Dysphagia rehabilitation in post-COVID patients: Review of the literature

COVID-19 causes acute respiratory failure syndrome (SIRA), leading patients to require intubation in the intensive care unit (ICU). A common complication of this ventilatory support is dysphagia, which has a prevalence of up to 30%.This work aims to describe rehabilitation methods in patients with coronavirus infection based on levels of evidence according to the GRADE System, so a systematic review of the literature was carried out. The selected articles were divided into the following subtopics: diagnosis of dysphagia and rehabilitation in COVID patients. The gold standard for the diagnosis of dysphagia is the videofluoroscopic swallowing study (VFS). Fiberoptic Evaluation of Swallowing Assessment (FEES) has high sensitivity and specificity, although they have the disjunction of an aerosol-generating procedure (AGP);however, in a pandemic situation, the study of choice in the literature is VF. Once the diagnosis is made, it is necessary to initiate rehabilitation as soon as possible, even from hospitalization in patients who have hemodynamic stability to prevent long-term effects and promote normal swallowing even before discharge. In patients with COVID-19 infection dysphagia, the risk-benefit of assessment tools and therapy used for diagnosis should be decided to help to maintain social distancing. It becomes imperative to carry out clinical studies with high levels of evidence that allow us to generate Clinical Practice Guides for the benefit of our patients.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

The prevalence of SARS-CoV-2 infection in an academic department of anaesthesiology

Background: Anaesthetists are frontline workers who perform aerosol-generating procedures (AGPs) in enclosed environments, which exposes them to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and increases their risk of contracting SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19). This study describes the prevalence of SARS-CoV-2 infection in the academic department of anaesthesiology of the University of the Witwatersrand prior to vaccination. Method(s): A cross-sectional, contextual, descriptive research design, using an anonymous electronic questionnaire, was followed in the study. Consecutive and convenience sampling methods were used. A p-value of < 0.05 was considered statistically significant. Result(s): A total of 147 participants met the inclusion criteria. There were 90 (61.22%) females and 57 (38.78%) males. The mean age was 35.26 years for the 36 participants who tested positive (26.47%) for SARS-CoV-2. Hospital admission was required by 2.78% of participants with COVID-19. Male participants had a higher prevalence of having SARS-CoV-2 infection (p = 0.045). There were no statistically significant associations between SARS-CoV-2 infection and pregnancy (p = 0.09), asthma (p = 0.11), autoimmune disease (p = 0.77), obesity (p = 0.9), diabetes (p = 0.96), hypertension (p = 0.9) and smoking (p = 0.69). Commonly reported COVID-19-like symptoms included fatigue (68.33%), headaches (61.67%) and myalgia (58.33%). Of the participants with a positive SARS-CoV-2 test, 38.46% had reported travelling within 14 days of testing positive (p < 0.001). Community exposure to a person with SARS-CoV-2 was associated with participants contracting SARS-CoV-2 infection (p = 0.001). Conclusion(s): AGPs are not a significant risk factor for anaesthetists in the context of work or community transmission of the virus. There was a statistically significant predisposition for contracting SARS-CoV-2 infection among males, participants who travelled and participants who had community exposure to a SARS-CoV-2 infected person.

COVID-19 and gastrointestinal endoscopy-proper strategies related to pandemic changes.

The outbreak of coronavirus disease 2019 (COVID-19) in December 2019 was associated with new challenges in many fields of medicine. Preventing transmission of the virus and infection of professional healthcare workers became of major concern in our daily clinical practice during the pandemic. Viral particles within aerosols can be detected up to 3h after aerosolization. Recent work defined endoscopic procedures of the upper gastrointestinal tract as being aerosol-generating procedures (AGPs);thus, they can carry the possibility of transmitting airborne viruses to personnel. Because severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is primarily transmitted by aerosols and/or droplets, the use of personal protective equipment (PPE) is warranted. Guideline recommendations from the WHO and other societies were also modified early to include PPE as an infection prevention measure. The strict use of PPE has proven to be an effective prevention strategy over the 3 years since its implementation. With the introduction of vaccinations against SARS-CoV-2, increasing immunization of the population, and a changing pandemic infection pattern, the requirements for endoscopic departments in hospitals and outpatient care settings continued to change. In the postpandemic situation, there are only minor restrictions that affect the new "postpandemic reality", thus, allowing endoscopic services to be performed without major restrictions. Here, we present a review of recent and most relevant knowledge to summarize the prophylactic measures that must be taken to perform endoscopy under safe conditions during the COVID-19 pandemic.Copyright © 2023, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Outcome of Long Term Ventilation (LTV) following remote initiation and monitoring in patients with Chronic Hypercapnic Respiratory Failure (CHRF) during the SARS-CoV-2 pandemic

