Autor : Falduti, Alejandra K1, Chiappero, Guillermo R1, Catini, María Eugenia1
1Hospital Juan A. Fernández, Av. Cerviño 3356, Autonomous City of Buenos Aires (CABA), C1425, Argentina.
https://doi.org/10.56538/ramr.ZGLX3121
Correspondencia : Alejandra Falduti, alejandrafalduti13@gmail.com; Zelada 4424, CABA, Argentina, CP 1407
ABSTRACT
Introduction: Patients with severe pneumonia due to COVID-19 may require orotracheal intubation, prolonged mechanical ventilation
and tracheostomy. The presence of an artificial airway can generate laryngeal
lesions and it is associated with swallowing dysfunction and increased risk of
aspiration.
Objective: The main objective of this study is to describe the prevalence of
laryngeal lesions and oropharyngeal dysphagia in
critically ill tracheostomized patients due to
COVID-19. As a secondary objective, is to evaluate the association between the
presence of laryngeal injury and dysphagia and each of them with other
variables related to the patient’s history, duration of the artificial airway
and the prone position maneuver.
Methods: This is an observational, longitudinal and retrospective study,
conducted at the Juan A Fernández Hospital, CABA, Argentina. Tracheostomized
patients diagnosed with COVID-19 were consecutively included. The presence of
laryngeal lesions and dysphagia was recorded by fibroscopic
evaluation of swallowing at the time of decannulation.
Results: 32 patients were analyzed, of which 28 (87.5 %) showed at least one laryngeal
lesion, mainly in the glottic region. The prevalence
of dysphagia was 65.6 % (21/32). No significant association was found between
laryngeal injuries and dysphagia (p = 0.70).
Conclusion: laryngeal injuries and dysphagia were highly prevalent in this cohort of
patients. The early evaluation through fibroscopic
evaluation of swallowing for the protocolized
follow-up of these patients, has provided us a timely
diagnosis to guide treatment individually until decannulation
and resolution of the dysphagia found.
Key words: Covid-19; Decannulation; Swallowing;
Dysphagia; Laryngeal Injury
RESUMEN
Introducción:
Los
pacientes con neumonía grave por COVID-19 pueden requerir intubación orotraqueal, ventilación mecánica prolongada y traqueostomía. La presencia de la vía aérea artificial
puede generar lesiones laríngeas y estar asociada a disfunción deglutoria con
aumento del riesgo de aspiración.
Objetivo:
Describir
la prevalencia de lesiones laríngeas y disfagia orofaríngea
en los pacientes críticos traqueostomizados por
COVID-19. Como objetivo secundario, evaluar la asociación entre la presencia de
lesión laríngea y disfagia y de cada una de ellas con antecedentes del
paciente, duración de la vía aérea artificial y maniobra de decúbito prono.
Material
y métodos: Estudio
observacional, longitudinal y retrospectivo, realizado en el hospital Juan A.
Fernández, CABA, Argentina. Se incluyeron de manera consecutiva pacientes con
diagnóstico de COVID-19 traqueostomizados. La
presencia de lesiones laríngeas y disfagia se valoró mediante estudio
endoscópico de la deglución al momento de la decanulación.
Resultados:
Se
analizaron 32 pacientes, de los cuales, 28 (87,5 %) evidenciaron al menos una
lesión laríngea, principalmente en la región glótica. La prevalencia de
disfagia fue de 65,6 % (21/32). No se encontró asociación significativa entre
lesiones laríngeas y disfagia (p = 0,70).
Conclusión:
En
esta cohorte de pacientes, las lesiones laríngeas y la disfagia fueron
altamente prevalentes. La evaluación precoz mediante endoscopia de la deglución
nos ha facilitado un diagnóstico oportuno para guiar el tratamiento de manera
individual hasta la decanulación y resolución de la
disfagia encontrada.
