key: cord-0856289-rr9f88oi
authors: Kimura, Yurika; Ueha, Rumi; Furukawa, Tatsuya; Oshima, Fumiko; Fujitani, Junko; Nakajima, Junko; Kaneoka, Asako; Aoyama, Hisaaki; Fujimoto, Yasushi; Umezaki, Toshiro
title: Society of swallowing and dysphagia of Japan: Position statement on dysphagia management during the COVID-19 outbreak
date: 2020-07-23
journal: Auris Nasus Larynx
DOI: 10.1016/j.anl.2020.07.009
sha: 4fa6294e92c5bf27957f40af30aa5c09471b7c34
doc_id: 856289
cord_uid: rr9f88oi

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning. Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including “terminology”, “clinical swallowing assessment and examination“, “swallowing therapy”, “oral care”, “surgical procedure for dysphagia”, “tracheotomy care”, and “nursing care”. In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection.

On April 3, 2020, the Society of Swallowing and Dyspha-2 gia of Japan (SSDJ) issued an emergency announcement enti- 3 tled "Emergency statement on dysphagia management during 4 the novel coronavirus outbreak". Shortly thereafter, on April 5 14, the SSDJ proposed a concrete statement for dysphagia 6 treatment in consideration of the ongoing spread of severe 7 acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 8 The main routes of transmission of SARS-CoV-2 are phys- 9 ical contact with infected persons and exposure to respiratory 10 droplets. In cases of infection, the nasal cavity and nasophar-11 ynx have the highest viral load in the body. Swallowing oc-12 curs in the oral cavity and pharynx, which correspond to the 13 sites of viral proliferation. In addition, the possibility of in-14 fection by aerosol transmission is also concerning. Dyspha-15 gia treatment includes a broad range of clinical assessment 16 and examinations, dysphagia rehabilitation, oral care, nurs- 17 ing care, and surgical treatments, and any of these can lead 18 to the production of droplets and aerosols, as well as con- 19 tact with viral particles. Recent studies have reported that 20 nosocomial infection, originating from caregiving staff, may 21 occur during meals. Moreover, it should be noted that per- 22 sons with asymptomatic infections in Japan or other countries 23 can form in-hospital clusters leading to the spread of infec-24 tion regardless of whether they are healthcare professionals or 25 patients [1] . 26 Most patients with dysphagia are elderly and have com- 27 plications, such as heart diseases, diabetes, respiratory dis-28 eases, and cerebrovascular diseases. They might be at a higher 29 risk for severe illness from the novel coronavirus disease is anticipated during the COVID-19 epidemic. The timing 44 of dysphagia rehabilitation and indication for treatment will 45 differ from the usual. Prioritizing the maintenance of medical 46 infrastructure will be paramount in consultation with teams 47 of medical experts at each facility. 48 This statement is arranged into separate sections provid-49 ing information and advice considering the COVID-19 out-50 break, including "clinical swallowing assessment and ex-51 amination", "dysphagia rehabilitation", "oral care", "nursing 52 care", "surgical procedure for dysphagia", and "tracheotomy 53 care". 54 As SSDJ proposed these statements for the purpose of 55 crisis management during the COVID-19 outbreak, based 56 on case series and guidelines from other countries where 57 the spread of COVID-19 occurred earlier, these statements 58 are not an evidence-based clinical practice guideline. Thus, 59 these statements would require later evaluation and revision 60 as needed. It should also be considered that patients could 61 receive appropriate care, but the care may be limited under 62 these circumstances where this statement is widely accepted 63 among healthcare professionals. 2.1. Regional division by infection status [ 2 , 3 ] The following precautions are recommended in addition 149 to the use of PPE when engaging in AGPs (strongly recom-150 mended for procedures possibly producing large amounts of 151 aerosols):

• Use an N95 mask and always perform a seal check when 153 donning the mask.

• Wear eye protection (goggles/face shield).

• Wear clean long-sleeved gowns (sterilization not neces-156 sary) and gloves.

