Dysphagia following endotracheal intubation and tracheostomy in patients following COVID-19 respiratory failure: A combined analysis of instrumental and clinical swallow evaluations

Abstract

Introduction Prolonged intubation and tracheostomy are associated with dysphagia (1). Complications are known to increase with the duration of intubation. COVID-19 patients underwent prolonged periods of intubation and tracheostomy. Previous research reports dysphagia prevalence in patients with COVID-19 following intubation between 53.6%-96.5% (2)(3). Yet, to date only one study has combined instrumental and bedside evaluation of swallowing (4). The aim of this study was to report the prevalence, severity and nature of dysphagia in patients who had undergone endotracheal intubation as a result of COVID-19 respiratory failure, combining Results from clinical swallow evaluation (CSE) and instrumental swallow examination (fibreoptic endoscopic evaluation of swallowing FEES] and videofluoroscopy VFS]. Material and Methods This single site, service evaluation took place in a large London ICU. Data were collected from March 2020 and May 2022. Data from initial CSE, FEES and VFS were collated by two experienced SLTs. Outcome measures were reported using the functional oral intake scale, the penetration aspiration scale (PAS), the New Zealand secretion severity scale, the Yale residue scale and the Patterson oedema scale. A blinded reviewer rated 20% of the images. Results A total of n = 167 patients were included. The mean age was 56 years (range 18-93). Mean duration of intubation was 19 (range 1-67). Duration of intubation was 19 days (range 1-67). 114 patients received a tracheostomy. Mean duration of tracheostomy was 29 days (range 6-100). Post-extubation dysphagia was reported as 68% on CSE, 45% on FEES and 36% on VFS. Severe dysphagia (PAS 6-8) was reported in 50% of FEES and 64% of VFS patients. Vocal cord palsy/paresis was the most commonly reported laryngeal injury, observed in 23% of patients. Arytenoid oedema was reported most frequently. Severe residue was reported in 22%. Inter-rater reliability was 80% on FEES and 100% on VFS. Discussion/Conclusion This study highlights the prevalence of post-extubation dysphagia in patients intubated and/or tracheostomised as a result of COVID-19 respiratory failure. This study adds to the few studies examining instrumental evaluation of swallowing in the COVID-19 cohort, and is only the second to combine CSE, VFS and FEES findings (4). Our study is in keeping with previously rates of aspiration (+/- silent), reported as 58-88% across previous studies. Those treating patients following mechanical ventilation for COVID-19 should remain vigilant for dysphagia and laryngeal injury and utilise instrumental evaluation early in patient care.