

Severe COVID-19 infection has been associated with various manifestations that can profoundly impact patients’ swallowing, voice, and motor speech. One notable challenge is the development of swallowing difficulties, with some studies suggesting that up to 50% of ICU patients with COVID-19 may experience these issues.

Moreover, the prolonged use of invasive techniques such as intubation and tracheostomy further exacerbates these swallowing difficulties. The pandemic has significantly extended the duration of respiratory support compared to pre-pandemic viral pneumonia cases, resulting in a rise in tracheostomy procedures. Initially, the absence of established guidelines led to extraordinarily long intubation times, ranging from 21 to 35 days, compared to the routine 7 to 10 days seen before the pandemic.

Tracheostomies became essential in weaning patients off sedation and avoiding resedation/intubation, but concerns about aerosolization of viral particles during the procedure added to the time patients remained intubated. These factors collectively contribute to the wide range of post-intubation sequelae experienced by COVID-19 patients.

Reports indicate that as many as 41% of patients suffer from dysphagia following extubation, consistent with findings from previous studies conducted before the pandemic, which established a link between intubation and moderate to severe dysphagia lasting seven days or more. Laryngeal injuries incurred during intubation, such as vocal cord paralysis, granuloma, and stenosis, are contributing factors to this phenomenon.

Additionally, the neurological symptoms associated with SARS-CoV-2 infection can cause dysarthria, dysphonia, and dysphagia, which are exacerbated by disuse and muscle atrophy.

Despite the critical importance of intubation and tracheostomy in managing COVID-19 patients’ airways, the effects of these procedures on swallowing function and the criteria for intubation and early tracheostomy remain unclear.

Objectives

The primary goal of this study is to retrospectively assess the airway and swallowing outcomes of patients infected with COVID-19 who required ICU-level care. In particular, the study aims to investigate changes in patients’ diets following hospitalization for COVID-19 infection. By examining the impact of intubation and tracheostomy on swallowing function and identifying indications for these procedures, we seek to enhance our understanding of the challenges posed by COVID-19 in the realm of airway management and swallowing difficulties.

Methodology

This retrospective study will involve a comprehensive review of medical records and clinical data of COVID-19 patients who required ICU-level care. The following steps will be undertaken:

  • Data Collection: We will collect data from medical records of patients admitted to ICUs with COVID-19 infection. This data will include demographic information, comorbidities, duration of intubation and tracheostomy, and neurological symptoms associated with COVID-19.
  • Swallowing Assessment: We will assess swallowing function in these patients through clinical evaluations, such as videofluoroscopic swallowing studies (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES), conducted both during and after their ICU stay.
  • Diet Progression: We will analyze the progression of diets for these patients, including the type of diet (e.g., clear liquids, pureed, regular), timing of diet initiation, and any diet modifications made during hospitalization.
  • Statistical Analysis: Statistical methods, including descriptive statistics and regression analysis, will be employed to identify associations between intubation, tracheostomy, neurological symptoms, and swallowing difficulties. We will also investigate whether certain patient characteristics or management strategies are associated with better swallowing outcomes.

Discussion

The coronavirus pandemic has ushered in a new era of challenges for critical care providers, fundamentally altering our understanding of airway management and invasive procedures. Among the many consequences of prolonged intubation, this study highlights the direct impact on dietary needs and outcomes in the critical care setting. Through a retrospective chart review, we have uncovered a significant association between extended intubation periods, the necessity for tracheostomy, altered diets upon discharge, and a higher likelihood of being discharged to an external healthcare facility.

Laryngeal complications have long been associated with extended intubation durations, and this phenomenon has been exacerbated during the COVID-19 pandemic. In our study, we found that 63.4% of ICU-admitted SARS-CoV-2 patients required intubation, with an average duration of 7.7 ± 9.7 days. Similar findings were reported by Hur et al., where 90% of patients had prolonged hospital stays exceeding 10 days. Such prolonged intubation times have raised concerns within the otolaryngologic community, leading to discussions about the potential adverse effects of overinflated cuffs and chronic pressure on various airway structures. This combination of factors can give rise to complications such as granulomas, webs, laryngotracheal stenosis, tracheomalacia, tracheal necrosis, and fistulae development.

