Co-author: Amanda Hereford, M.A. CCC-SLP

Mayra Ramirez. Leo Castillo. Jill Holker. Arthur Sanchez. Brian Kuhns. What do these people have in common?  Their stories made the national news this past year because they required double lung transplants due to devastating COVID-19 complications. Despite advances in medical treatment for COVID-19, some patients have developed irreversible lung damage. For these critically ill patients, who cannot be weaned from mechanical ventilation or extracorporeal membrane oxygenation (ECMO), lung transplantation may be the only life-saving option (Bharat et al., 2020). The story of one patient’s long and difficult road battling post-COVID-19 complications in acute care, including the eventual need for a lung transplant, illustrates the vital role that speech-language pathologists play in the treatment of patients with COVID-19.

Case Study

At the start of his story, “Sam” ( The purpose of this case study, the patient will be referred to as Sam) was in his late thirties. He had a loving and supportive family with two young children. He was one of millions of people worldwide who was infected with COVID-19 in 2020. His story began when he developed COVID-19 associated pneumonia and was admitted to his local community hospital. Unfortunately, his health declined significantly, which warranted a transfer to a major medical center for a higher level of care.  At this medical center, Sam required ECMO and endotracheal (ET) intubation with mechanical ventilation. As he became more stable, a tracheotomy was performed, and the ET tube was replaced with a tracheostomy tube. Eventually, he was transferred from the COVID unit to the medical intensive care unit. Due to non-resolving COVID-19 respiratory failure, he was not able to be weaned from mechanical ventilation, and this led to his being placed on the lung transplant list. Three months after admission, a donor was identified, and he underwent a bilateral lung transplant. This was not the end of his story. Instead, it was the beginning of his recovery from COVID-19. 

Role of the Speech-Language Pathologist

Non-verbal Communication

The speech-language pathology team initially received a consult for a communication evaluation after the tracheostomy tube was placed. At that time, Sam was still in the COVID-19 unit and did not meet the criteria for cuff deflation and in-line Passy-Muir® Valve (PMV) use as he had high ventilator support requirements. General guidelines for in-line PMV use include:  FIO2 < .50, PEEP < 10 cm H2O, and PIP/PAP < 40 cmH20. At the time of the initial evaluation, Sam had an FI02 of .60 to maintain adequate oxygen saturations; therefore, an assessment for accessing a nonverbal means of communication was performed. During the initial evaluation, Sam was able to answer yes/no questions reliably and to write legibly. Due to his appropriate mental status and cognitive functioning, Sam also was introduced to applications for his smart phone and tablet to improve the efficiency of his communication. The following applications were downloaded for use during his stay:  

  • Text to Speech! app
    • Is a free app available for Apple and Android products.
    • Offers 95 different voices and 38 languages.
    • Allows user to type messages that are then spoken aloud.
  • Whiteboard apps
    • Several free whiteboard apps are available for Apple and Android products (e.g., Simple Whiteboard by Qrayon, Whiteboard: Just Draw Together).
    • Allow users to write messages with their fingertip and share to others.
  • TRACHTOOLSTM app
    • Is a free app for Apple and Android products.
    • Offers several voice options, including male, female, and child.
    • Has pre-recorded phrases and a custom phrase record option.
    • Has a Spanish option available with the Apple version.
    • Provides patient videos for education.

Unlike many COVID-19 patients, Sam’s mental status was intact. This allowed him to use several non-verbal communication options successfully.   

In-line PMV Use

Once criteria for cuff deflation and in-line PMV use was met, the SLP and respiratory therapist (RT) worked closely together with Sam to establish verbal communication. For successful in-line PMV placement, the expertise of both the SLP and RT was needed. The SLP and RT teamwork included:

  • Obtaining baseline parameters and measurements. 
    • O2 saturations, heart rate, respiratory rate, and work of breathing.
  • Educating the patient and family.
  • Determining readiness for cuff deflation and in-line PMV placement.
  • Slowly deflating the cuff.
  • Conducting an airway patency assessment.
  • Placing the PMV with appropriate adapters.
  • Suctioning, as needed.
  • Adjusting ventilator settings.
  • Establishing phonation.
  • Troubleshooting.
  • Patient monitoring.

