Martin B. Brodsky, PhD, ScM and Richard J. Gilbert, MD
Arch Phys Med Rehabil. 2020 Sep; 101(9): 1662–1664. Published online 2020 Jun 10. doi: 10.1016/j.apmr.2020.05.006
Fear of the viral syndrome severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) termed COVID-19 (ie, coronavirus disease 2019)1 is real. Government mandates intended to reduce the rate of transmission, such as social distancing (read as physical distancing), community lock-downs, and public masking, are the only options available for containment.2, 3, 4This new normal, amid the constant threat of COVID-19, has led to an upheaval in rehabilitation care, forcing us to rethink the manner in which we deliver it.
Aerosol generating procedures + vulnerabilities = opportunities
The virus is with us and will likely remain so, even when the more stringent methods of disease mitigation have been lifted. Rehabilitation professionals work physically close with patients, caregivers too. Health care professionals who make a living assessing and treating the oropharynx, nasopharynx, larynx, and upper and lower airways, the anatomical epicenters of the SARS-CoV-2 virus, share the responsibility for constructive clinical engagement. Specific to dysphagia assessment, highly affected geographical regions have limited use of the gold standards—videofluoroscopic swallow study (VFSS) and flexible endoscopic evaluation of swallowing (FEES). Less affected regions have adjusted practice to address safety concerns. Under the current regime, guided by professional societies down to departments of clinicians, VFSS and FEES are considered: (1) aerosol generating procedures5, 6, 7 and (2) electiveprocedures (defined as neither emergent nor urgent for medical care7, 8, 9). The irony is that patients with COVID-19, especially those postextubation from mechanical ventilation in intensive care units, may be among those who need these procedures most.10 , 11 Moreover, if we take the perspective that all patients with a potentially compromised (ie, vulnerable) airway may be carriers of SARS-CoV-2 (ie, person under investigation12), determining a safe swallow of foods and liquids may be less relevant than quantifying the degree of airway risk. In this light, VFSS and FEES are both insufficient and unsafe. We are caught in a clinical time warp, assessing patients with little more than clinical examinations. How do we resume evaluations of swallowing and airway protection in this post-COVID-19 world?
We could consider risk stratification of airway vulnerability with noninvasive imaging and noninvasive metrics. Assessments could include such swallowing characteristics as laryngeal structure and dynamics, lingual deformation during swallowing, airway compromise during swallowing, and efficiency of swallowing physiology. Among the methods that address these characteristics are noninvasive imaging,13 ,14 strength or somatosensory testing,15, 16, 17, 18, 19patient-reported symptoms,20, 21, 22, 23, 24accelerometry,25, 26, 27, 28, 29 cervical auscultation,30, 31, 32, 33 and swallowing frequency.34, 35, 36, 37 Still largely being developed and what many might consider not ready for prime time, none of these methods have been substantively tested in the clinical setting. Characterizing pathology across the spectrum of diseases, distinguishing macroscale from microscale aspiration, and quantitative assessment of airway vulnerability and its risk of pneumonia using tools with translatable and reproducible metrics to clinical outcomes are needed—now more than ever.
We must embrace noninvasive testing of swallowing and airway safety. Combining a detailed medical history, validated patient-reported symptoms inventory, and cranial nerve examination are a good start, but with variable reliability,38 but this cannot be all there is. We need to work constructively with industry and regulatory bodies to develop and test inventions for routine, value-based care. Health care, especially rehabilitation, is dynamic. This necessitates continued engagement with third-party payors, including state and federal governments, to welcome and respond to these changes. Skepticism and reluctance need to be quelled when innovation and onboarding must be the ever-present themes. “We’ve always done it that way” never was an acceptable ideology.
LEIA O ARTIGO NA ÍNTEGRAhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286637/