ABSTRACT

Purpose

To describe the contributions of speech therapy performance in tracheostomized patients in the context of COVID-19.

Methods

Retrospective descriptive and quantitative analysis research, using medical records to collect clinical and general variables from patients and speech therapy interventions. For statistical analysis, the Pearson or Spearman correlation coefficient was adopted and a significance level of 5% (p< 0.05).

Results

Twenty-eight medical records of patients were included (57.1% male) and an average age of 52 years and 1 month, who were hospitalized for approximately 53.7 days and progressed to tracheostomy after 22.1 days of orotracheal intubation. There were ten speech therapy sessions per patient, which started on average 38.4 days into hospitalization and were requested in 39.3% of cases for the progression of tracheostomy and oral feeding. The tracheostomy cuff was kept deflated on the third intervention, decannulation was suggested seven days after the start an d the patient was given an oral diet after five interventions. When we analyzed the time speech therapy interventions began, it showed a positive correlation with the length of hospital stay (p<0.0001), but not with the decannulation process and the length of time with the tracheostomy. On the other hand, the number of speech therapy interventions had a positive correlation with the length of time the tracheostomy was in use and the time until the oral diet was released.

Conclusion

Speech therapy performance contributes to swallowing rehabilitation and the safe return to oral feeding in patients submitted to tracheostomy in the context of COVID-19.

Keywords:
Speech, language and hearing sciences; COVID-19; Tracheostomy; Deglutition disorders; Hospital care

RESUMO

Objetivo

Descrever as contribuições da atuação fonoaudiológica em pacientes traqueostomizados no contexto da COVID-19.

Métodos

Estudo retrospectivo de natureza descritiva e análise quantitativa, com coleta em prontuários de variáveis clínicas e gerais dos pacientes e dos atendimentos fonoaudiológicos. Para análise estatística, foi adotado o coeficiente de correlação de Pearson ou Spearman e nível de significância de 5% (p< 0,05).

Resultados

Foram incluídos 28 prontuários de pacientes (57,1% gênero masculino) com média de idade de 52 anos e 1 mês, que permaneceram internados por, aproximadamente, 53,7 dias e evoluíram para traqueostomia após 22,1 dias de intubação orotraqueal. Foram registrados dez atendimentos fonoaudiológicos por paciente, que iniciaram, em média, 38,4 dias de internação e foram solicitados em 39,3% para progressão da traqueostomia e da dieta por via oral. O cuff da traqueostomia foi mantido desinsuflado no terceiro, sugerida a decanulação em sete dias após o início e liberada dieta por via oral com cinco atendimentos. Quando analisado o tempo de início dos atendimentos fonoaudiológicos, verificou-se correlação positiva com o tempo de internação hospitalar (p<0,0001), mas não com o processo de decanulação e com o tempo de traqueostomia. Já o número de atendimentos fonoaudiológicos teve correlação positiva com o tempo de uso da traqueostomia e até a liberação da dieta por via oral.

Conclusão

A atuação fonoaudiológica contribuiu para reabilitação da deglutição e retorno seguro à alimentação por via oral de pacientes internados por COVID-19 e submetidos à traqueostomia.

Palavras-chave:
Fonoaudiologia; COVID-19; Traqueostomia; Transtornos de deglutição; Assistência hospitalar

INTRODUCTION

The COVID-19 pandemic, a disease caused by the new coronavirus (SARS-CoV-2), was declared by the World Health Organization (WHO) in March 2020. The characterization and manifestation of respiratory infection caused by SARS-CoV-2 can vary in severity, from mild symptoms such as fever, cough, fatigue and myalgia, to serious complications including pneumonia, multiple organ dysfunction and severe acute respiratory syndrome (SARS)(¹1 WHO: World Health Organization. Coronavirus disease (COVID-19). Geneva: WHO; 2020.,²2 Zareifopoulos N, Lagadinou M, Karela A, Karantzogiannis G, Velissaris D. Intubation and mechanical ventilation of patients with COVID-19: what should we tell them? Monaldi Arch Chest Dis. 2020;90(1). http://dx.doi.org/10.4081/monaldi.2020.1296. PMid:32268719.
http://dx.doi.org/10.4081/monaldi.2020.1... ).