Palabras
claves: Covid-19;
Decanulación; Deglución; Disfagia; Lesiones laríngeas
Received: 12/20/2021
Aceptado: 06/29/2022
INTRODUCTION
At the end of 2019, in the city
of Wuhan, China, a new beta coronavirus was identified, the SARS-CoV 2, finally called coronavirus disease 2019 (COVID-19).
The World Health organization (WHO) declared it a pandemic on March 11th, 2020.1-3
The predominant finding in a
seriously ill patient is acute hypoxemic respiratory failure due to acute
respiratory distress syndrome (ARDS), and the patient may need to be admitted
to the Intensive Care Unit (ICU).4
At the beginning of the pandemic,
one in five infected persons was hospitalized; one in ten could be admitted to
the ICU and most of these patients required orotracheal
intubation (OTI) and had to be connected to invasive mechanical ventilation
(IMV).5 Prolonged OTI
can cause laryngeal injuries that impact on the function of the upper airway,
alter its permeability, and cause voice or swallowing disorders. These
injuries can be detected after extubation and
sometimes require tracheostomy (TQT).6-8 Having OTI for more than 7 days increases the
degree of the laryngeal injury, according to the duration of the intubation,
the size of the endotracheal tube, the general condition of the patient, and
the presence of infection.9
In these cases, the prone
position maneuver was used as treatment of ARDS. The effect of this maneuver
over the larynx and the pharynx hasn’t been studied yet, but it is believed
that it could determine laryngeal and upper airway edema.8
Patients with prolonged IMV
require TQT. Williams et al.10
reported that TQT rates during the coronavirus pandemic varied
significantly, from 16% to 61%, but were higher than pre-pandemic rates. The
SATICOVID study reported that one quarter of the patients who had received IMV
were tracheostomized.3 The TQT is a
risk factor for swallowing disorder, and up to 50% of these patients show risk
of aspiration. The presence of the TQT cannula causes the translaryngeal
airflow to cease, thus causing desensitization of the laryngopharynx, lack of
coordination of the glottic closure, and disuse
atrophy of the muscles involved in the swallowing process, which may cause
dysphagia.8
There isn’t much information yet
about the frequency of laryngeal injuries and dysphagia in this population.11 The main objective of this study was to describe the
prevalence of laryngeal injuries and oropharyngeal
dysphagia at the time of decannulation in patients
who required TQT after receiving prolonged mechanical ventilation secondary to
COVID-19. The secondary objective was to evaluate the association between the
presence of laryngeal injuries and dysphagia and of each one of them with
other variables related to the patient’s medical history, the duration of the
artificial airway (AAW) and the decubitus prone position maneuver.
MATERIALS AND METHODS
The following study was conducted
in the Hospital General de Agudos Dr. Juan Antonio Fernández (HGAJAF), Autonomous City of Buenos Aires (CABA),
Argentina, in the period between July, 2020 and December, 2020. The study was
retrospective, cross-sectional and observational.
It included consecutive patients
older than 18 years hospitalized at the HGAJAF who had been diagnosed with
COVID-19 upon hospital admission, had required OTI and IMV for more than 72
hours, and were tracheostomized and weaned from IMV
or going through the weaning process.
The following demographic and
clinical data were recorded: age, sex, personal
history, duration of sedation, analgesia, and neuromuscular blockade. Regarding
the IMV and AAW, we recorded the following: OTI and TQT dates, IMV start and
end dates, the need to reintubate and number of
prone cycles. Also, the days of ICU stay and hospital stay were recorded.
At the beginning and during the decannulation process, we evaluated the following: the
degree of agitation and sedation through the Richmond Agitation and Sedation
Scale (RASS); the delirium acquired at the ICU, with the CAM-ICU tool
(Confusion Assessment Method for the Intensive Care Unit); the maximum
expiratory pressure, and the peripheral muscle strength, through the Medical
Research Council scale (MRC). The blue staining test was done and we recorded
the first evaluation made when the patient was breathing spontaneously without ventilatory support for 24 hours; also the peak cough flow
was measured.