Initially, Sam was able to produce weak phonation and tolerated in-line PMV use for short periods. With continued RT and SLP intervention, his breath support, volume, and tolerance of in-line PMV use improved. With the PMV in-line, Sam was able to converse with his family and express his wishes to the medical team. It was amazing to see how excited the medical team was to communicate with Sam. They had been working with him for months but had never heard his voice. More importantly, Sam was finally able to communicate with his children who were not allowed in the hospital due to COVID-19 and were several hours away. With the PMV, he was able to talk during FaceTime calls, rather than being a passive observer.  Verbal communication made such a positive impact on Sam, the staff, and his family. 

Etiology of Dysphagia

During this hospital course, Sam initially presented with severe dysphagia. The cause was likely multifactorial:  prolonged intubation, critical illness myopathy and polyneuropathy, and tracheostomy. It was also possible that COVID-19 oropharyngeal symptoms such as cough, loss of taste/smell, and pain in the pharynx impacted laryngeal function (El-Anwar et al., 2020).

Sam remained intubated for 23 days. The incidence of aspiration following intubation of 48 hours or longer is 50%, with 25% of patients demonstrating silent aspiration (Ajemian et al., 2001; El Sohl et al., 2003; Borden et al., 2011). The longer the intubation, the higher the likelihood of dysphagia and aspiration (Kwok et al., 2013). Borders et al. (2019) found a significant relationship between laryngeal sensory deficits and aspiration with 47% of patients intubated longer than 48 hours demonstrating both. Because tracheostomy insertion was considered a high risk and an aerosol generating procedure (AGP), many patients with COVID-19 remained intubated longer than the typical one to two weeks. 

Sam was critically ill and required hospitalization for over 4 months. Although he did not undergo electromyography testing, it was highly likely that he experienced critical illness myopathy (CIM) and critical illness polyneuropathy (CIP).  CIM and CIP are frequent complications of severe illness, involving both motor and sensory axons. In a study investigating the clinical characteristics of patients after a prolonged ICU stay due to COVID-19, 72.7% of patients presented with muscle weakness in all major muscle groups (Wiertz et al., 2021). Ponfick et al. (2015) evaluated the prevalence of dysphagia in non-neurologic patients with critical illness polyneuropathy using fiberoptic endoscopic evaluation of swallowing (FEES). The authors reported pathologic swallowing in 91% of patients, and 78% of patients demonstrated aspiration. 

Lastly, Sam eventually had a tracheostomy tube placed during his course of treatments. There has been considerable research regarding the negative impact of tracheostomy on swallow function including impaired laryngeal elevation (Ding & Logemann, 2005; Amethieu et al., 2012; Jung et al., 2012), reduced subglottic air pressure (Gross et al., 2003), decreased coordination of breathing and swallowing (Prigent et al., 2011), and reduced effectiveness to clear secretions (Bailey, 2005).  

Swallowing Evaluations and Therapy

Even though Sam could not use a speaking Valve initially, he had numerous Fiberoptic Endoscopic Evaluations of Swallowing (FEES) during his hospitalization. FEES was chosen to assess swallowing as it allowed for: 

  • The potential for longer evaluation periods with FEES compared to the Videofluoroscopic Swallowing Study (VFSS).
  • Direct visualization of the nasopharyngeal, pharyngeal, and laryngeal tissues and structures.
  • Visualization of secretion management.
  • Easier accessibility than with VFSS.
  • Portability.

For Sam, the portability of FEES was especially advantageous. Initially, transport to radiology was not feasible due to his medically fragile condition and the requirement for ECMO. Hafner et al. (2013) reported that the use of FEES in critically ill patients allows for a rapid evaluation of deglutition and provides immediate initiation of symptom-related rehabilitation or an early resumption of oral feeding.

