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.

Tracheoesophageal Fistula Presenting With Gastrostomy Tube Pressurization

Introduction: Patients with COVID pneumonia who require intubation and prolonged mechanical ventilation are at risk for complications such as recurrent infection, tracheomalacia, tracheal stenosis, and the development of tracheoesophageal fistula (TEF). TEF is a devastating complication where the trachea and esophagus develop an abnormal connection in the lower airway that dramatically increases the mortality of critically ill patients by recurrent aspiration and pneumonias. Though commonly associated with neoplasms another risk is pressure induced ischemia of the common wall between the trachea and esophagus. This can occur due to overinflation of the endotracheal (ET) cuff, especially with concomitant use of a nasogastric tube (NGT). Definitive management requires surgical repair. Case Description/Methods: A 69-year-old male patient presented with acute hypoxemic respiratory failure secondary to COVID pneumonia requiring intubation and insertion of an NGT. On day 29 the patient underwent percutaneous enterogastrostomy (PEG) placement and tracheostomy;it was noted intraoperatively that the tracheal mucosa was inflamed and friable. On day 36 bronchoscopy was performed through the tracheostomy tube due to concerns for mucus plugging. Friable mucosa with granulation tissue was seen at the distal end of the tube, so an extra-long tracheostomy tube was exchanged to bypass the granulation tissue. Later that night the ventilator measured a 50% discrepancy between the delivered and exhaled tidal volumes, triggering an alarm. Exam noted distension of the PEG-bag with a fluid meniscus in the tubing moving in sync with each respiration. TEF was considered and bronchoscopic evaluation confirmed a 1-centimeter TEF. The patient underwent successful TEF repair and is slowly recovering (Figure). Discussion(s): Critically ill patients who require prolonged support are at high risk of complications and device related injury. With each device-day there is an increased risk of complications, such as infection, dislodgement, and pressure-related injuries. This case highlights the importance of serial physical examinations as well as understanding possible device related complications. An unexpected finding, such as a persistent air leak, air in a PEG bag, or a fluctuating meniscus should raise suspicion for the development of a serious complication and would warrant prompt confirmatory testing. Our literature review revealed no reports of a PEG tube abnormalities as a presenting finding for TEF.

Percutaneous tracheostomy in head and neck oncology surgery: How Covid-19 changed our practice

Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group;28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.Copyright © 2023 The Authors

Knowledge of tracheostomy care and emergencies amongst adult intensive care unit staff during the COVID-19 pandemic

Introduction: The COVID-19 pandemic has posed unique challenges to the undertaking of tracheostomies in the critical care setting. With patients quickly overwhelming intensive care units (ICU) worldwide and requiring ventilatory support for extended periods of time, many of them have required tracheostomies to facilitate recovery.1 Whilst considerable attention has been paid to optimising staff safety during the procedure and the timing of the procedure itself,2 it is equally crucial to ensure that critical care staff are well-trained and confident in dealing with routine tracheostomy care and potential emergency scenarios on a day-to-day basis. Objectives: To qualitatively assess the knowledge of tracheostomy care and emergencies through the administration of a questionnaire to nurses and doctors working in our general adult ICU department. To subsequently construct a teaching curriculum informed by the questionnaire results and deliver a formal course to all ICU staff members caring for tracheostomy patients. Methods: A 15-item paper questionnaire was designed. In order to gauge a reliable baseline of staff familiarity with tracheostomies, the format used was open questions rather than multiple choice, with pre-determined ideal answers set in line with the guidelines issued by the National Tracheostomy Safety Project (NTSP) and our own Trust. Six questions focused on tracheostomy care and five questions were based on tracheostomy emergency scenarios. The questions and answers were subsequently validated by a panel of consultant ICU nurses with a specialist interest in tracheostomy care and education. The final questionnaire was then distributed to junior doctors and nurses in our ICU department. Results: A total of 32 completed questionnaires were returned from 60 distributed (53% response rate): 9 from junior doctors and 23 from nursing staff. Of the nurses, 15 were Band 5 and 8 were Band 6. The grade of junior doctor respondents ranged from Foundation Programme Year 1 to Core Training Year 2. The average total of correct answers submitted by doctors was 30.9%, 39.1% by Band 5 nurses and 75% by Band 6 nurses. All respondents stated that they would benefit from a tracheostomy teaching course, highlighting physiology, tracheostomy tube types and emergency simulation as preferred areas of focus. Based on the responses to individual questions, five domains were identified and selected for a proposed teaching curriculum aimed all at ICU clinical staff: (1) Clinical science, (2) Tracheostomy tubes, (3) Suctioning, (4) Cuff management and (5) Emergency scenarios. Conclusion: The survey indicated that there was a lack of sufficient knowledge relating to tracheostomy care and emergencies amongst junior doctors and Band 5 nurses working in the ICU department and an unmet need for appropriate training dedicated to the subject. There is no doubt that the COVID-19 pandemic caused significant disruption to educational opportunities. Using the areas highlighted from the questionnaire, we propose the delivery of a tracheostomy course aimed at all critical care staff members. Our aim would be to eventually expand the curriculum to also encompass the ward setting, ensuring that all hospital staff responsible for the care of tracheostomy patients are component and confident in doing so.

