aOne publication3 met the inclusion criteria for both tracheostomy and laryngectomy; for this reason, the final number of studies included was 6.
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Vergara J, Starmer HM, Wallace S, et al. Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review. JAMA Otolaryngol Head Neck Surg. Published online October 15, 2020. doi:10.1001/jamaoto.2020.3720
The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries.
From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis.
Conclusions and Relevance
Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.
We are in the midst of a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). Management of patients with surgically modified airways, such as tracheostomy and laryngectomy, is challenging for the health care team in this novel context. Although there are few studies detailing infection rates and level of risk in the management,1 those with tracheostomy and laryngectomy represent a potential transmission and infection risk for health care professionals2,3 owing to the high viral load present in the upper aerodigestive tract.4-6 Several professional organizations worldwide have published guidelines on the management of these patients for otorhinolaryngologists and head and neck surgeons.7
Urgent and essential care provision is still required for these patients during the current pandemic,8 and many more patients are requiring tracheostomy insertion as part of their recovery from severe COVID-19.9 Multidisciplinary teams involved in the treatment of patients with tracheostomy or laryngectomy often include allied health professionals, such as speech-language pathologists (SLPs), who are responsible for the therapeutic restoration of swallowing and communication.10,11 Speech-language pathologists are routinely involved with stoma and voice prosthesis care procedures and may perform suctioning of the lower airways. The objective of this study is to review and synthesize the literature regarding tracheostomy and laryngectomy management in the context of the COVID-19 pandemic to inform best practice and provide guidance for SLPs and the multidisciplinary team managing care for this population.
Using elements from a rapid review approach,12 a comprehensive search of a single database and guidance documents published by relevant professional societies/organizations was completed. Guidelines unrelated to those of the current pandemic were also considered for synthesis. Two searches were conducted simultaneously using the PubMed database on May 15, 2020, using descriptors relevant to our objective—specifically, (1) tracheostomy, COVID-19, and SARS-CoV-2 using the Boolean operator and; and (2) laryngectomy, COVID-19, and SARS-CoV-2, also using the Boolean operator and. Using the selection criteria, a single reviewer (J.V.) screened all titles and abstracts for possible inclusion. Those meeting the criteria were selected for a full-text review by the same reviewer (J.V.), following which the final selection was completed. Relevant online guidance documents produced by SLP professional societies and associations were searched from several countries,13-18 including (1) the Americas (Brazilian Society of Speech and Hearing Therapy, Speech-Language and Audiology Canada, and American Speech-Language-Hearing Association), (2) Oceania (Speech Pathology Australia), (3) Africa (South African Speech-Language and Hearing Association), and (4) Europe (Royal College of Speech and Language Therapist). These sources were accessed on May 15, 2020, using their websites.
Included were English publications that described tracheostomy and/or laryngectomy management (in the postsurgical stage) of patients during the COVID-19 pandemic and included procedures involving SLPs. We excluded those studies that were limited to describing only aspects of surgical procedures, personal protective equipment (PPE), and/or drug management. Once the relevant publications and documents were determined from included sources, a descriptive narrative synthesis was conducted that stratified information germane to our objective according to themes/practice area.
In the database search, a total of 24 unique, relevant citations were captured. Following full-text review, 7 met inclusion criteria for tracheostomy and laryngectomy (4 and 3 publications, respectively) with one3 duplicated in both searches, resulting in 6 included publications (Figure). Study characteristics are summarized in Table 1.3,19-22 When searching the websites of professional organizations, we found that 3 had produced relevant guidance documents.13-15 Following data extraction and synthesis, the results were categorized according to practice domains for tracheostomy and laryngectomy. The main recommendations according to each practice area are shown in Table 2.3,13,14,19-25
Given their surgically altered airways, patients with tracheostomy and laryngectomy present unique challenges for clinicians because the virus manifests in the respiratory tract and is transmitted through droplets. Furthermore, many of these patients normally require SLP assessment and management of their airway,26 swallowing,27-30 and communication.31,32 This may result in reflexive coughing and secretion expulsion with risk for aerosol generation.13-15,33 Understandably, the primary focus of the evidence base was the delineation of which procedures were considered “at risk” for aerosol generation. Given this risk, the evidence supported modifications for the evaluation and management of this population’s surgically modified airway, including delaying certain practices until viral testing is negative.19-21 These modifications need to be considered according to local regulations regarding practice as well as the use of PPE.