• Observe hand hygiene before and after contact with pa-160 tients and surrounding environmental surfaces, as well 161 as after removing PPE. 162 

164

The selection of PPE should be made according to the 165 risk of infection due to the procedure. In this proposal, PPE 166 for dysphagia management is described as follows, according 167 to the purpose. • Nasal/oral protection: N95 mask * or powered air purifying 182 respirator (PAPR) 183 * Before using an N95 mask, conduct a user 184 seal check ( Fig. 2 ) . 185 • Eye protection: Face shield ± goggles * 186 * Recommend using an anti-fogging agent in advance, 187 when using goggles. should be followed ( Table 1 ) . 210 

Removal of PPE may inadvertently spread the infec-212 tion. Conduct training for donning and doffing PPE be-213 forehand. Consideration should also be given to the sep-214 aration of spaces for the donning and doffing PPE (clean 215 areas/passage areas/semi-contaminated areas/contaminated ar-216 eas) as much as possible at each facility. 217 The standard methods for donning and doffing of PPE are 218 described in detail at the following websites (The Research 219 Group of Occupational Infection Control and Prevention in 220 Japan homepage) [ • Gloves: https://www.safety.jrgoicp.org/ppe-3-usage-glove. 230 html. and pharyngeal and laryngeal function 255 In the current pandemic context, the clinical swallowing as-256 sessment without producing aerosols is more preferable com-257 pared to AGPs. Dysphagia screening tools, such as the Eating 258 Assessment Tool-10 [8] and the Seirei Questionnaire of Swal-259 lowing, can be utilized to detect dysphagia. Pharyngeal sen-260 sory testing or flexible endoscopic evaluation of swallowing 261 with sensory testing are considered as AGPs, can be incredi-262 bly high risk, and require different PPE that do not produce 263 aerosols. Screening tests for dysphagia are intended to select the 267 patients who are strongly suspected without videofluorogra-268 phy (VF) and fiberoptic endoscopic evaluation of swallow-269 ing (FEES, VE), and include repetitive saliva swallowing test 270 (RSST), cervical auscultation of swallowing, water swallow 271 test, modified water swallow test, and food test. Among them, 272 RSST and cervical auscultation of swallowing can be per-273 formed for patients wearing a mask without oral intake, and 274 thus, the risk of aerosol generation is very low. However, 275 some screening tests, such as water swallow test and modi-276 fied water swallow test, are AGPs ( Table 2 ) . 277 Considering some procedures such as water swallow 278 test and modified water swallow test may induce cough-279 ing, adoption of the highest level of PPE is highly rec-280 ommended when undertaking these procedures for patients 281 with suspected or confirmed COVID-19. Concerning water 282 swallow test, modified water swallow test (3 mL) overrides 283 the original version of the water swallow test (30 mL). 284 