Faced with hypoxemia secondary to SARS due to COVID-19, patients are indicated for ventilatory support through invasive mechanical ventilation (IMV), undergoing orotracheal intubation (OTI) to maintain airway patency and control pulmonary ventilation(²2 Zareifopoulos N, Lagadinou M, Karela A, Karantzogiannis G, Velissaris D. Intubation and mechanical ventilation of patients with COVID-19: what should we tell them? Monaldi Arch Chest Dis. 2020;90(1). http://dx.doi.org/10.4081/monaldi.2020.1296. PMid:32268719.
http://dx.doi.org/10.4081/monaldi.2020.1... ,³3 Chiang SS, Aboutanos MB, Jawa RS, Kaul SK, Houng AP, Dicker RA, et al. Controversies in tracheostomy for patients with COVID-19: the when, where, and how. Respir Care. 2020 Nov;65(11):1767-72. http://dx.doi.org/10.4187/respcare.08100. PMid:32873749.
http://dx.doi.org/10.4187/respcare.08100... ), and may progress to tracheostomy, depending on prolonged dependence on IMV(⁴4 Rappoport WD, González AT, Capdeville FF, Valdés GF, Rojas PH, Zanolli DL, et al. Traqueostomía en pacientes con COVID-19: recomendaciones actuales. Rev Cir. 2020 Out;72(5):449-54. http://dx.doi.org/10.35687/s2452-45492020005870.
http://dx.doi.org/10.35687/s2452-4549202... ). This procedure varies between ten(⁵5 Oliveira JSD, Quaresma TK, Dornelles S, Berwig LC, Scheeren B. Comparação dos marcadores de alteração na deglutição entre pacientes com e sem COVID-19 pós-intubação orotraqueal. Audiol Commun Res. 2023;28:e2692. http://dx.doi.org/10.1590/2317-6431-2022-2692pt.
http://dx.doi.org/10.1590/2317-6431-2022... ) and 24(⁶6 Rouhani MJ, Clunie G, Thong G, Lovell L, Roe J, Ashcroft M, et al. A prospective study of voice, swallow, and airway outcomes following tracheostomy for COVID-19. Laryngoscope. 2021;131(6):e1918-25. http://dx.doi.org/10.1002/lary.29346. PMid:33341953.
http://dx.doi.org/10.1002/lary.29346... ) days of OTI, but early tracheostomy (before 14 days of OTI) in COVID-19 patients is associated with shorter duration of IMV and ICU stay, with no change in mortality rate, when compared to late tracheostomy(⁷7 Ji Y, Fang Y, Cheng B, Li L, Fang X. Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis. Crit Care. 2022 Fev 8;26(1):40. http://dx.doi.org/10.1186/s13054-022-03904-6. PMid:35135597.
http://dx.doi.org/10.1186/s13054-022-039... ).

The presence of a tracheostomy can have an impact on mechanical and functional changes related to breathing, swallowing and oral communication (vocal production and speech articulation)(⁸8 Barros AP, Portas JG, Queija DS. Implicações da traqueostomia na comunicação e na deglutição. Rev Bras Cirurgia Cabeça Pescoço. 2009;38(3):202-7.), making speech therapy essential in the rehabilitation of these patients, with active participation in the decannulation process alongside the multi-professional team in the context of COVID-19(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹⁰10 Cerqueira SBG, Teixeira JP, Carneiro TC, Ferreira GP, Silva JHSD, Graça LOD, et al. Manejo fonoaudiológico do paciente traqueostomizado no contexto da COVID-19: uma revisão do conhecimento atual. Distúrb Comun. 2021;33(1):178-85. http://dx.doi.org/10.23925/2176-2724.2021v33i1p178-185.
http://dx.doi.org/10.23925/2176-2724.202... ).

The available evidence on this process in COVID-19 patients is limited (mostly from case studies) and shows varied results(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ). Among these results, we highlight the complete deflation of the cuff within 22 days of speech therapy follow-up, the exchange of the TQT cannula for a metal model, if according to the service's protocol, occlusion training and the adaptation of the speech valve, when available. The literature also shows that the ability to tolerate occlusion should be assessed over a period of 24 to 48 hours for subsequent decannulation, which usually takes place between seven and 59 days of device use(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ). During the period described, the patients received between five and 37 sessions of speech therapy, which also contributed to the reintroduction of exclusive oral feeding(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ).