Patients with tracheostomy are at high risk for dysphagia.27 To the best of our knowledge, the frequency of dysphagia in patients with tracheostomy with SARS-CoV-2 is undetermined. Available evidence regarding tracheostomy and COVID-19 SLP practice focused on cuff manipulation, swallowing assessments, tracheal suction, communication, and decannulation.3,13-15,19
According to the literature, where possible, maintenance of cuff inflation is recommended for patients with known or suspected COVID-19 along with avoidance of cuff manipulation/deflation3,19 and cannula manipulation.3,13,14,21 As a result, nonoral feeding is recommended until cuff deflation is tolerated21 and swallowing may be assessed. Among other adverse outcomes, prolonged cuff inflation may hinder secretion management and negatively affect swallowing physiology34; therefore, where cuff deflation is medically necessary, the multidisciplinary team should agree on the best approach. Should tracheal suctioning be required, it is recommended that it be performed using closed suction systems with viral filters3,13,14,19,20 and enhanced PPE, such as an N95 or FFP2/3 respirator and face shield.3
Communication is often enhanced for those with tracheostomy through the use of speaking valves, digital occlusion, and/or above-cuff vocalization (ACV). In the current context, clinical care requires modifications owing to the risk of aerosol generation. First, to decrease viral transmission risk, speaking valve assessments should be delayed until viral testing is negative.13 Similarly, we suggest that digital occlusion also be avoided; however, if digital occlusion is necessary, diligent hand hygiene should be performed before and after. Another method, ACV, allows for vocalization with the cuff inflated by introducing airflow through the subglottic port of the tracheostomy tube.35 Because of the high risk of secretion aerosolization as well as the likelihood that ACV may be contraindicated in patients with severe cases of COVID-19 or intubation trauma causing airway edema, consensus expert opinion advises against the use of ACV in these patients.23,24 Furthermore, we see value in the use of telerehabilitation (eg, online, telephone) wherever possible to reserve in-person visits for urgent cases. While these recommendations may not be ideal, we believe that SLPs can adapt alternative communication devices remotely and/or in advance, to maximize communication effectiveness in patients with a surgically modified airway (be it tracheostomy or laryngectomy) while reducing transmission risk. These may include low-tech options, such as disposable communication boards and writing utensils, and/or the use of high-tech options, such as text-to-speech applications on portable devices.
A systematic multidisciplinary approach to decannulation is typically undertaken to wean patients from tracheostomy, which often includes increasing periods of cuff deflation, use of speaking valves and caps, and/or tracheostomy cannula downsizing.20,21 Because of the variable access to resources as well as operational mandates, approaches to decannulation in the current environment have been largely determined at the institution level, with recommendations including delaying the decannulation process until after 2 consecutive days of negative test results.21
Adequate management of swallowing and communication difficulties in patients with laryngectomy is important to increase the quality of life of this highly vulnerable population in the current context of the pandemic. In this review, the relevant domains of practice throughout the literature were related to the management of breathing,3,22,25 pulmonary aspiration,3,13,14,22,25 and laryngeal voice.3,13,14,25
After laryngectomy, patients have a surgically modified airway with a permanent stoma that limits respiration to the front of the neck, without the possibility of air passage through the upper airway.36 Current guidelines suggest that patients wear a mask to cover the nose and mouth along with humidification filters over the stoma.3,22,25 Where masks are not available, some regions have suggested the use of a T-shirt, scarf, or cloth bandana to cover the mouth, nose, and stoma,22 while ensuring that air exchange is sufficient for adequate respiration. The most frequently cited heat and moisture exchanger (HME) devices were Provox Micron (Atos Medical), associated with the use of an adhesive baseplate, and the Blom-Singer HME filter with the TruSeal adhesive base (InHealth Technologies).22,25 These filters could reduce aerosol transmission and filter viruses3; however, the ability of these devices to filter the SARS-CoV-2 virus has not yet been tested, and superiority of one HME over another remains undetermined in this context.
In cases of tracheoesophageal prosthesis leakage, the temporary use of a plug (although this results in aphonia) or changes in food/fluid consistencies appropriate to the patient’s swallowing physiology may be recommended.3,13,14,22,25 To ensure timely provision of care, it is important that the patient has access to these resources, including an alternative means of communication (eg, electrolarynx), should the voice prosthesis fail.13,14 In situations where a prosthesis change is deemed essential and urgent, the SLP should perform the procedure in an appropriate clinical setting that facilitates environmental decontamination and the use of enhanced PPE to reduce the risk of viral transmission.13 Leakage of food/liquid through or around the tracheoesophageal voice prosthesis puts the patient at risk of aspiration and pneumonia, critical for vulnerable populations, including those with COVID-19.22
Regardless of the pandemic, patients will continue to require prosthesis management.25 To minimize virus transmission, urgent cases should be considered where the risks cannot be adequately mitigated by compensatory measures or where the risk of harm outweighs the risk associated with the procedure. For example, when the situation is an emergency and while using appropriate PPE for aerosol precautions, the SLP may inspect the tracheoesophageal puncture as well as the open stoma.13,14 To reduce transmission risk, patients using a tracheoesophageal voice prosthesis may benefit from using a hands-free speaking device, such as the Provox FreeHands FlexiVoice (Atos Medical) or the Blom-Singer Adjustable Tracheostoma Valve (InHealth Technologies). These facilitate alaryngeal speech while minimizing the direct contact between the hand and stoma.13,22 The use of an electrolarynx or pneumatic artificial larynx may be suggested. The electrolarynx should be sanitized frequently and only used by the patient following handwashing.3 Furthermore, we acknowledge that some patients may rely on communication methods that include the use of esophageal voice. While this method of voicing may pose risks of aerosol generation akin to coughing, this has not been fully investigated. As this technique does not require accessory devices or digital occlusion of the stoma, we suspect that the risk of viral transmission is similar to that of communication in those without modified airways.