Background: In the absence of LTV, CHRF leads to recurrent hospital admissions, poor quality of life and increased mortality. Anticipating a significant surge in SARS-CoV-2 our long term ventilation staff were redeployed to provide acute COVID service. NIV was considered as an aerosol generating procedure and due to lack of regular outpatient clinical activity, we implemented a remote LTV initiation and review service and have evaluated the clinical outcomes Method: Consecutive patients started on LTV over a 12 month period were included. Patient demographics, LTV indications, trial duration, remote review and clinical outcomes were evaluated Results: N=54, mean age;60+/-16, mean FEV1;45+/-24, mean BMI;39+/-18, males-54%. indications for LTV were OHS-56%, COPD-28%, NMD-7%, Chest wall disorders-6% and others (overlap syndromes and opioid induced)-3%. A third of patients needed supplemental oxygen therapy (2-4 lts/16-24 hours/day). The median (IQR) duration of LTV trial was 4.3 (1-5-4.5) months and mean (SD) NIV compliance was 5.5 (2.3) hours. Patients were regularly monitored remotely (via modem or telephone) due to clinical shielding advice and this prevented hospital admissions in 56% of patients. A significant improvement in pCO2 was noted (P -0.0009, mean pCO2 pre LTV: 9 +/- 2.85 v/s post LTV: 6.7 +/- 1.3, DELTA change 2.2 kpa, 95% CI: 1.2 -3.52). 9.3% had SARS-CoV-2 infection with all-cause mortality of 3.7% Conclusion(s): LTV can be initiated and monitored remotely & effectively. Adequate compliance and improvement of hypercapnia are key parameters of good outcome with LTV and remote monitoring may be cost effective.

Physician-led ultrasound interventions: Rapid diagnosis of lung cancer during the COVID-19 pandemic

Introduction: Lung cancer management depends upon a timely histological diagnosis. Unprecedented pressure on various diagnostic facilities were observed during the COVID-19 pandemic. In our hospital, physician-led thoracic ultrasound guided biopsies and Rapid-On-Site-Evaluation (ROSE) ensured the prompt enrollment in the lung cancer diagnostic pathway. Aim and objectives: The COVID-19 pandemic has affected the lung cancer pathway adversely due to aerosol generating procedures, infection control, limited bronchoscopy, endobronchial ultrasound and computed tomography (CT) sessions. During this challenging time, we aimed to maintain a swift and consistent lung cancer pathway, aided by physician-led ultrasound guided interventions. Method(s): A twelve-month prospective analysis was performed on a cohort of all patients with a histological diagnosis of lung cancer, examining methods used for tissue sampling. Result(s): Between April 2020 to March 2021, our lung multi-disciplinary meeting decided the clinical management of 91 patients with confirmed histology. 41% (37/91) of those had biopsies via physician-led ultrasound-interventions. Sites sampled yielding tissue diagnosis were;59% (22/37) supraclavicular fossa nodes, 30% (11/37) lung lesions, 5% (2/37) pleural lesions, 3% (1/37) bone and 3% (1/37) axillary lymph node. Conclusion(s): Our study shows that physician led ultrasound guided biopsies and ROSE are safe and robust for prompt and speedy lung cancer management. It has future research potentials. We welcome comments and experience of other teams in this regard.

Neuroanesthesia practice during COVID-19: A single-center experience

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.

Assessing the implementation of guidelines surrounding aerosol generating procedures

This paper assesses the changing guidelines regarding Aerosol Generating Procedures and fallow time in Oral and Maxillofacial Surgery Departments in the UK. Many departments have variable local policies and protocols and this could be a contributing factor in increased waiting lists for patients during a time when patients have less access to primary and secondary care.Copyright © 2021

Development of an emergency airway response system for COVID-19 at a tertiary care hospital in resource limited country.

The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.

Head and neck cancer recurrence with limited mouth opening, radiation fibrosis and confirmed COVID-19 infection: Approach to airway management.