During the COVID-19 pandemic, speech therapy clinical practice has needed to adapt due to the implementation of precautionary and safety measures. In relation to patients with a tracheostomy and a positive test for the virus, the initial guidelines did not recommend manipulating the cuff and clinically assessing swallowing, given the potential risk of spreading aerosols(¹²12 BRASPEN-SBNPE: Sociedade Brasileira de Nutrição Parenteral e Enteral. A importância do fonoaudiólogo no combate ao COVID-19: Orientações aos fonoaudiólogos atuantes no ambiente hospitalar e Unidades de Terapia Intensiva quanto aos cuidados durante a pandemia de COVID-19 [Internet]. São Paulo: BRASPEN-SBNPE; 2020 [cited 2023 July 2]. Available from: https://www.braspen.org/post/a-import%C3%A2ncia-do-fonoaudi%C3%B3logo-no-combate-ao-covid-19
https://www.braspen.org/post/a-import%C3...

13 Manzano-Aquiahuatl C, Tobar-Fredes R, Zavala-Solares MR, Salle-Levy D, Imamura R, Morales-Fernández R, et al. Posicionamiento de la Sociedad Latinoamericana de Disfagia para el manejo de la disfagia orofaríngea y esofágica durante la pandemia COVID-19. Rev Gastroenterol Mex. 2021;87(1):63-79. http://dx.doi.org/10.1016/j.rgmx.2021.08.002. PMid:34728891.
http://dx.doi.org/10.1016/j.rgmx.2021.08... -¹⁴14 ASHA: American Speech-Language-Hearing Association. ASHA Guidance for SLPs on Aerosol Generating Procedures. Rockville: ASHA; 2020.).

In addition, it was recommended that speech therapy interventions be postponed until the patient tested negative for COVID-19 or when the benefits for the patient outweighed the risks of the intervention(¹³13 Manzano-Aquiahuatl C, Tobar-Fredes R, Zavala-Solares MR, Salle-Levy D, Imamura R, Morales-Fernández R, et al. Posicionamiento de la Sociedad Latinoamericana de Disfagia para el manejo de la disfagia orofaríngea y esofágica durante la pandemia COVID-19. Rev Gastroenterol Mex. 2021;87(1):63-79. http://dx.doi.org/10.1016/j.rgmx.2021.08.002. PMid:34728891.
http://dx.doi.org/10.1016/j.rgmx.2021.08... ,¹⁵15 Zaga CJ, Pandian V, Brodsky MB, Wallace S, Cameron TS, Chao C, et al. Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: an international multidisciplinary perspective. Am J Speech Lang Pathol. 2020;29(3):1320-34. http://dx.doi.org/10.1044/2020_AJSLP-20-00089. PMid:32525695.
http://dx.doi.org/10.1044/2020_AJSLP-20-... ).

Of the two pieces of evidence in the literature(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ) that presented data on the process of tracheostomy decannulation and swallowing rehabilitation in patients affected by COVID-19, only one(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.) mentioned recommendations for precautionary and safety measures and the other(¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ) did not specify when the speech therapy interventions began. In any case, it can be seen that the results presented by them are varied, justifying this research in order to contribute to this information.

Therefore, more scientific evidence is needed to better understand and elucidate professional practice in relation to these patients during the pandemic. In view of this, this study aims to describe the contributions of speech therapy performance in tracheostomized patients in the context of COVID-19.

METHODS

This is a retrospective, descriptive, and quantitative analysis research, based on a medical records database of users with a confirmed diagnosis of COVID-19, admitted to a public tertiary-level teaching hospital in the central region of the state of Rio Grande do Sul.

The database used was constructed from the list of medical records provided by the Medical and Statistical Archive Service (Serviço de Arquivo Médico e Estatística, SAME) of the hospital, and belongs to the project approved by the Research Ethics Committee the Universidade Federal de Santa Maria – UFSM with CAAE: 52260621.30000.5346, in accordance with Resolution 510/2016 of Brazil's National Health Council (Conselho Nacional de Saúde). All individuals involved or their legal guardians signed the Informed Consent Form (ICF).

Data collection took place from November 2021 to July 2022 through the University Hospitals Management Application (Aplicativo de Gestão dos Hospitais Universitários, AGHU), which is the online document management system implemented as a standard in all Federal University Hospitals of the Brazilian Company of Hospital Services (Empresa Brasileira de Serviços Hospitalares, EBSERH) network. For this purpose, we validated 664 medical records, and extracted information provided by the SAME of users admitted from March 2020 to May 2022, covering a total of 26 months.

