Setup of Examination Environment for Dysphagia Evaluation
VFSS is preferable to FEES in the current situation of COVID-19 as it
does not involve invasive instrumentation during the procedure and the
administering clinician (speech-language pathologists, radiologists or
otolaryngologists) can maintain a greater distance from the patient
while the examination is undertaken. However, it does require patients
to be transferred to radiology department. As most radiology departments
do not have negative pressure rooms for containment of any airborne
particulates during VFSS, the use of
IQAir® HealthPro® (Incen AG,
Switzerland) air-filter with HEPA class H13 filtration system is
recommended. The filter is capable of screening 99.97% of all particles
> 0.3 microns and would be able to filter any
micro-droplets and aerosol generated during VFSS during coughing events.
In contrast to VFSS, FEES is more portable and can be moved into
negative pressure ventilation rooms. Thus, it may be the preferred
option for SARS-CoV-2 positive patients or those under investigation if
assessment must be performed in an urgent manner. Preferably, FEES would
also be performed in a room with setup of IQAir® air-filter for all
patients to reduce environmental contamination by respiratory droplets
during the COVID-19 pandemic (Figure 1). Figure 2 summarizes the
workflow for instrumental swallowing evaluation in head and neck cancer
patients during the COVID-19 pandemic.
Role of Speech-Language-Pathologists and Dysphagia Clinicians
in Head and Neck Patients During COIVID-19 Pandemic
While instrumental assessment of swallowing is should be limited during
the COVID-19 pandemic, speech-language pathologists (SLP) and dysphagia
clinicians (DC) must still find ways to appropriately evaluate and
manage patients with suspected dysphagia. Various tools may be
implemented to obtain the most objective, comprehensive evaluation
possible. The clinical swallowing assessment should include a thorough
case history, evaluation of oral motor and laryngeal function, and oral
trials of food and liquid. The Mann Assessment of Swallowing Ability –
Cancer (MASA-C)12 may be utilized to quantify the
degree of swallowing impairment, though multiple items may be difficult
to capture if conducted through telehealth. When the clinical evaluation
is conducted through telehealth, advanced preparation is necessary to
ensure the patient has appropriate food and liquid boluses available.
Providing the patient with the International Dysphagia Diet
Standardization Initiative (IDDSI)13 diet level
descriptions in advance will allow the clinician to better understand
the complexity of the boluses administered. Additional considerations
for performance of a clinical evaluation through telehealth is use of
clear feeding instruments to allow the clinician to best gauge the size
of bolus presented, use of food coloring in boluses to increase
visibility, and application of colored tape at the level of the thyroid
cartilage to aid in visualization of laryngeal elevation during the
swallow.14
A clinical swallowing evaluation, whether in person or via telehealth
should be combined with quantitative swallowing measures to minimize the
potential for bias. A number of patient-reported outcome (PRO) measures
and clinician-rated scales have been validated for use in the head and
neck cancer population. The MD Anderson Dysphagia Inventory is a 20-item
PRO that can be used to capture the patient’s perception of their
swallowing difficulties and has been broadly used in the head and neck
cancer population and adapted and validated in many
languages.15,16 Other swallowing specific PROs include
the EAT-1017, the Sydney Swallow
Questionnaire18,19 and the Royal Brisbane Hospital
Outcome Measure for Swallowing (RBHOMS)20. In addition
to patient reported outcomes, there are several clinician related tools
that can be utilized to quantify dysphagia and its outcomes. The
Performance Status Scale Head and Neck (PSSHN)21 has
two items which are routinely administered to quantify dysphagia impact;
the normalcy of diet subscale and the eating in public subscale.
Further, the Functional Oral Intake Scale (FOIS)22 and
Food Intake Level Scale (FILS)23 can provide
additional information about diet level in regard to tube feeding use.
This combination of thorough case history, clinical observation, PROs,
and clinician rating scales can provide the clinician with needed
information to guide recommendations and treatment planning until
instrumental assessment becomes more readily available.
It is important for the SLP and DC to recognize the limitations of
non-instrumental methods of swallowing evaluation. While agreement
between telehealth and in-person clinical swallowing evaluations is
good, there are limitations to clinical evaluations, particularly in
patients with more severe dysphagia.24 Thus,
clinicians may need to adopt a more conservative approach to dysphagia
management with close attention to potential markers of complications
such as increased cough, fever, and weight loss. In those circumstances,
the benefits of completing an instrumental evaluation may outweigh the
disadvantages. Given higher risks associated with aerosolization and
close proximity during FEES exams, the modified barium swallow would be
the preferred tool during the COVID-19 outbreak.
In addition to dysphagia diagnostics, swallowing therapy also may need
to be adapted during the pandemic. In general, swallowing therapy should
be reserved for telehealth whenever possible to minimize transmission
risk. There is a paucity of evidence on the benefits of telehealth in
dysphagia therapy, but there is some suggestion of improved treatment
adherence in patients receiving telehealth in comparison to patient-lead
home treatment.25 In addition to telehealth, other
technology-driven options such as mobile applications may play a role
when available.26,27 Swallowing therapists should
strive to adapt their virtual visits to provide the highest level of
care possible. Post-irradiated patients with history of virally mediated
nasopharyngeal and oropharyngeal cancer may find these mobile app and
telehealth options very beneficial because they are relatively young,
independent, knowledgeable, and receptive to the use of technology.
Engaging home caregivers and
advanced planning of materials needed may help to facilitate treatment
sessions. Table 1 summarize the guidelines for telehealth in swallowing
management.
Conclusions
In the global pandemic of COVID-19 disease when the health care system
is under unprecedented pressure, any implementation of medical care
should be prioritized according to urgency and safety. Dysphagia can be
potentially life threatening if left unattended as it may cause
aspiration pneumonia or airway obstruction. While we suggest deferring
any non-urgent instrumental swallowing studies, particularly in patients
considered at high risk for COVID19 based on TOCC and acute respiratory
symptoms, screening and assessment of swallowing function can still be
possible through telehealth using various non-instrumental methods. Such
assessments can help to mitigate risks associated with dysphagia and to
triage those patients most in need of instrumental evaluation.
Telehealth can also be used to
implement swallowing training, for monitoring, and to review progress as
well as to engage home caregivers and plan future services. In cases
where instrumental assessment is deemed necessary, we advocate for
adoption of conservative, high level PPE use to minimize risk to
patients and health care providers.