We present a case that describes the airway management of a patient with recurrent head and neck cancer and confirmed COVID-19 infection. Securing airway of these patients with anticipated difficulty and at the same time limiting virus exposure to providers can be challenging. The risk of aerosolization during awake tracheal intubation is extreme as it carries a high risk of transmitting respiratory infections. A multidisciplinary team discussion before the procedure highlighted aspects of both airway management and the urgency of surgical procedure where particular care and modifications are required. Successful flexible bronchoscopy and intubation was done under inhalational anaesthetics with spontaneous breathing. Although fiberoptic intubation during sleep,in anticipated difficult airways, have led to enhanced intubation time, this technique was opted to minimize the risk of aerosol generation associated with topicalisation, coughing and hence reduced incidence of cross infection to health care workers.

Aerosol Generation During Nasal Airway Instrumentation.

OBJECTIVE: Airborne aerosol transmission, an established mechanism of SARS-CoV-2 spread, has been successfully mitigated in the health care setting through the adoption of universal masking. Upper airway endoscopy, however, requires direct access to the face, thereby potentially exposing the clinic environment to infectious particles. This study quantifies aerosol production during rigid nasal endoscopy (RNE) and RNE with debridement (RNED) as compared with intubation, a posited gold standard aerosol-generating procedure. STUDY DESIGN: Prospective cross-sectional study. SETTING: Subspecialty single-center clinic and surgical study. METHOD: Three aerosol detectors (NANOSCAN-3910, OPS-3330, and APS-3321) with a particle size sensitivity of 10 to 20,000 nm were utilized to detect particulate production during the clinical care of 209 patients undergoing RNE/RNED and 25 patients undergoing intubation. RESULTS: RNE and RNED produced statistically significant particles over baseline in 29.3% and 51.0% of subjects (P = .003-.049 and .002-.047, respectively). Intubation produced statistically significant particles in 31.2% (P = .001-.015). The mean ± SD particle diameter in all tests was 69.9 ± 10.5 nm with 99.7% <300 nm. There were no statistical differences in particle production among RNE, RNED, and intubation. The presence of concomitant cough, sneeze, or prolonged speech similarly did not significantly affect particle production during any procedure. CONCLUSIONS: Instrumentation of nasal airway produces airborne aerosols to a similar degree of those seen during intubation, independent of reactive patient behaviors such as cough or sneeze. These data suggest that an improved understanding is necessary of both the definition of an aerosol-generating procedure and the functional consequences of procedural aerosol generation in clinical settings.

A review of infection prevention and control guidelines for dental offices during the COVID-19 pandemic in mid-2020

Background: The COVID-19 pandemic was a challenge for all dental professionals who had to rapidly update infection prevention and control (IPAC) guidelines and protocols due to increased risk of SARS-CoV-2 transmission during common aerosol-generating procedures (AGPs), and a lack of consensus on how best to mitigate the risk of transmission in a dental office. Thus, the purpose of this descriptive study was to compare the variance in IPAC guidelines for dental offices that emerged, and to assess practice consistency from early to mid-2020. Methods: A comprehensive literature search was conducted from May 26 to July 8, 2020 for IPAC documentation specific to the dental office during the COVID-19 pandemic. Documents that met the inclusion criteria were independently reviewed. Data was extracted using a framework based on the following IPAC domains: pre-appointment, waiting room, personal protective equipment (PPE) selection, treatment room, and post-dismissal. Results: A total of 67 IPAC documents specific to dental offices were reviewed in this study. Included documents originated from 22 dental associations, 17 peer-reviewed articles, 13 dental regulators, 11 government bodies, two public health units, and two dental corporations. There was a great degree of variance with IPAC guidelines from the pre-appointment stage, during treatment, and post-treatment. Recommendations that emerged with some level of consistency involved pre-screening patients for COVID-19 symptoms (97%), staggering appointments (84%), social distancing, minimizing occupants in the waiting room, wearing a face shield over protective eyewear for AGPs (92%), and preprocedural rinses (84%). There was less consistency with recommendations for consolidating multiple appointments (36%), waiting room ventilation (46%), N95 masks (47%) versus FFP2/FFP3 masks (30%) use for AGPs, fit-testing respirators (37%), enclosing open operatories for AGPs (28%), prioritizing minimally invasive procedures (30%), and using third-party laundry companies (32%). Conclusions: The risk of SARS-CoV-2 transmission, lack of consensus on mode of spread, and need for rapid action resulted in a significant variation in most downstream IPAC interventions in the hierarchy of controls, including choice of PPE, treatment room, and post-dismissal domains. Upstream interventions, including pre-appointment and waiting room domains, were relatively consistent in practices in early to mid-2020.