The Fiberoptic
Endoscopic Evaluation of Swallowing (FEES) was carried out in patients who
presented altered permeability of the AW during the decannulation
process, or those who tolerated occlusion of the TQT cannula for 24 hours or
upon the physician’s request for the assessment of the AW or the swallowing
ability.
The study was carried out by an
intensive care physician and a kinesiologist, with flexible
videoscope (Ambu®
aScope™). First, the study evaluated the anatomical
structures, the mobility of the vocal cords and glottic
closure; then, the sensitivity was assessed, by touching the epiglottis, the
arytenoid folds, and vocal cords with the tip of the endoscope. The Murray
scale was used7 for the
assessment of the saliva (Appendix A), for which a score of 3 was considered as
risk of aspiration. Then, semi-solid food was administered in three different
volumes, and blue liquid in 5 mL, 10 mL and 15 mL, and the patient was
evaluated with the Penetration-Aspiration Scale (PAS)12
(Appendix B).
The existence of laryngeal
injuries, the Murray saliva score and the PAS scale were also recorded. A PAS
score ≥ 2 points was considered as dysphagia for each consistency. Some
patients couldn’t complete the test with food due to a high risk of aspiration,
difficulty in swallowing maneuvers or because they didn’t understand the task.
To finish the study, the transtracheostomy evaluation was carried out. After
removing the TQT cannula, the endoscope was introduced through the ostomy in the cephalic direction with the tip directed
towards the subglottic region; this region and the lower side of the vocal
cords were observed. The presence of sub-glottic
injuries was assessed, and the patient was administered blue liquid in order to
observe the presence of aspiration.
The study was recorded to be
subsequently analyzed by the evaluation team. Data were registered in a
database for subsequent analysis.
STATISTICAL ANALYSIS
The data were considered as
nonparametric due to the small sample size, and are reported with median and
interquartile range (IQR), if numerical, and with the absolute number of
presentation and percentage, if categorical. Two groups were created taking
into account the presence or absence of clinically evaluated dysphagia. Also a subanalysis was conducted in patients who received the
instrumental evaluation of the AW through the FEES, and were categorized
according to the presence or absence of laryngeal injuries. We used the
Fisher’s Exact Test to compare the categorical variables. And for the
comparison of continuous variables, we used the Mann Whitney Test. A p value
of ≤0.05 was considered significant. For the data analysis, we used the
IBM SPSS Macintosh software version 24.0 (IBM Corp., Armonk, NY, USA).
RESULTS
Sample characteristics
A total of 39 tracheostomized
patients on IMV due to COVID-19 were included in the study. Four of those
patients were excluded for the following reasons: three patients showed
infectious complications and died, and the other one was excluded due to data
loss.
Three (9.4%) out of the 35
subjects couldn’t be evaluated with the FEES (for logistic reasons) and were
removed from this subanalysis.
Demographic, clinical and ICU stay-related variables
8 (22.9%) of the 35 patients
included in the study were female, and the median of age was 57 years (IQR
49-66). Arterial hypertension and obesity were the most prevalent
comorbidities.
Regarding the medication
administered during the ICU stay, all the patients required analgesia and
sedation with a median of 28 d (IQR 20-37.5) and 24 d (IQR 16.7-31.2),
respectively. Thirty three (94.3%) patients required neuromuscular blocking
agents and antipsychotics with a median of 8 d (IQR 6-15) and 29 d (IQR
19.5-44), respectively. Thirty subjects (85.7%) required inotropic drugs with a
median of 8.5 days (IQR 3.7-13.2).
19 (54.3%) of the total sample
subjects required the decubitus prone position as rescue maneuver. 7 of them
(36.8%) received only one cycle of decubitus prone; 5 (26.3%) received two
cycles, and 7 (36.8%) had three or more cycles.
Instrumental evaluation: FEES (n = 32)
Before decannulation,
and after 24 hours of occlusion of the tracheostomy cannula or use of the phonatory valve, the FEES was
carried out.