Bedside echocardiographic diagnosis of Pericardial effusion in the critically ill patient and prevention of catastrophic hemodynamic compromise

Introduction: In recent years, the use of ultrasound in critical care has revolutionized the bedside assessment of ICU patients. Though operator dependent, the advantage of repeatability and being relatively inexpensive makes it imperative for critical care physicians to stay updatedwith thismodality. The purpose of this report is to describe an incidental finding of pericardial effusion in a patent admitted with respiratory distress. Main body: A 26 years old female was admitted with shortness of breath and increase in oxygen requirements. She had a background of cerebral palsy, tracheostomized since 2009 after being operated for scoliosis and had a vagal nerve stimulator in situ. On admission, her 1st covid swab was negative. She normally required home ventilation only at night, however 2 days prior to admission, she required 24 hours of ventilator support. A large leak was noted on the ventilator and had a non-cuffed tracheostomy tube in situ, which was later changed to a cuffed one. A quick bedside FICE (Focused Intensive Care Echocardiography) revealed a large circumferential pericardial effusion with fibrin strands. There was no haemodynamic compromise on admission, however the large pericardial effusion could have been an attributing factor to her severe respiratory distress. She progressively started deteriorating hemodynamically, requiring intravenous fluids and vasopressor support. A definitive ECHO done by the cardiologist confirmed the findings of FICE. There was a rapid change in her condition post-pericardiocentesis. As per the institute protocol, a second covid swab was sent for her, which reported positive. Covid-19 RTPCR testing was not validated on pericardial fluid, hence was not undertaken. The culture of pericardial fluid revealed staphylococcus aureus, but there was a high index of suspicion of COVID and bacterial pericarditis was unlikely. Conclusion: Echocardiographic evaluation of Pericardial effusion is of paramount importance for timely and appropriate diagnosis. In view of quick bed side diagnosis with ultrasound, our patient was able to survive this life-threatening condition and treatment was initiated promptly. If left undiagnosed based on clinical presentation, it could have been catastrophic for a completely treatable cause. Brief description of ultrasound video: Pericardial effusion appears as an echo-free space between the 2 layers of pericardium. This video shows a 4-chamber echocardiographic view suggestive of a globular pericardial effusion with fibrin strands. An element of hemodynamic compromise was visible on 4-chambered view as well as para-sternal long axis view.