Initial FEES were conducted while Sam was on ECMO and mechanical ventilation via a tracheostomy tube but without a speaking Valve. During this time, the cuff was inflated due to high ventilator requirements, and he did not meet criteria for cuff deflation or speaking Valve use. These exams revealed severe dysphagia and aspiration. He was started on an exercise regimen to improve pharyngeal strength and prevent further disuse atrophy. As mentioned previously, Sam’s mental status was intact, so he was able to perform daily swallow exercises independently. His rehabilitative swallow program included oral care, limited ice chips to increase swallow frequency, effortful swallow exercise, and lingual resistance exercise. 

Following his lung transplant, he was able to be removed from ECMO. His respiratory status slowly improved, and he progressed with ventilator weaning.  During this time of improvement, the team again addressed the use of a Passy-Muir Valve, which he could use successfully. Additional FEES also were conducted when the cuff was deflated and the PMV was in-line with the ventilator circuitry. With improvement in his overall status, participation in swallowing rehabilitation, and with use of the PMV to restore positive pressure and upper airway airflow, his swallow function improved. Sam gradually was able to swallow various foods and liquids with the use of compensatory techniques. He continued to participate in rehabilitative swallow therapy as well, which included cuff deflation, in-line PMV use, and both indirect and direct swallow therapy. Sam even got to enjoy snacks with his wife in the MICU for their special “date nights.” 

Discharge

After four long months of hospitalization related to COVID-19 complications, Sam was discharged to a long-term acute care hospital (LTACH) for continued rehabilitation. Tireless, complex medical care was provided to Sam during his acute care hospitalization to give him every chance to survive, rehabilitate, and eventually get back home to his family. Although he has moved on to the next level of care, his amazing journey has not been forgotten.  He was one of those patients who will forever remain in the hearts and minds of his healthcare providers.  

Summary

The complications of COVID-19 have caused many patients to experience severe communication and swallowing impairments. Speech pathologists have a vital role in assessing and treating these patients.  Intervention includes such areas as:

  • Advocating for early communication and swallowing referrals.
  • Providing patient and family education.
  • Establishing non-verbal communication.
  • Establishing verbal communication. 
  • Collaborating with the medical team to provide patient-centered care.
  • Assessing swallowing.
  • Treating dysphagia.
  • Assisting with discharge planning.

Although, there is a glimmer of hope in this dark season in medicine, patients with COVID-19 complications will continue to present to intensive care units, LTACHs, rehabilitation centers, skilled nursing facilities, outpatient clinics, and in the home health environment for the foreseeable future.  Thus, SLPs will continue to be faced with the challenges of treating these medically complex patients, will continue to be vital members of healthcare teams, and will make vast differences in patients’ lives by restoring communication and swallowing ability.  

Watch for part 2 in this series: COVID-19 Complications and the Role of the SLP:  An LTACH Case Study and part 3: COVID-19 Complications and the Role of the SLP:  A Home Care Case Study.

Helpful resources:

Information from ASHA about managing communication and swallowing disorders in patients with COVID-19:

Guidelines about tracheostomy management during COVID-19 from the UK National Tracheostomy Safety Project:

Resources about in-line PMV use: 

Links to Passy-Muir, Inc. webinars: 

References:

Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of Surgery, 136(4), 434-437. https://doi.org/10.1001/archsurg.136.4.434

Amathieu, R., Sauvat, S., Reynaud, P., Slavov, V., Luis, D., Dinca, A., Tual, L., Bloc, S., & Dhonneur, G. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia, 109(4), 578-583. https://doi.org/10.1093/bja/aes210

Bailey, R.L. (2005). Tracheostomy and dysphagia: A complex association. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(4), 2-7. https://doi.org/10.1044/sasd14.4.2