Prevalence and characteristics of the laryngeal injuries
As regards the existence and
types of laryngeal injuries, 28 (87.5%) of the 32 patients showed at least one
injury. 21 (75%) of them (n = 28) showed only one injury; 6 (21.4%), two
injuries, and 2 (7.1%) showed three injuries. Three patients weren’t able to
complete the evaluation of the subglottic region because they couldn’t tolerate
the procedure. 39 injuries were registered [n = 21 (75%)], followed by
paresis/unilateral vocal cord paralysis [n = 10 (35.7%)] and incomplete glottic closure [n = 6 (21.4%)] (Table 2).
Factors associated with laryngeal injuries
For the purpose of evaluating the
association between the presence of laryngeal injuries and other variables,
the 32 subjects under evaluation were divided in two groups: “without laryngeal
injury” [n = 11 (34.4%)] and “with laryngeal injury” [n = 21
(65.6%)]. The “without laryngeal injury” group included patients who didn’t
have any injuries in the larynx or an ulcer in the posterior commissure, which
was considered a mild injury with no clinical implication.
The presence of diabetes was more
prevalent in patients without laryngeal injury [4/11; (36.4%)] compared to the
group with laryngeal injury [(1/21; (4.8%)]. This association was statistically
significant (p = 0.03). When we compared the presence of laryngeal
injuries with the rest of the variables, we didn’t observe any statistically
significant variables.
Prevalence of dysphagia
The swallowing evaluation was
done with semi-solid food and liquids in the 32 patients who underwent the
FEES. The median score of the Murray scale was 1 (0.2-2) point. When we
compared the Murray scale score between the group without laryngeal injuries [median
1 point (IQR 0-2)] and the group with laryngeal injuries [median 1 point (IQR
1-2)], we didn’t observe any statistically significant differences between both
groups (p = 0.3). In the assessment of semi-solid intake with the PAS
scale we observed penetration through the AW in eight patients without
aspiration in any of them. In the case of the liquids, nine patients (37.5%)
showed aspiration and 5 showed penetration. Patients
who couldn’t be evaluated with liquids (n = 9) or semi-solids (n =
8) due to risk of aspiration were classified as “with dysphagia”. The
prevalence of dysphagia was 65.6% (21/32).
Factors associated with dysphagia
The 32 evaluated subjects were
classified in two groups: “with dysphagia” (PAS ≥ 2) [n = 21] and
“without dysphagia” (PAS = 1) [n = 11]. When we related the presence or
absence of dysphagia to the presence or absence of laryngeal injuries, we
observed dysphagia in 8 out of 11 patients without laryngeal injury (72.7%) and
in 13 out of 21 patients with laryngeal injury (61.9%). In the comparison of
both groups, the differences weren’t statistically significant (p =
0.70) (Table 4). When we compared the Murray scale score between the group
without dysphagia [median 1 point (IQR 0-1)] and the group with dysphagia
[median 1 point (IQR 1-2)], we didn’t observe any statistically significant
differences (p = 0.09).
Other results
Delirium
The presence of delirium was
evaluated after the patients had sustained 12 h of spontaneous ventilation and when they were decannulated,
through the CAM-ICU. 34 patients received the initial evaluation; 11 (32.4%)
obtained a positive result, 20 (58.8%) had a negative result, and 3 (8.8%) were
non-evaluable. Upon discharge, 33 subjects had received this evaluation; 6
(18.2%) yielded a positive result, 26 (78.8%), a negative result, and 1 (3%)
was non-evaluable.
Functional status
We evaluated
dependency in daily living activities (DLAs) at the beginning of the decannulation process and also upon discharge from the ICU
through the Katz Index score. Thirty-two patients received the first
evaluation. Two patients (6.3%) obtained an F category, and 30 patients (93.8%)
obtained a G. Upon discharge, 30 patients received this evaluation; 1 (3.3%)
of them obtained a C category, 2 (6.7%) had E, 8 (26.7%) had F and 19 (63.3%)
had a G category.