Tracheoesophageal fistula: A rare complication after tracheostomy in Covid-19

Background: Tracheoesophageal fistula (TEF) is a rare condition that can be congenital or acquired. Patients of COVID-19 remain intubated for prolonged periods that can give rise to a multitude of complications. We came across a case where patient develop TEF after 7 days of tracheostomy. Case Study: 34 years female admitted with Covid pneumonia. Patient required ICU care for respiratory distress, required intubation. Patient was treated with standard treatment and kept on controlled ventilation. Patient underwent tracheostomy on day 12 of intubation. On day 17 of patient had an episode of sudden severe respiratory distress, desaturation, hypotension tachycardia not generating tidal volumes and rising peak pressures on ventilator. Patient developed bilateral tension pneumothorax immediately bilateral intercostal drainage tubes insertion done and patient settled. On day 19 patient had persistent cough with RT feeds coming through tracheostomy tube and site. Suspecting TEF CT neck with thorax was done. A rent is seen in the tracheal and esophageal walls close to the bulb of tracheostomy tube. with a TEF. Long tracheostomy tube was inserted as conservative management. Discussion: COVID-19 patients with severe pneumonia may require and remain on prolonged mechanical ventilation. The sudden deterioration of respiratory status, gastric distension and food particles in intubated tube are suspicious to TEF. Conclusion: Early tracheostomy can prevent some complications of prolonged intubation. If a patient develops sudden desaturation, gastric distension and food particles in tracheostomy tube then TEF should always be in the differential diagnosis.

Transverse myelitis in a pediatric patient with COVID-19

Case Report Transverse myelitis is the segmental inflammation of the spinal cord with motor and sensory abnormalities at and below the level of the lesion. Often, the etiology is unknown but may be attributed to autoimmune conditions or viruses. Here we describe a rare case of transverse myelitis secondary to severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]/coronavirus disease (COVID-19). Case A 5-year-old male with a history of asthma presented for vomiting and altered mental status. The patient was noted to be altered, lethargic, and in respiratory distress. Intubation was performed. After family collateral was obtained, it was revealed that patient possibly ingested Sertraline and/or Risperidone at an unknown time prior to arrival. History also revealed that he had slurred speech, ataxia, and a fall with trauma to forehead 1 day prior to arrival. He tested positive for COVID-19 via PCR and chest x-ray revealed RLL consolidation. Dexamethasone was started. When sedation was weaned in hopes of extubation, patient was noted to be alert, but not moving extremities and had minimal gag and cough reflex. MRI of Brain and Spine were conducted and revealed findings suggestive of long segment transverse myelitis involving C2 to C3. LP was performed with unremarkable CSF studies and IV Solumedrol was started. In light of active COVID-19 infection, and worsening respiratory status, patient started on 5 days Remdesivir. Further, patient underwent ten sessions of plasmapheresis. Repeat MRI was consistent with previous. Physical and occupational therapy initiated at the onset of illness in hopes of achieving musculoskeletal improvement. Patient had some minimal musculoskeletal improvement, however, given his condition, decision was made for patient to undergo placement of gastrostomy and tracheostomy tubes. Patient was weaned off of sedatives and withdrawal was treated with a clonidine taper. Once stabilized, patient was transferred to neurological inpatient rehabilitation center. Discussion Neurological manifestations in children affected by SARS-CoV-2 are relatively common but are often non-specific. Worldwide data reports only 1% of children with COVID-19 present with severe symptoms of encephalopathy, seizures, and meningeal signs. Pathophysiology is multifactorial, including direct invasion of the CNS, vascular insufficiency, immune dysregulation and autoimmunity. Imaging is paramount in the diagnosis of transverse myelitis. Treatments are emerging and may include steroids, immunoglobulin, plasmapheresis, and monoclonal antibodies. Conclusion Much is unknown about COVID-19. Information is emerging and evolving daily. Cases of transverse myelitis in COVID-19 have been reported in few adult patients and minimal pediatric patients. Practitioners should keep transverse myelitis on their list of differentials for neurological complications of SARS-CoV-2 infections and initiate aggressive treatment with a multidisciplinary approach.

Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry.

INTRODUCTION: Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. STUDY DESIGN AND METHODS: A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. RESULTS: 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). INTERPRETATION: This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.

Combined Percutaneous Tracheostomy and Endoscopic Gastrostomy Tubes in COVID-19: A Prospective Series of Patient Outcomes.

