I remember clearly the very first patient I treated for COVID-19 in our hospital.
She would turn out to be the first of many.
“Lisa” was a retired pediatrician, very active and fit prior to her admission, who had been extubated the day before following nine days of intubation. As is the policy in our hospital, she had been screened for dysphagia following extubation and had failed the screen, prompting a swallow consult. We had attempted to complete the consult the day before, but the nurse had asked us to wait a day as Lisa was very fatigued. According to her nurse that morning, she was still very weak and tired but asking for water, so I checked (and re-checked) my N95 and PPE, and in I went.
Lisa was in bed, sitting semi-upright, with a high-flow nasal cannula in place. Her voice was weak but audible, and she expressed that she had been coughing quite a bit and felt that her mouth and throat were very dry. Her oral movements were slow, and she had significant weakness in her lips and tongue.
I decided to proceed with some ice chips, both to wet her mouth and to get my first look at her ability to swallow. As I handed her the cup of ice, she attempted to reach for it but couldn’t raise her arm sufficiently to hold the cup.
She looked like a patient who just had spent nine weeks in bed rather than nine days.
In the coming weeks and months of the pandemic, we would soon realize that this profound weakness is one of the hallmarks of COVID-19. And, unfortunately, it doesn’t always resolve when the initial COVID-19 symptoms resolve, a condition that has come to be known as “Long COVID.”
Post-Acute (or Long) COVID-19
After recovery from acute COVID-19 viral infection, as many as 40 percent of patients continue to report hypoxemia and dysphagia.1 Dyspnea, in particular, may persist for several months, regardless of the severity of the initial COVID-19 symptoms.2
Post-acute or “long” COVID-19 is not a well-defined or well-understood phenomenon but generally refers to those symptoms that persist for at least three to four weeks following the initial onset of COVID-19 symptoms. Patients have reported brain fog, prolonged taste and smell loss, fatigue, joint pain, dizziness, and, of course, ongoing issues with dyspnea, hypoxemia, and dysphagia.3, 4
Patients with post-acute COVID-19 present with prolonged respiratory issues, including restrictive abnormalities, fibrosis, and hypoxia-related damage. This results in discoordination in breathing-swallow patterns and ongoing dysphagia.
Swallowing places considerable demand on the respiratory system–demands that patients with respiratory compromise often can’t manage safely. The result, unfortunately, is aspiration with possible exacerbation of the existing lung damage. It also means that activity and exercise leave patients feeling short of breath and fatigued.
So what’s a rehab therapist to do?
It’s a Balancing Act
ICU-acquired weakness is a frequent complication of prolonged illness, including (but not exclusive to) prolonged intubation.5 Muscle wasting and weakness are the result of not only the critical illness itself, but also of the lack of activity that accompanies the illness. This lack of muscle use results in disuse atrophy, which further exacerbates the weakness… which results in less use… which worsens the atrophy… and around and around we go.
For swallow therapists, then, it’s a balancing act. Clearly, we need to get those muscles moving—but how do we provide some practice and retraining for the weakened swallow muscles without further compromising the airway? And how do we do that in the context of the dyspnea and activity-associated hypoxemia that our post-acute COVID-19 patients are experiencing?
It’s tempting to focus on the risks of swallowing: aspiration, exacerbation of lung disease, pneumonia. But what are the risks of not swallowing? Weakness and disuse atrophy, which result in, again, aspiration, exacerbation of lung disease, and pneumonia.
Balancing those risks while keeping our patients as safe as possible is an ongoing challenge for the dysphagia clinician.
Improve Swallowing by Swallowing
How can we provide safe practice with swallowing in these complicated, compromised patients?
- Cold—Cold boluses such as water sips or ice chips can help stimulate a swallow response by tapping into the thermal, tactile, and chemoreceptors in the mouth and throat that transmit sensory information to the brainstem.6 Our experience has been that cold is particularly effective in patients with COVID-19, given the ongoing sensory changes they experience.
- Diet options—Texture modification can be a helpful tool given the fatigue and breathing-swallow discoordination that patients with COVID-19 struggle with. Foods that require mastication can further disrupt breathing-swallow coordination and certainly require more energy. Thickening liquids is often a “go-to” intervention, but it is not without risk. Thick liquids are meant to slow the flow of the liquid and prevent aspiration, but if they are in fact aspirated, they are far more difficult to clear from the lungs and are more dangerous to lung health.7 Given the fluctuations in respiration and, therefore, in respiration-swallow coordination that we see in patients with COVID-19, it is difficult to completely eliminate aspiration risk. This means that we must proceed cautiously with thickening. Finally, build in flexibility in diet recommendations. Respiratory status, fatigue levels, and cognition will likely fluctuate from day to day—and even from hour to hour. What works today may not work tomorrow, and what works in the morning may not work at the end of the day.
