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Insights From An Interprofessional Post Covid 19 Rehabilitation Unit A Speech and Language Therapy and Respiratory Medicine Perspective
Insights From An Interprofessional Post Covid 19 Rehabilitation Unit A Speech and Language Therapy and Respiratory Medicine Perspective
Insights From An Interprofessional Post Covid 19 Rehabilitation Unit A Speech and Language Therapy and Respiratory Medicine Perspective
CASE REPORT
Paraplegic Centre, 3Spinal Cord and Rehabilitation Medicine, Swiss Paraplegic Centre, and 4Swiss Paraplegic Research, Nottwil, Switzerland
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Insights from a post-Covid-19 rehabilitation unit p. 3 of 4
tipping the balance toward benefits over the risks of struggled with accumulated pharyngeal secretion, but
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using ventilator-compatible speaking valves. with some compression of the abdomen, he was able
The SPC has approximately 20 years of positive to cough it up. This led to an improvement in airflow
experience with this interprofessional approach to early in the upper respiratory tract and the first step toward
valve use. The earlier the patient is able to physiolog enabling vocalization. After the second attempt, he was
ically exhale, at least intermittently, the greater the successful in speaking with the speaking valve, and a
Journal of Rehabilitation Medicine
likelihood that desensitization and dysphagia can be higher frequency of swallowing was observed. The
avoided and the earlier these problems can be treated, patient was even able to swallow, albeit hesitantly, the
if necessary. Moreover, there is some evidence that the first bolus of food (raspberry sorbet), which he clearly
use of speaking valves decreases the respiratory rate enjoyed, verbally commenting “it is good”; a small step
and the amount of CO2 in exhaled air (EtCO2) (14). It towards normalcy. After 2 weeks of intensive functional
is important to note, however, that since the approach dysphagia therapy, he was able to eat soft food with
of deflating the cuff and deployment of a ventilator- supervision while breathing spontaneously with the
compatible speaking valve with Covid-19 patients is speaking valve. However, due to limited pharyngeal/
considered an aerosol-generating measure, the deci- laryngeal sensitivity and the associated risk of saliva
sion to employ this treatment approach must weigh aspiration, and weak voluntary coughing (200 L/min),
the health risks to the interdisciplinary team members tracheal suctioning was required. Moreover, his lungs
vs the patient benefits. In light of the risk–benefit were severely strained by Covid-19. To avoid unneces-
considerations, SPC decided to employ this approach sary complications due to aspiration, the SLTs conducted
with Covid-19 patients with strict adherence to the frequent clinical evaluations of swallowing functions,
established precautionary protection measures and and together with the ear-nose-throat (ENT) physician,
optimal use of personal protective equipment (PPE). performed fibreoptic endoscopic evaluation of swallo-
There has been no evidence of virus transmission from wing to monitor swallowing. Four weeks after admission
patient to staff resulting from this approach at SPC. to the ICU, it was possible to safely remove the patient’s
nasogastric and tracheostomy tubes. Interprofessional
tracheostomy management enabled the patient to com-
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CASE REPORT municate verbally with his family, express his feelings
An example of employing ventilator-compatible spea- about his dramatic experience with Covid-19, and eat
king valves in the treatment of Covid-19 patients is a and enjoy his favourite foods.
62 year-old man who was admitted to SPC with severe
acute respiratory distress syndrome due to Covid-19.
DISCUSSION
With no relevant pre-existing conditions, he presented
with critical illness polyneuromyopathy, ventilator- Speaking and swallowing are major milestones in a
Journal of Rehabilitation Medicine
associated diaphragm dysfunction, weaning failure, patient’s rehabilitation, as evidenced by this case re-
tracheotomized, and completely mechanically ventilated port. The authors have observed that improvement in
with inflated cuff. He was completely nourished through these aspects of functioning have an anti-delirogenic
a nasogastric tube. Due to the cuffed tracheostomy effect, and can be a motivator for patients to be more
tube that was inserted 6 weeks prior to admission, the actively involved in their rehabilitation. We postulate
patient was unable to inform the treatment team of that early intervention with dysphagia therapy and
his needs or express his fears and experience of pain. speech therapy and the use of ventilator-compatible
Furthermore, it was impossible for him to (video) call speaking valves provided within an interprofes-
with his family, and he was unable to write messages sional collaborative team can mitigate the potential
due to his tetraplegia. During a time of a serious health negative consequences of prolonged intubation fol-
crisis and uncertainty about the patient’s prognosis, lowed by long-term use of cuffed tracheostomy, and
the inability to communicate, coupled with the impos- extensive ICU-acquired weakness or PICS resulting
sibility of receiving visits from family (as part of the from Covid-19. Furthermore, the early application
Covid-19 precautionary protection measures) implies of ventilator-compatible speaking valves supports
for the patient unimaginable isolation, a feeling of being weaning off mechanical ventilation (14–16). The
trapped, stress, psychological burden and, ultimately, authors recognize that this approach may be difficult
physical burden. Interventions to restore the ability to to implement in some acute settings; nevertheless, the
communicate verbally are therefore essential. benefits to patients warrant the attempt. Specifically,
In close collaboration between the SLTs and inten- such an intervention approach can improve verbal
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sive care nurses, a ventilator-compatible valve could communication and help patients to regain their sense
be inserted for the first time in this patient. Initially he of taste and smell (if not damaged by Covid-19) and
7. Bader CA, Keilmann A. Schluckstörungen bei tracheo(s) Ventilation distribution and lung recruitment with spea-
tomierten Patienten. [Swallowing Disorders in Tracheo(s) king valve use in tracheostomised patient weaning from
tomized Patients.] Laryngorhinootologie 2017; 96: mechanical ventilation in intensive care. J Crit Care 2017;
280–292 (in German). 40: 164–170.
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