key: cord-0855209-muo01j1z authors: Archer, Sally K.; Iezzi, Christina M.; Gilpin, Louisa title: Swallowing and voice outcomes in patients hospitalised with COVID-19: An observational cohort study date: 2021-01-30 journal: Arch Phys Med Rehabil DOI: 10.1016/j.apmr.2021.01.063 sha: 5013fe1ddaa2a46018228337166f38aec01af82c doc_id: 855209 cord_uid: muo01j1z Objective To evaluate the presentations and outcomes of inpatients with COVID-19 presenting with dysphonia and dysphagia in order to investigate trends and inform potential pathways for ongoing care. Design Observational cohort study. Setting An inner city NHS Hospital Trust in London, UK. Participants All adult inpatients hospitalised with COVID-19 who were referred to Speech and Language Therapy (SLT) for voice and/or swallowing assessment for 2 months from April 2020. Interventions SLT assessment, advice and therapy for dysphonia and dysphagia. Main Outcome Measures Evidence of delirium, neurological presentation, intubation, tracheostomy and proning history were collected, along with type of SLT provided and discharge outcomes. Therapy Outcome Measures (TOMs) were recorded for swallowing and tracheostomy pre/post SLT intervention and GRBAS for voice. Results 164 patients (104M), age 56.8±16.7y were included. Half (52.4%) had a tracheostomy, 78.7% had been intubated (mean 15±6.6days), 13.4% had new neurological impairment and 69.5% were delirious. Individualised compensatory strategies were trialled in all and direct exercises with 11%. Baseline assessments showed marked impairments in dysphagia and voice but there was significant improvement in all during the study (p<0.0001). On average patients started some oral intake 2 days after initial SLT assessment (IQR 0-8) and were eating and drinking normally on discharge but 29.3%(n=29)of those with dysphagia and 56.1% (n=37) of those with dysphonia remained impaired at hospital discharge. 70.9% tracheostomised patients were decannulated, median (IQR) time to decannulation 19 days(16-27).Across all (n=164), 37.3% completed SLT input while inpatients, 23.5% were transferred to another hospital, 17.1% had voice and 7.8% required community follow-up for dysphagia. Conclusions Inpatients with COVID-19 present with significant impairments of voice and swallowing, justifying responsive SLT. Prolonged intubations and tracheostomies were the norm and a minority had new neurological presentations. Patients typically improved with assessment that enabled treatment with individualised compensatory strategies. Services preparing for COVID-19 should target resources for tracheostomy weaning and to enable responsive management of dysphagia and dysphonia with robust referral pathways. There is a wide range of symptomatic severity in COVID-19 (1) and a significant proportion 53 of hospitalised patients require intensive care unit (ICU) admission, with reports varying 54 from (12-32%) (1-3). There is an association between COVID-19 and dysphonia and 55 dysphagia with studies demonstrating dysphagia in 90% of patients admitted to a COVID-19 56 rehabilitation facility (4) and in over 70% of critically ill COVID-19 patients following 57 extubation (5). 58 59 Mechanisms placing COVID-19 patients at risk of dysphagia include multilevel damage to the 60 swallowing network (6). Dyspnoea affects over half of COVID-19 cases (3) and could 61 compromise airway protection from disruption to the tight temporal coupling between 62 respiration and swallowing (7). Furthermore, the high incidence of critical illness in COVID- 63 19 is a risk factor for swallowing difficulties (8) and ICU acquired weakness (ICUAW), 64 resulting from disuse, sedation and/or neuromuscular blocking agents may affect the swallowing musculature (9) . Over half of all critically ill patients who require intubation 66 develop swallowing difficulties (10) and a longer duration significantly increases the risk of 67 dysphagia at hospital discharge (11). COVID-19 patients admitted to ICU require a longer 68 median duration of mechanical ventilation than non-COVID-19 viral pneumonia (3), 69 suggesting an increased risk of dysphagia in this cohort. 70 A quarter of inpatients with mild-moderate COVID-19 present with dysphonia, likely due to 72 upper airway inflammation (12). The rates of dysphonia among those with more severe 73 illness and who have required critical care are unknown but are likely to be higher. 74 Intubation has a significant impact on laryngeal anatomy and function and a systematic 75 review of 775 (non COVID-19) extubated patients found 76% presented with dysphonia (13). 76 The effects of intubation, coupled with the COVID-19 inflammatory process is therefore In other pathologies, dysphagia is known to be associated with an increased risk of 88 pneumonia, dehydration, malnutrition, length of stay, dependency and mortality (18) J o u r n a l P r e -p r o o f Clinical 387 features of patients infected with 2019 novel coronavirus in Wuhan, China. 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