Muscle strength
We assessed the peripheral muscle
strength on two occasions, at the beginning of the decannulation
process and at the time of decannulation through the
Medical Research Council (MRC) scale. At the initial evaluation (n =
28), a median of 42 points was obtained (IQR 35-48.7), and in the second
evaluation (n = 26) there was a median of 48 points (IQR 40.7-56). A
total of 26 patients received this evaluation in both instances. At the initial
assessment, 17 patients (65.4%) showed values of <48 points. Upon discharge,
11 patients (42.3 %) showed values of <48 points. The median of change according
to the MRC was 3.5 points (IQR 0-8.5), with a minimum and maximum of 0 and 23 changepoints, respectively.
Peak cough flow
The cough strength was evaluated
by registering the cough peak flow (CPF) in two instances: when the patient had
a phonatory valve or cannula occlusion and, then, at
the time of decannulation. Twenty one patients
received the first evaluation with a median of 140 L/m (IQR 60-180) and 22
subjects received the second evaluation with a median of 165 L/m (IQR 105-205).
Twenty patients were evaluated in both instances. The median of the CPF in the
first and second instances was 140 L/m (IQR 65-180) and 165 L/m (IQR 95-215),
respectively. The median of change in the CPF was 10 L/m (IQR 0-50), with a
minimum and maximum change of –20 and 130 L/m, respectively.
Blue staining test
After 12 and 24 hours of
spontaneous breathing we did the blue staining test for the purpose of starting
with the decannulation process. The patient’s tongue
was stained with natural blue dye, then the tracheal tube cuff of the TQT
cannula was deflated and either the cannula was occluded or a phonatory valve was placed. This test evaluates the
presence of aspiration if there are stained secretions in the periosteum, through tracheal aspiration or through the
subglottic catheter, and the presence of stained secretions is considered as a
positive test. A positive result was observed in 5 out of 30 evaluated patients
(16.7%).
Decannulation
All tracheostomized
patients achieved decannulation before discharge and
with a median of TQT time of 25 days (IQR 18.7-50.2), with a minimum and
maximum of 8 and 123 days, respectively. When summing up the OTI days and the
total TQT days, we obtained a median of AAW days of 48 d (36.7-75), with a
minimum and maximum of 25 and 143 days, respectively.
Dysphagia upon discharge
At the time of discharge, 34
patients received the clinical swallowing evaluation; 7 patients with suspected
dysphagia underwent a videofluoroscopic swallowing
study. Six subjects (17.6%) had dysphagia at the time of hospital discharge.
ICU and hospital stay
The median of ICU length of stay
was 50 days (IQR 37-68), with a minimum and maximum of 20 and 191 days,
respectively. The median of hospital length of stay was 67 days (IQR
52.5-120.5), with a minimum and maximum of 16 and 287 days, respectively. Two
patients died during their hospital stay.
DISCUSSION
87.5% (n: 28/32) of tracheostomized COVID-19 patients showed at least one
laryngeal injury evaluated through AW endoscopy. Most injuries were located in
the glottic region. Similar results with a high
frequency of laryngeal injuries were also reported in previous studies by Sandblom et al.,11 Boggiano et al.13 and Nauheim
et al.14 in similar cohorts of critically ill tracheostomized
COVID-19 patients. Also, in these studies, the most commonly affected region
was the glottic region. Due to the V-shaped anatomy
of the larynx, it is particularly vulnerable to an injury, because of the
mechanical effect exercised by the orotracheal tube.8
A previous study presented at the
2018 Congress of the Argentinean Society of Intensive Care Medicine of the
same authors analyzed the presence of laryngeal injuries and dysphagia through
the FEES. The study included 71 patients with a mean of 10 OTI days. 55 of
those patients were tracheostomized. The frequency of
laryngeal injuries in this study was lower (63%), laryngeal edema and abnormal
movement of the vocal cords as the most prevalent.15 These findings
agree with Boggiano et al.,13 who reported
a lower percentage of laryngeal injuries in critically ill patients before the
COVID-19 pandemic.