A longitudinal cohort study by Lindh et al. assessed intubated COVID-19 patients for dysphagia using a bedside swallowing evaluation following extubation. They discovered that 71% of patients exhibited dysphagia symptoms, including pharyngeal muscle weakness, cough, and bolus retention. While 47% of these patients regained the ability for oral intake at discharge, it remains a substantial concern in the hospital setting. To mitigate the risk of in-hospital dysphagia and potential long-term consequences, early tracheostomy has been recommended. In our cohort, 14% of patients required tracheostomy, and those who did not undergo this procedure had significantly longer ICU stays, intubation durations, and ventilation durations, underscoring the importance of early tracheostomy to reduce the need for prolonged ventilatory support and associated airway complications.

Dysphagia is a significant concern among intubated COVID-19 patients, as evidenced by changes in discharge diets. Our study found that 30.4% of patients required a different diet upon discharge compared to their admission diet. Interestingly, there was no significant difference in the discharge diet between intubated and non-intubated patients. Lindh et al. reported similar findings, indicating that patients with dysphagia were more likely to be older, experience longer periods of invasive ventilation or tracheostomy, and have extended ICU and hospital stays. Weight loss during hospitalization has also been associated with increased length of stay and worse disease severity. Malnutrition during hospitalization can exacerbate the overall disease burden and increase mortality. Our findings support this, as NPO status in intubated patients resulted in significantly longer durations of intubation and ventilation.

The association between age, prolonged ICU stay, intubation duration, ventilation duration, and discharge to a healthcare facility highlights the need for heightened vigilance in intubated ICU patients, who are at high risk for dysphagia and malnutrition, often requiring extended post-discharge care.

Beyond the immediate physical effects, COVID-19 patients face prolonged mental and physical challenges after discharge. Martillo et al. reported high rates of post-intensive care syndrome (PICS) among COVID-19 ICU survivors, with 91% exhibiting symptoms affecting physical, psychiatric, or cognitive domains, including depression, posttraumatic stress disorder, and insomnia. This underscores the need for comprehensive post-discharge care and support, particularly for patients who experienced ICU admission.

A secondary finding of this study was the role of vaccination in in-hospital outcomes. Since the availability of the SARS-CoV-2 vaccine, vaccinated and unvaccinated individuals have been compared in terms of their hospital stays. Our study revealed that unvaccinated individuals had significantly longer ICU stays, intubation durations, and ventilation durations, though no association with increased risk of death was found. Tenforde et al.’s case-control study further supports the notion that vaccination is associated with reduced disease severity, as unvaccinated patients accounted for the majority of cases progressing to death or invasive mechanical ventilation. Breakthrough cases, where vaccinated individuals still developed COVID-19, were generally less severe than those in unvaccinated individuals.

While our findings suggest that vaccination may reduce the risk of severe COVID-19, further research is needed to determine its impact on mortality. Discrepancies in results between countries may be attributed to differences in patient populations and vaccine types.

This study has limitations, notably the absence of standardized parameters to evaluate swallowing function before and after intubation. Future studies should investigate patients’ swallowing function and dietary habits post-discharge to gain a more comprehensive understanding of the long-term effects of prolonged intubation.

Conclusion

The COVID-19 pandemic has presented a unique set of challenges in the field of infectious disease and critical care medicine. Among these challenges is the impact of airway management techniques, such as intubation and tracheostomy, on swallowing function in ICU patients with COVID-19. This retrospective study aims to shed light on the relationship between these procedures and swallowing difficulties, as well as to identify potential indications for intubation and early tracheostomy in the context of COVID-19 care. By understanding the nuances of COVID-19’s effects on the airway and swallowing function, we can better tailor treatment strategies and improve the quality of care for patients affected by this global health crisis.


reference link : https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/oto2.74

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