The nasopharynx carries a higher viral load than the 286 oropharynx. Thus, FEES has a higher risk of aerosoliza-287 tion from the nasal passage and nasopharynx. FEES can trig-288 ger sneezing and/or coughing, leading to aerosolization during 289 Healthcare professionals, who provide dysphagia therapy 320 in close patient proximity, can be at high risk of transmitting 321 the COVID-19 virus. Both indirect exercises (non-swallowing 322 exercises) and direct exercises (swallowing exercises) involve 323 direct contact with a patient's oral mucosa and secretions and 324 exposure to droplets/aerosols that can be generated by cough-325 ing and sneezing. Furthermore, if a healthcare professional 326 is an asymptomatic or pre-symptomatic carrier of COVID-327 19, the virus can be transmitted to patients from the healthcare 328 professional through rehabilitation and may cause hospital-329 acquired infections. 330 It is strongly advised that standard and additional precau-331 tions for AGPs, including use of PPE, hand hygiene, and dis-332 infection of environmental surfaces and equipment, be imple-333 mented during swallowing therapy. If PPE, disinfectants, and 334 other materials are in short supply, and adequate infection pre-335 vention cannot be achieved, swallowing therapy should be 336 suspended under the COVID-19 outbreak. Especially for dysphagic patients, oral hygiene is necessary 444 because aspiration of oropharyngeal flora into the lung may 445 cause aspiration pneumonia. However, we must be thoroughly 446 cautious to avoid spreading the virus through oral care during 447 the COVID-10 outbreak. 448 Oral care can involve a visible spray that contains saliva 449 and microorganisms. From the study of spattering during oral 450 care using an adenosine triphosphate (ATP) monitoring sys-451 tem [9] , large amounts of ATP, which denotes the presence 452 of organic material and living cells, were detected on the 453 As the patients may choke on water during rinsing, it 479 is recommended to wipe oral mucosa with wet tissue for oral 480 use, wet gauze, or swab after mechanical cleaning. Among 481 water rinsing, wiping with wet tissue for oral use, and wip-482 ing with sponge brush, wiping with wet tissue is the most 483 effective method to decrease bacteria on the tongue, palate, 484 or gingivobuccal fold [13] . 485 2 Denture cleaning of patients with suspected or con-486 firmed COVID- 19. 487 To avoid the spread of the microorganisms from the den-488 ture, disinfect the denture before washing with water. After 489 cleaning, rinse the denture with enough water to eliminate the 490 chemical agents. It would be recommended to sink the den-491 ture for 30 min into 0.05-0.5 % of sodium hypochlorite aque-492 ous solution or ethanol for disinfection or wiping the denture 493 with gauze saturating with it [14] ) . The spray on the denture 494 may cause airborne infectious agents [15] ) . For dentures with 495 metal clasps or metal bases, rust-preventive additive sodium 496 hypochlorite aqueous solution should be used [16] . 497 3) Consideration for reducing the aerosol generation during 498 oral care 499 1 Tooth brushing with water-based mouth moisturizer 500 As a substitute for tooth paste, teeth should be brushed 501 with water-based mouth moisturizer, which can contribute to 502 preventing the spread of dental plaque by retaining it in the 503 mouth [ 17 , 18 ] . Given that tracheostomy is a high-risk procedure that can 559 generate aerosols, to protect the staff members that are in-560 volved in tracheostomy care, it is essential that staff wear 561 appropriate PPE prior to any intervention. There is no other 562 choice of wearing available PPE as an alternative countermea-563 sure for viral infection, when the stock of appropriate PPE is 564 insufficient. 565 It is recommended that clinicians consider that any crit-566 ically ill patient recovering from COVID-19 pneumonitis is 567 considered high risk of infection to staff during tracheostomy 568 insertion. Be careful not to generate aerosols during tra-569 cheostomy care as follows. 570 • Tracheostomy procedures such as dressing, cuff care, tube 571 care, and heat moisture exchanger change are consid-572 ered high risk for staff as aerosols can be generated.

• When suctioning to remove respiratory secretions, pay at-574 tention not to cause coughing.

• Closed suction systems should be used.

• A simple face mask may be applied over the face of pa-577 tients if the cuff is deflated to minimize droplet spread 578 from the patient.

• Use of double lumen tracheostomy tube is recommended 580 for patients with COVID-19, and to reduce the frequency 581 of changing tracheostomy tube, only inner tube change 582 may be permitted.

• After withdrawing mechanical ventilation, a heat moisture 584 exchanger should be put on a tracheostomy tube. Be sure 585 to prevent the heat moisture exchanger from being de-586 tached from the tube.

• Tracheostomy tube change can be delayed until the patient 588 is confirmed as COVID-19 negative or COVID-19 symp-589 toms improve. However, an individual assessment must be 590 made for each patient.

• Avoid use of fenestrated tubes for patients with suspected 592 and confirmed COVID-19 to reduce the aerosol risks to 593 staff. Cuffed non-fenestrated tubes should to be used until 594 the patient is confirmed as COVID-19 negative.

• Not changing the tracheostomy tube and dressings can be 596 allowed, unless obvious signs of infection or problems. 597 In view of the change in the domestic and oversea situa-598 tions, tracheostomy tubes can be in a short supply. You should 599 check the stock status of tracheostomy tubes in the medical 600 facilities and in the country. Subsequent planned tube changes 601 can be postponed unless signs of infection or problems such 602 as bleeding or severe granulation are observed. Nurses provide various forms of care to patients with dys-605 phagia, such as oral care, and indirect/direct swallowing ex-606 ercises as dysphagia therapy, meal support, and oral or tra-607 cheal suctioning. Patients with dysphagia often have multiple 608 underlying conditions, which are more likely to become se-609 vere in conjunction with infection by SARS-CoV-2. With the 610 ongoing spread of SARS-CoV-2 infection, there is a possi-611 bility that infections will be transmitted between healthcare 612 workers, asymptomatic carriers, and patients. Thus, appropri-613 Only if unavoidable *

As usual As usual * suggested priority for COVID-19 testing.