It has been reported that the
frequency and severity of laryngeal injuries are directly related to the number
of days with AAW, with important consequences that may result in respiratory
failure and failure to extubate or decannulate.6,
8 However, we haven’t found an association between the number of days
with AAW and the development of laryngeal injuries. This coincides with other
studies that didn’t find such association either.12, 16
The cause of the lack of
statistical significance to show this association that has been thoroughly
investigated could be our small sample size. The effects of the viral infection
by SARS-CoV-2, which haven’t been completely clarified yet, could also explain
this lack of statistical significance.
Despite the fact that we found
high prevalence of laryngeal injuries, all the patients could be decannulated. We believe it’s important to mention that 6
of the 32 patients who showed the most severe injuries took a longer time to
achieve decannulation, with a mean of 50 days of TQT,
due to the involvement of the AW permeability.
The greater use of the decubitus
prone position as treatment of refractary hypoxemia
has posed the hypothesis that the movement of the head and neck to reach such
position would generate a bigger movement of the orotracheal
tube, which would develop friction and excessive pressure over the AW
structures that could generate a higher incidence of injuries.12, 13
54% of our patients were in decubitus prone position. However, we coudn’t find an association between the decubitus prone
position and the development of laryngeal injuries in our series of patients.
With regard to the
characteristics of the sample, we found a higher percentage of males, mean age
of 54 years, and a mean of OTI days of 19, which are similar to the reported
characteristics.17, 18 Arterial hypertension and obesity were the
most prevalent comorbidities in our population of patients, just like the data
reported in the Argentinean study of Estenssoro et
al.3 and the research carried out by Richardson et al.18
There are previous comorbidities
that have been associated with a higher risk of laryngeal complications after extubation; the most important being: age, female gender,
obesity, diabetes, arterial hypertension, and renal or liver failure.8
These conditions influence tissue perfusion and the capacity of the tissues to
scar, thus facilitating or worsening the AW injury. Also, some of these
comorbidities are related to higher severity of the COVID-19 infection, thus
suggesting that these patients have higher risk of intubation and also of
suffering OTI sequelae.14 We didn’t find
this relationship in our patient sample; and surprisingly, diabetes was more
prevalent in the group without laryngeal injuries.
The prevalence of dysphagia in
the series of patients under evaluation was 65.6% (21/32). Other studies
conducted in COVID-19 patients obtained higher numbers. Sandblom
et al.11 and Boggiano et al.,13 found that almost all analyzed patients had
some degree of dysphagia assessed by the FEES.
Our lower percentage of
dysphagia, compared to these studies, could be due to the kinetic treatment
received by the patients from the moment they entered the decannulation
protocol, prioritizing oral hygiene, stimulation of orofacial
praxis, voluntary swallowing, sensorimotor laryngeal stimulation, stimulation
of phonation, techniques to improve the respiratory muscle strength and
expiratory flow, and the continuity of motor rehabilitation, according to each
particular case.
The median score of the Murray
scale in our study was 1 point (0.2-2). When we compared the score between the
group without laryngeal injuries [median 1 point (IQR 0-2)] and the group with
laryngeal injuries [median 1 point (IQR 1-2)], we didn’t observe any
statistically significant differences between both groups (p = 0.3).