Personnel Protective Equipment for Healthcare Professionals During COVID-19 Pandemic

COVID-19 is highly contagious and transmission dynamics of COVID-19 are not yet fully elucidated. It is known that the ill person begins to become contagious before the symptoms of the disease begin. Also asymptomatic person who are infected but does not have symptoms and signs, can infect other individuals. The only way for health workers to protect themselves from COVID-19 is proper use of personal protective equipment and to ensure hand hygiene. COVID-19 is transmitted through close contact and large respiratory droplets and not transmitted by airborne. The surgical mask prevents the passage of respiratory droplets. However, during the aerosol producing procedures performed on the patient, small particles containing infectious particles are scattered to air in high amounts. Healthcare workers are more likely become infected during these procedures. It is recommended to wear respirator during these procedures. Use of masks or respirators must be in conjunction with other recommended PPE and appropriate hand hygiene.

Experience with 2D Exoscope System for Bilateral Simultaneous Cochlear Implant Surgery in the Era of the COVID-19 Pandemic.

We report the first case series utilizing the exoscope exclusively for bilateral simultaneous cochlear implant surgery and discuss the advantages, disadvantages, as well as surgical outcomes in the Covid-19 era. The VITOM® 2D is compatible with enhanced PPE and draping techniques which can improve safety while providing comparable surgical outcomes.

Droplet nuclei are generated during colonoscopy and are decreased by the use of carbon dioxide and water immersion technique.

OBJECTIVES: The COVID-19 pandemic has raised concerns on whether colonoscopies (CS) carry a transmission risk. The aim was to determine whether CS are aerosol-generating procedures. METHODS: This was a prospective observational trial including all patients undergoing CS at the Prince of Wales Hospital from 1 June to 31 July 2020. Three particle counters were placed 10 cm from each patient's anus and near the mouth of endoscopists and nurses. The particle counter recorded the number of particles of size 0.3, 0.5, 0.7, 1, 5, and 10 µm. Patient demographics, seniority of endoscopists, use of CO2 and water immersion technique, and air particle count (particles/cubic foot, dCF) were recorded. Multilevel modeling was used to test all the hypotheses with a post-hoc analysis. RESULTS: A total of 117 patients were recruited. During CS, the level of 5 µm and 10 µm were significantly higher than the baseline period (P = 0.002). Procedures performed by trainees had a higher level of aerosols when compared to specialists (0.3 µm, P < 0.001; 0.5 µm and 0.7 µm, P < 0.001). The use of CO2 and water immersion techniques had significantly lower aerosols generated when compared to air (CO2 : 0.3, 0.5, and 0.7 µm: P < 0.001; water immersion: 0.3 µm: P = 0.048; 0.7 µm: P = 0.03). There were no significant increases in any particle sizes during the procedure at the endoscopists' and nurses' mouth. However, 8/117 (6.83%) particle count tracings showed a simultaneous surge of all particle sizes at the patient's anus and endoscopists' and nurses' level during rectal extubation. CONCLUSION: Colonoscopy generates droplet nuclei especially during rectal extubation. The use of CO2 and water immersion techniques may mitigate these risks.

Healthcare workers' preparedness and response during COVID-19 pandemic

Background: Healthcare workers (HCWs) are most at risk of contracting SARS-CoV-2 and COVID-19 infection. Their preparedness, as a result of provision and access to personal protective equipment (PPE), training programmes and awareness and practices on infection prevention and control measures, is integral for the prevention of infectious disease transmission. Objective(s): This study was conducted to assess the preparedness and practices of HCWs during COVID-19 first wave outbreak in Brunei Darussalam. Method(s): A cross-sectional study using a pre-designed and self-administered web-based questionnaire was conducted among HCWs from government and private health sectors ranging from primary to tertiary health facilities in Brunei Darussalam. Data were analysed using descriptive statistics, and chi-square test was used for statistical significance. Result(s): A total of 511 HCWs participated in the study. Nurses (64%) and HCWs based at hospitals (66%) made up the majority of the study participants, with 74% having occupational exposure to COVID-19 cases. More than 99% of HCWs used respiratory PPE, and 94% used gloves. 74% had undergone respirator fit testing and 65% had received PPE awareness session within the last one year. Coverage in training programmes was found to be low among HCWs from private health facilities. Conclusion(s): Majority of HCWs who had received updated training programmes and therefore were better prepared came from government health facilities. HCWs from private health facilities lacked preparedness training programmes and as such, there needs to be improvement to enhance preparedness measures in light of the ongoing COVID-19 pandemic and for future infectious disease outbreaks. Copyright © The Author(s) 2021.