While our searches were conducted recently, our review has limitations. To expedite our synthesis, we undertook a rapid review process using a single database and reviewer without quality assessment of the included literature. In addition, the number of organizations reviewed for guidelines was also limited. Taken together, this may have resulted in a narrow perspective, as the implications of study quality on the evidence were not discussed, and some evidence may have been missed. Despite this, included SLP organizations spanned multiple countries across 4 continents with information compiled from living documents/guidelines. This format ensures the use of up-to-date information necessary during these times of rapidly changing information. Understandably, given that this pandemic has relatively recently become a global concern, most information reviewed was limited to commentaries and expert opinions. Given the dearth of outcomes-based research to date, the effect of the virus on those with surgically modified airways is only emerging, quickly evolving and requiring regular updates. This leaves much to be learned about how best to care for these patients in the current context.
The current state of the literature is largely based on expert opinion and consensus while lacking in empirical studies, particularly for patients with modified airways. While the current guidelines are a useful starting point, to move our practice forward, their focus should be broadened. This should include diverse setting and service care delivery considerations as well as advanced knowledge across 3 main areas: aerosol-generation risk, viral effect on sensory and motor aspects of the upper aerodigestive tract, and the epidemiology/risk factors associated with severe SARS-CoV-2 infection. Specifically, determining practice areas that are aerosol generating and their corresponding transmission risk level will help to inform assessment and treatment modifications required for this population across settings. Current opinion supports the use of cuff inflation and filters to reduce aerosols; however, understanding whether these activities have a measurable impact on aerosol reduction is required, as these modifications may have deleterious effects on swallowing function and communication as well as social/emotional ramifications for the patient. Future research should also seek to determine methods of instrumental swallowing assessment that minimize aerosol generation, as well as determining viral effects on the mucosa and upper aerodigestive tract structures. This would afford patients continued access to diagnostic services while informing our understanding of swallowing function, airway complications, and communication impairments over the short, medium, and long term in the context of SARS-CoV-2. Finally, understanding the epidemiologic characteristics among those affected by severe SARS-CoV-2 will support the development of risk profiles to expedite the identification of those at risk for swallowing and communication impairments. Doing so would support the delineation of multidisciplinary team membership to preserve the quality of care while mitigating adverse outcomes.
Current literature regarding the assessment and treatment of patients with surgically modified airways in the context of the COVID-19 pandemic is largely based on expert opinion and guidelines from relevant organizations. The primary recommendations center on minimizing transmission risk during swallowing and communication management (eg, cuff inflation maintenance, closed-circuit suction system utilization) for those procedures with high risk for aerosol generation. This often leads to recommended delays for nonurgent procedures until virus testing is negative as well as harnesses remote support without face-to-face contact (eg, telerehabilitation). Empirical studies are required in this area to better inform our practice for those with surgically modified airways, and it behooves our clinical community to continue advocacy for patients while keeping current with the emerging information and guidelines.
Accepted for Publication: August 20, 2020.
Corresponding Author: José Vergara, BSc, SLP, Department of Surgery, University of Campinas, Campinas, R. Tessália Vieira de Camargo, 126, Campinas, São Paulo 13083-887, Brazil (email@example.com).
Published Online: October 15, 2020. doi:10.1001/jamaoto.2020.3720
Author Contributions: Mr Vergara and Dr Skoretz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Vergara, Starmer, Wallace, Seedat, de Souza, Skoretz.
Acquisition, analysis, or interpretation of data: Vergara, Wallace, Bolton, Seedat, de Souza, Freitas.
Drafting of the manuscript: Vergara, Starmer, Wallace, Bolton, Seedat, de Souza, Skoretz.
Critical revision of the manuscript for important intellectual content: All authors.
Administrative, technical, or material support: Starmer, Wallace, Bolton, Seedat, de Souza.
Study supervision: Vergara, Freitas, Skoretz.
Conflict of Interest Disclosures: None reported.
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