Previously mentioned studies reported higher numbers in this scale.12
The presence of dysphagia in
critically ill tracheostomized patients is common. It
has been stated that the presence of a TQT cannula increases the risk of
aspiration. The physiopathological mechanism is
multifactorial and includes causes related to oropharyngeal
and laryngeal trauma, decreased oropharyngeal
sensitivity due to the absence of airflow because of the tracheal tube cuff of
the TQT cannula, the resulting loss of subglottic positive pressure, disuse
atrophy, altered breathing-swallowing coordination, and alterations in the
level of consciousness that impact on AW protection mechanisms and affect the
safety of swallowing. We assume that apart from these mechanisms, now we have
to add the effects of the SARS CoV-2 virus itself. A hypothesis has been posed
that this virus can induce injuries in the central and peripheral nervous
systems, because it affects the sensory and motor functions related to
swallowing.11 It isn’t possible yet to draw a conclusion about the
impact this virus has on said functions, but we shouldn’t forget about the
alteration in smell and taste, two symptoms observed with this infection, that
could be an added value for the development of swallowing disorders.
However, the frequency of
dysphagia found in our patients before the pandemic was 67.9%,15
that is to say, very similar to the one reported in this study of the
population with COVID-19. Future research is necessary to determine which is the real impact of the SARS-Co-V-2 virus on the physiopathological mechanism of oropharyngeal
dysphagia reported in these patients.
We didn’t find any statistically
significant association between laryngeal injuries and the presence of
dysphagia that agrees with the results of our previous study.15 And we didn’t find any other publications investigating this
association. The study of Rohuani et al. that was
conducted in post-COVID-19 patients two months after ICU discharge showed an
association between the laryngeal injuries evaluated through the FEES and the
swallowing alterations through the EAT 10 (Eating Assessment Tool)
questionnaire.16
In our study, 17.6% (n =
6) of the patients showed dysphagia at the time of hospital discharge. On this
regard, Boggiano et al. reported similar values of
dysphagia upon discharge (20%).13 Patients who presented dysphagia
upon discharge received outpatient and telecommunication-based follow-up
All the patients achieved decannulation before discharge, and the median of TQT time
was 25 days, with a CPF of 165 L/min (IQR 105-205), similar to data reported in
the various studies, where a cough peak flow of 160 L/min or higher represents
effective cough.20
A limitation to our study is the
fact that we didn’t calculate the rate of tracheostomized
patients, because some data were missing from all the patients admitted to the
intensive care unit that was necessary for us to assess the analyzed subgroup.
On the other hand, we can mention our small sample size, even though it is
similar to other studies available up to now about laryngeal injuries and dysphagia
caused by COVID-19.
CONCLUSION
This is the first study conducted
in Argentina that reports the prevalence of laryngeal injuries and dysphagia in
critically ill tracheostomized patients during the
first wave of the COVID-19 pandemic; and a high prevalence was found. We
believe that an early evaluation through the FEES has facilitated a timely
diagnosis that allows us to guide the treatment individually and to define the
moment for decannulation. It also provided us the
necessary tools to define the feeding route until dysphagia resolution.
Conflict of interest
Authors have no conflict of
interest to declare.
REFERENCES
1. Ren
LL, Wang YM, Wu ZQ, et al. Identification of a novel coronavirus causing severe
pneumonia in human: a descriptive study. Chin Med J (Engl).
2020; 133: 1015-24.
https://doi.org./10.1097/CM9.0000000000000722
2. Spiteri
G, Fielding J, Diercke M, et al. First
cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January
to 21 February 2020. Euro Surveill. 2020; 25:
2000178. https://doi.org./10.2807/15607917.ES.2020.25.9.2000178.
3.
Estenssoro E, Loudet CI, Ríos F, et al. Clinical characteristics and outcomes of invasively ventilated patients
with COVID-19 in Argentina (SATICOVID): a prospective, multicentre
cohort study. LancetRespir Med. 2021; 9: 989-98.
https://doi.org/10.1016/S2213-2600(21)002290.
4.
Ríos F, Risso-Vazquez A, Diaz
Ballve L. Enfermedad por coronavirus 2019 (COVID-19)
aspectos de interés para cuidados críticos.: Revisión narrativa. Rev Arg de Ter Int.
2020;1-11.
5. Hosey
MM, Needham DM. Survivorship after COVID-19 ICU stay. Nat Rev
Dis Primers. 2020; 6: 60. 2020.
https://doi.org./10.1038/s41572-020-0201-1
6.