Bharat, A., Querrey, M., Markov, N., Kim, S., Kurihara, C., Garza-Castillon, R., Manerikar, A., Shilatifard, A., Tomic, R., Politanska, Y., Abdala-Valencia, H., Yeldandi, A., Lomasney, J., Misharin, A., & Budinger, G. (2020). Lung transplantation for patients with severe COVID-19. Science Translational Medicine, 12(574), eabe4282. https://doi.org/10.1126/scitranslmed.abe4282 

Borders, J. C., Fink, D., Levitt, J.E., McKeehan, J., McNally, E., Rubio, A., Scheel, R., Siner, J.M., Taborda, S.G., Vojnik, R., Warner, H., White, S.D., Langmore, S.E., Moss, M., & Krisciunas, G.P. (2019). Relationship between laryngeal sensation, length of intubation, and aspiration in patients with acute respiratory failure. Dysphagia, 34, 521 – 528. https://doi.org/ 10.1007/s00455-019-09980-1.

Bordon, A., Bokhari, R., Sperry, J., Testa, D., Feinstein, A., & Ghaemmaghami, V. (2011). Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients. American Journal of Surgery, 202(6), 679-682. https://doi.org/10.1016/j.amjsurg.2011.06.030

Davis, D. G., Bears, S., Barone, J. E., Corvo, P. R., & Tucker, J. B. (2002). Swallowing with a tracheostomy tube in place: Does cuff inflation matter? Journal of Intensive Care Medicine, 17(3), 132-135. https://doi.org/10.1177/088506660201700304

Ding, R., & Logemann, J. A. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head & Neck, 27(9), 809-813. https://doi.org/10.1002/hed.20248 

El Solh, A., Okada, M., Bhat, A., & Pietrantoni, C. (2003). Swallowing disorders post orotracheal intubation in the elderly. Intensive Care Medicine, 29(9), 1451-1455. https://doi.org/10.1007/s00134-003-1870-4

El-Anwar, M., Elzayat, S., & Fouad, Y. (2020) ENT manifestation in COVID-19 patients. Auris Nasus Larynx, 46(4); 559-564. https://doi.org/10.1016/j.anl

Gross, R. D., Mahlmann, J., & Grayhack, J. P. (2003). Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Annals of Otology, Rhinology & Laryngology, 112(2), 143-152. https://doi.org/10.1177/000348940311200207

Hafner, G., Neuhuber, A., Hirtenfelder, S., Schmedler, B., & Eckel, H. (2008). Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients. European Archives of OtoRhinoLaryngology, 265(4), 441-446. https://doi.org/10.1007/s00405-007-0507-6

Jung, S. J., Kim, D. Y., Kim, Y. W., Koh, Y. W., Joo, S. Y., & Kim, E. S. (2012). Effect of decannulation on pharyngeal and laryngeal movement in post-stroke tracheostomized patients. Annals of rehabilitation medicine, 36(3), 356–364. https://doi.org/10.5535/arm.2012.36.3.356

Kwok, A., Davis, J., Cagle, K., Sue, L., Kaups, K. (2013) Post-extubation dysphagia in trauma patients: it’s hard to swallow.  American Journal of Surgery, 206(6), 924-927. https://doi.org/ 10.1016/j.amjsurg.2013.08.010

Ponfick, M., Linden, R., & Nowak, D. (2015). Dysphagia–a common, transient symptom in critical illness polyneuropathy: a fiberoptic endoscopic evaluation of swallowing study. Critical Care Medicine, 43(2), 365-372. https://doi.org/10.1097/CCM.0000000000000705

Prigent, H., Lejaille, M., Terzi, N., Annane, D., Figere, M., Orlikowski, D., & Lofaso, F. (2011). Effect of a tracheostomy speaking valve on breathing–swallowing interaction. Intensive Care Medicine, 38(1), 85-90. https://doi.org/10.1007/s00134-011-2417-8 

Co-author Bio:

Amanda P. Hereford is the manager of an adult acute care department at one of the largest academic medical centers in the Southeast.  Her areas of interest include evaluation and management of dysphagia in medically complex patients and care for patients following traumatic brain injuries. She has been a guest presenter for graduate courses and at local and state-level conferences.

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