Assessment of Endodontic Emergency Care in a COVID-19 Pandemic

Objective: This study compared the aerosol-generating and non-aerosol-generating endodontic emergency procedures' success and assessed the outcome of endodontic treatments initiated before a pandemic but could not be completed in the targeted time. Material(s) and Method(s): Emergency treatments were performed according to symptoms of teeth. Treatment success or failure was determined according to patients whether not re-referral with untimely pain. Short-term outcome and complications arising from teeth, which endodontic treatments were prolonged were also recorded. A chi-square test was used in the statistical analysis, and p<0.05 was considered significant. Result(s): The aerosol-generating procedure group's success rate was 86.2%, while it was 70.0% in the non-aerosol generating procedure group (p=0.050). The short-term survival rate of teeth was 83.7% in patients whose endodontic treatment had been prolonged. Conclusion(s): Considering the pros and cons, each emergency patient should be evaluated case-by-case. Copyright ©Meandros Medical and Dental Journal, Published by Galenos Publishing House.

Modified Negative Pressure Enclosure During Tracheostomy in Patients With COVID-19.

COVID-19 also known as severe acute respiratory syndrome coronavirus 2 is the result of a highly transmissible coronavirus which can result in severe infection of the respiratory tract. The global pandemic which began in early 2020 has created a number of challenges for the medical community to contain the rate of transmission, especially to health care workers. A minority of the infected population will progress toward severe respiratory distress ultimately requiring mechanical ventilator assistance. Although preliminary data suggest a poor prognosis for those requiring ventilation support, there is a subgroup who will eventually be weaned off. As the pandemic evolves, this cohort of infected, chronically intubated and ventilated individuals will become more prevalent and may require tracheostomy to aid in recovery. Unfortunately, tracheostomy is an aerosol-generating procedure which poses high risks to all members within the operating room, as described by previous authors. There is an urgent need to explore and develop methods to maximize the safety of tracheostomy and other aerosol-generating procedures in order to reduce intraoperative transmission. In the present article, we present a modified technique for negative pressure enclosure in patients with COVID-19 who underwent tracheostomy.

Updated Review about Liver Cirrhosis in the COVID-19 Era

Background: The clinical manifestations in patients with COVID-19 may be nonspecific, but most have fever, cough, followed by dyspnea, fatigue, or sputum production. approximately 14% to 53% of patients experience various degrees of liver damage, although most of these injuries are mild and transient, with a satisfactory prognosis in patients without prior liver disease. In contrast, COVID-19 in patients with pre-existing liver disease has been reported to result in higher hospitalization and mortality rates. Among these pre-existing liver diseases, cirrhosis is a chronic liver disease that involves the collapse of the structure of the liver and distortion of the vascular architecture. Cirrhosis is associated with inherent immune dysfunction and an altered gut-liver axis;patients with cirrhosis are particularly at elevated risk of infections and the associated complications. It remains uncertain whether immunocompromised patients with COVID-19 have a higher risk of adverse outcomes. Patients with cancer or solid organ transplant recipients may have an elevated risk of more severe COVID-19;whereas patients taking biologic therapies may not have a greater risk of developing severe COVID-19. No additional risk of death was observed in cancer patients receiving active treatment except in those undergoing chemotherapy. Whether patients with human immunodeficiency virus infection are at higher risk of mortality due to COVID-19 is unclear.Limited evidence has shown that the clinical manifestations in cirrhotic patients with COVID-19 are similar to those in the general population with COVID-19, with fever and cough remaining the most common symptoms, followed by shortness of breath and sputum production. Interestingly, whereas similar proportions of cirrhotic and noncirrhotic patients developed respiratory and cardiovascular symptoms, cirrhotic patients were less likely to develop gastrointestinal symptoms (e.g., diarrhea, nausea, vomiting). Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.