Brodsky MB, Levy MJ, Jedlanek
E, et al. Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical
Ventilation During Critical Care: A Systematic Review. Crit Care Med. 2018; 46: 2010-7.
https://doi.org/10.1097/CCM.0000000000003368
7. Rovira
A, Dawson D, Walker A, et al. Tracheostomy care and decannulation
during the COVID-19 pandemic. A multidisciplinary clinical
practice guideline. Eur Arch Otorhinolaryngol. 2020;1-9. https://doi.org/10.1007/s00405-020-06126-0
8. Wallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy.
BJA Educ. 2021; 21: 250-7.
https://doi.org/10.1016/j.bjae.2021.02.005.
9. Mehel
DM, Özdemir D, Çelebi M, Aydemir S, Akgül G, Özgür A. Classification of
laryngeal injury in patients with prolonged intubation and to determine the
factors that cause the injury. Am J Otolaryngol.
2020; 41: 102432. https://doi.org/10.1016/j.amjoto.2020.102432.
10. Williams T, McGrath BA.
Tracheostomy for COVID-19: evolving best practice. Crit
Care. 2021; 25: 316.
https://doi.org/10.1186/s13054-021-03674-7.
11. Sandblom
H, Dotevall H, Svennerholm
K, Tuomi L, Finizia
C. Characterization of dysphagia and laryngeal findings in COVID-19 patients
treated in the ICU-An observational clinical study. PLoS One. 2021; 16: e0252347.
https://doi.org/10.1371/journal.pone.0252347.
12. Butler SG, Markley L, Sanders
B, Stuart A. Reliability of the penetration aspiration scale with flexible
endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol. 2015; 124: 480-3. https://doi.org/10.1177/0003489414566267.
13. Boggiano
S, Williams T, Gill S E, Alexander P, Khwaja S, Wallace
S, McGrath B. Multidisciplinary management of laryngeal pathology identified
in patients with COVID-19 following trans-laryngeal intubation and tracheostomy.
J Intens Care Soc
(IF). https://doi.org/10.1177/17511437211034699
14. Naunheim
MR, Zhou AS, Puka E, et al. Laryngeal complications
of COVID-19. Laryngoscope Investig Otolaryngol.. 2020; 5: 1117-24.
https://doi.org/10.1002/lio2.484. PMID:
15.
Chiappero G, Falduti A, Catini ME, Raimondi N. Evaluación endoscópica de la
deglución: una necesidad creciente en terapia intensiva. RATI 2018; 35: 48.
16. Rouhani
MJ, Clunie G, Thong GA Prospective Study of Voice,
Swallow, and Airway Outcomes Following Tracheostomy for COVID-19.2021.
Laryngoscope, 131: E1918-E1925.
17. Chao TN, Harbison
SP, Braslow BM, et al. Outcomes After
Tracheostomy in COVID-19 Patients. Ann Surg. 2020;272(3): e181-e186. https://doi.org/10.1097/
SLA.0000000000004166.
18.
Tornari C, Surda P, Takhar
A, et al. Tracheostomy, ventilatory
wean, and decannulation in COVID-19 patients. Eur Arch Otorhinolaryngol. 2021; 278:
1595-604. https://doi.org/10.1007/s00405-020-06187-1.
19. Richardson S, Hirsch JS, Narasimhan M, et al; the Northwell
COVID-19 Research Consortium. Presenting Characteristics, Comorbidities, and
Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City
Area. JAMA. 2020 May 26;323:2052-9.
https://doi.org/10.1001/jama.2020.6775. Erratum in: JAMA. 2020;
323: 2098.
20. Garuti
G, Reverberi C, Briganti A.
et al. Swallowing disorders in tracheostomised
patients: a multidisciplinary/multiprofessional
approach in decannulation protocols. Multidiscip Respir
Med 2014; 9: 36.
https://doi.org/10.1186/2049-6958-9-36.