- Slow Down—Swallowing places significant demands on the respiratory system, and nowhere is this more apparent than in our COVID-19 patients with dyspnea. While we wait for recovery from the illness, which may take weeks or months, what can we do to limit those demands? Sometimes the simplest solutions are the best: encourage breaks intermittently throughout the meal, take small bites and sips, slow down the rate of intake. These seemingly obvious interventions can be extremely effective in improving endurance, increasing airway safety, and enhancing overall oral intake.
- Take Control of Breathing—Swallowing and breathing are both reflexive processes over which we can also exert voluntary control. If someone asks you to swallow, you can (as long as you have sufficient amounts of saliva, food, or liquid in your mouth). You can take a big breath or a small one, or even hold your breath. Tapping into that voluntary control can be a helpful strategy. Train your patients to use a bolus “hold.” Take a bite or sip, chew up the food as you normally would, but just before the swallow, “hold” for a second. This allows respiration to regulate and decreases the likelihood of dyspnea. After the swallow, encourage a voluntary exhalation to facilitate airway clearance and normalize respiratory-swallow patterning. Exerting voluntary control over breathing and swallowing can improve bolus control and improve breathing-swallow coordination.8, 9 The rhythm will look like this: sip/bite/chew… pause… swallow …exhale.
Patients with long-haul COVID-19 are likely to struggle with dyspnea, hypoxemia, and dysphagia for weeks and months. Let’s make sure we’re in it with them for the long haul as well, ready to provide them with the care they need.
- Wiertz, C. M. H., Vintz, W. A. J., Maas, G. J. C. M., Rasquin, S. M. C., van Horn, Y. Y., Dremmen, M. P. M., Hemmen, B., & Verbunt, J. A. (2021). COVID-19: Patient characteristics in the first phase of postintensive care rehabilitation. Archives of Rehabilitation Research and Clinical Translation, 3(2), 100190. https://doi.org/10.1016/j.arrct.2021.100108
- Cortés-Telles, A., López-Romero, S., Figueroa-Hurtado, E., Pou-Aguilar, Y. N., Wong, A. W., Milne, K. M., Ryerson, C. J., & Guenette, J. A. (2021). Pulmonary function and functional capacity in COVID-19 survivors with persistent dyspnoea. Respiratory Physiology & Neurobiology, 288, 103644. https://doi.org/10.1016/j.resp.2021.103644
- Abdelrahman, M. M., Abd-Elrahman, N. M., & Bakheet, T. M. (2021). Persistence of symptoms after improvement of acute COVID19 infection, a longitudinal study. Journal of Medical Virology, 93(10), 5942–5946. https://doi.org/10.1002/jmv.27156
- Wildwing, T., & Holt, N. (2021). The neurological symptoms of COVID-19: a systematic overview of systematic reviews, comparison with other neurological conditions and implications for healthcare services. Therapeutic Advances in Chronic Disease, 12, 2040622320976979. https://doi.org/10.1177/2040622320976979
- Schefold, J. C., Bierbrauer, J., & Weber-Carstens, S. (2010). Intensive care unit-acquired weakness (ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic shock. Journal of Cachexia, Sarcopenia and Muscle, 1(2), 147–157. https://doi.org/10.1007/s13539-010-0010-6
- Pisegna, J., and Langmore, S. (2018). The ice chip protocol: A description of the protocol and case reports. Perspectives of the ASHA Special Interest Groups, 3(13), 28. https://doi.org/10.1044/persp3.SIG13.28
- Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., Brandt, D., Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Gramigna, G. D., McGarvey-Toler, S., & Miller Gardner, P. J. (2008). Comparison of 2 interventions for liquid aspiration in pneumonia incidence: a randomized trial, Annals of Internal Medicine, 148(7), 509–18. https://doi.org/10.7326/0003-4819-148-7-200804010-00007
- Palmer, J. B., Hiiemae, K. M., Matsuo, K., & Haishima, H. (2007). Volitional control of food transport and bolus formation during feeding. Physiology & Behavior, 91(1), 66–70. https://doi.org/10.1016/j.physbeh.2007.01.018
- Martin-Harris, B., McFarland, D., Hill, E. G., Strange, C. B., Focht, K. L., Wan, Z., Blair, J., & McGrattan, K. (2015). Respiratory-swallow training in patients with head and neck cancer. Archives of Physical Medicine and Rehabilitation, 96(5), P885–893. https://doi.org/10.1016/j.apmr.2014.11.022