Recommended management of meal support and suctioning. Q3

Negative and 2-week change to negative after confirmation criticized it as unrealistic. In the background, there is a lack 715 of medical resources, such as PPE and rubbing alcohol, but 716 healthcare professionals must recognize that they may need 717 to diverge from conventional protective measures. Moreover, 718 management of dysphagia produces droplets and aerosols in 719 many situations. We must recognize that procedures should al-720 ways be performed using the same PPE and knowledge. These 721 standards should apply not only for SARS-Cov-2, but other 722 dysphagia cases suspected to be complicated because of infec-723 tion from multidrug-resistant bacteria or unknown pathogens. 724 Therefore, as a responsible medical association in this field, 725 it is inevitable that our society repeatedly uses the terms for 726 standard precautions and abbreviations of equipment, such as 727 PPE and full PPE, which are globally used, in creating this 728 statement. Although these terms may make it difficult to read 729 this statement, please be sure to read the first section "Termi-730 nology used in this statement and basic concept of classifica-731 tion" before reading each medical treatment category because 732 they have been briefly explained. This committee consists 733 of medical doctors, dentists, speech therapists, and registered 734 nurses who are experts in the medical treatment of dyspha-735 gia with a deep knowledge of infectious diseases and public 736 health selected from the members of this society. Needless 737 to say, this statement is not a standard manual for dysphagia 738 management but a guide for all healthcare workers involved 739 in treatment of dysphagia during the COVID-19 epidemic. We 740 would appreciate it if you could operate it flexibly according 741 to the supply of medical resources at each medical institution. 742

Toshiro Umezaki, MD, PhD. 743 SSDJ President 2020-2021. 744 

ANL [mNS

CoV-2, all patients and their families should be advised 672 of the necessity of observing the general requests to 673 avoid close contact, narrow spaces

Suctioning must be considered as an AGP, although it con-683 ventionally requires protection only against droplet infection

• During suctioning, anticipate splashes due to coughing and 685 gag reflex and do not stand in front of the patient

• Outdoor-air ventilation (entrance door should be closed)

Regarding suctioning at tracheostomy sites, refer to the 693 previous chapter

Appendix: Message from the President of SSDJ

On the 708 premise of this alert, this position statement, which consists 709 of all seven chapters, was released on

Epidemiology of Covid-19 in a long-term care facil-747 ity in King County, Washington

Ministry of Health, Labour and Welfare. Reported number of 750 COVID-19 patients in Japan by prefecture

COVID-19 JAPAN. SARS-CoV-2 countermeasures dashboard

755 ASHA Guidance to SLPs regarding aerosol gener-756 ating procedures

Aerosol-generating procedures in ENT

Guide-761 lines for Responding to cases of SARS-CoV-2 infection at medical 762 facilities

Research Group of Occupational Infection Control and Prevention in 765 Japan homepage

Validity and reliability of the Eating Assessment Tool

Investigation of spattering and intraoral envi-771 ronment during oral care of patients

Society of swallowing and dysphagia of Japan: Position statement on dysphagia management during the COVID-19 outbreak

the COVID-19 Response

The Japanese Society of Oral Care. Considerations of oral hygiene 777 care for the patients who are suspected the infection of COVID-19

First report

The Japanese Society of Oral Care. Considerations of oral hygiene care 781 for the patients who are suspected the infection of COVID-19

Comparisons of methods eliminating contaminants after oral care. 786 -Preliminary study in healthy individuals

Labour and Welfare. Revision of the disinfec-789 tion/sterilization guideline based on the Infectious Disease Law

Q&A about new coron-792 avirus

Infection control guidelines during 795 prosthodontic procedures

et 798 al. Introduction of oral care method with use of moistening agent

A new oral care gel to prevent aspiration during oral 802 care

Guidelines for nosocomial in-804 fection control during general dental care

Transmission 807 routes of 2019-nCov and controls in dental practice

The Oto-Rhino-Laryngology Society of Japan. Guidance for tra-810 cheostomy