Background: A significant number of patients with severe respiratory failure related to COVID-19 require prolonged mechanical ventilation. Minimal data exists regarding the timing, safety, and efficacy of combined bedside percutaneous tracheostomy and endoscopy gastrostomy tube placement in these patients. The safety for healthcare providers is also in question. This study's objective was to evaluate the effectiveness and safety of combined bedside tracheostomy and gastrostomy tube placement in COVID-19 patients. Design and Methods: This is a single arm, prospective cohort study in patients with COVID-19 and acute respiratory failure requiring prolonged mechanical ventilation who underwent bedside tracheostomy and percutaneous endoscopic gastrostomy placement. Detailed clinical and procedural data were collected. Descriptive statistics were employed and time to event curves were estimated and plotted using the Kaplan Meier method for clinically relevant prespecified endpoints. Results: Among 58 patients, the median total intensive care unit (ICU) length of stay was 29 days (24.7-33.3) with a median of 10 days (6.3-13.7) postprocedure. Nearly 88% of patients were weaned from mechanical ventilation postprocedure at a median of 9 days (6-12); 94% of these were decannulated. Sixty-day mortality was 10.3%. Almost 90% of patients were discharged alive from the hospital. All procedures were done at bedside with no patient transfer required out of the ICU. A median of 3.0 healthcare personnel total were present in the room per procedure. Conclusion: This study shows that survival of critically ill COVID-19 patients after tracheostomy and gastrostomy was nearly 90%. The time-to-event curves are encouraging regarding time to weaning, downsizing, decannulation, and discharge. A combined procedure minimizes the risk of virus transmission to healthcare providers in addition to decreasing the number of anesthetic episodes, transfusions, and transfers patients must undergo. This approach should be considered in critically ill COVID-19 patients requiring prolonged mechanical ventilation.

Healthcare Personnel Safety During Percutaneous Tracheostomy in Patients With COVID-19: Proof-of-Concept Study.

BACKGROUND: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. METHODS: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. RESULTS: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. CONCLUSIONS: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.

Methods for a Seamless Transition From Tracheostomy to Spontaneous Breathing in Patients With COVID-19.

The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. The majority of reports thus far have focused on the epidemiology, clinical factors, and acute care of these patients, with less attention given to the recovery phase and care of those patients requiring extended time on mechanical ventilation. In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.

Tracheostomy care: the role of the nurse before, during and after insertion.

A tracheostomy is a surgical procedure that involves creating an opening and inserting a tube in the trachea to enable air transit from the external atmosphere to the lungs. The insertion of a tracheostomy is a common procedure used to wean patients from mechanical ventilation and to manage patients with upper respiratory tract complications. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has resulted in many patients requiring a tracheostomy as part of respiratory management. The two most commonly used tracheostomy insertion procedures are the open surgical tracheostomy and the percutaneous dilatation tracheostomy, both of which are associated with a range of complications. This article outlines the indications, benefits and complications of tracheostomy insertion, as well as the various types of tracheostomy tube that may be used. It also explains the role of the nurse in caring for patients before, during and after tracheostomy insertion, including the management of tracheostomy-related complications and emergencies.

[Management of tracheostomy patients during the COVID-19 pandemic: review of the literature and demonstration]. / Management von Patienten mit Tracheostoma während der COVID-19-Pandemie: Literaturüberblick und Demonstration.

BACKGROUND: Since emergence of the new coronavirus in China in December 2019, many countries have been struggling to control skyrocketing numbers of infections, including among healthcare personnel. It has now been clearly demonstrated that SARS-CoV­2 resides in the upper airways and transmits easily via aerosols and droplets, which significantly increases the risk of infection when performing upper airway procedures. Ventilated COVID-19 patients in a critical condition in the intensive care unit may require tracheotomy for long-term ventilation and to improve weaning. However, the risk of secondary infection of medical personnel performing subsequent tracheostomy care remains unclear. OBJECTIVE: This study aimed to evaluate the risk of droplet dispersion during tracheostomy tube change and overview tracheostomy tube change in COVID-19 patients. MATERIALS AND METHODS: The current literature was reviewed, quantitative and qualitative analyses of droplet formation during tracheostomy tube change in n = 8 patients were performed, and an overview of and checklist for tracheostomy tube change were compiled. RESULTS: This study demonstrates that tracheostomy tube change, in particular insertion of the new tube, may cause significant droplet formation. The aerosolization of particles smaller than 5 µm was not analyzed. CONCLUSION: Our data, together with the current literature, clearly emphasize that tracheostomy care is associated with a high infection risk and should only be performed by a small group of well-trained, maximally protected healthcare personnel.