For the selection of medical records to analyze in this study, the inclusion criteria were defined as follows: users aged 18 years or older, hospitalized for COVID-19 (positive RT-PCR)(¹⁵15 Zaga CJ, Pandian V, Brodsky MB, Wallace S, Cameron TS, Chao C, et al. Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: an international multidisciplinary perspective. Am J Speech Lang Pathol. 2020;29(3):1320-34. http://dx.doi.org/10.1044/2020_AJSLP-20-00089. PMid:32525695.
http://dx.doi.org/10.1044/2020_AJSLP-20-... ), subjected to tracheostomy, and who received speech therapy intervention during hospitalization and/or in the home health care service linked to the hospital. The exclusion criteria were as follows: medical records not found or repeated; users with only a record of speech therapy anamnesis, without any more interventions; and medical records that did not show clinical outcomes regarding the use of tracheostomy or progression of oral feeding, due to death, transfer to another hospital, or permanent and prior use of tracheostomy.

The systematization of the selected medical records for this study was based on the extraction of the following variables, that were recorded in an Excel spreadsheet for subsequent analysis:

1. General characteristics of patients: age; gender; pre-existing comorbidities - systemic arterial hypertension (SAH), diabetes dellitus (DM), obesity, alcoholism, and smoking; cardiac, pulmonary, gastroenterologic, neurological, psychiatric, endocrine, kidney, and oncologic diseases.

2. Hospitalization data: length of hospital stay; duration of connection with the home health care service; medical specialty responsible for hospital admission.

It is worth noting that no distinction was made between the hospital units, considering that during the pandemic, all patients admitted with a positive diagnosis for COVID-19 were considered critical and remained in a hospital wing called COVID ICU.

1. Speech therapy intervention data: time from admission to the start of interventions; reason for intervention; total number of interventions during hospitalization and in the hospital's home health care service; time from hospital admission to OTI; time from OTI to tracheostomy.

   3.1 Progress in the tracheostomy decannulation process: type of tracheostomy and need for oxygen (O2) support via a T'Ayre tube on the first visit; total number of visits during the stages of keeping the tracheostomy cuff deflated, suggesting changing the tracheostomy to a metal model, occluding the tracheostomy and suggesting decannulation(¹⁶16 Medeiros GCD, Sassi FC, Silva CL, Andrade CRFD. Critérios para decanulação da traqueostomia: revisão de literatura. CoDAS. 2019;31(6):e20180228. http://dx.doi.org/10.1590/2317-1782/20192018228. PMid:31800881.
   http://dx.doi.org/10.1590/2317-1782/2019... ); length of time using the tracheostomy, time elapsed in this process.

   3.2. Speech therapy clinical evaluation of swallowing: feeding route/diet at the first and last speech therapy intervention; total number of speech therapy interventions until oral feeding was allowed.

All speech therapy interventions were conducted by three professionals from the hospital, according to the service routine during the pandemic period, starting with a negative test result for COVID-19. These speech therapists have between 8 and 15 years of experience in the field of dysphagia and had their practice guided by the Manual de Gerenciamento da Rotina da Unidade Multiprofissional - Fonoaudiologia (Manual of Routine Management for the Multiprofessional Unit - Speech Therapy)(¹⁷17 EBSERH: Empresa Brasileira de Serviços Hospitalares. Procedimento Operacional Padrão da Unidade Multiprofissional - Fonoaudiologia. Versão 2. Emissão. Santa Maria: EBSERH; 2022.), currently in effect in the service, document provides all standard operating procedures to be adoted in service, including the clinical evaluation of swallowing and the patients with tracheostomy.

The Speech Therapy Protocol for Risk Assessment for Dysphagia (Protocolo Fonoaudiológico de Avaliação do Risco para Disfagia, PARD)(¹⁸18 Padovani AR, Moraes DP, Mangili LD, Furquim de Andrade CR. Protocolo Fonoaudiológico de Avaliação do Risco para Disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. http://dx.doi.org/10.1590/S1516-80342007000300007.
http://dx.doi.org/10.1590/S1516-80342007... ) and the Functional Oral Intake Scale (FOIS)(¹⁹19 Crary MA, Mann GDC, Groher ME. Initial Psychometric Assessment of a Functional Oral Intake Scale for Dysphagia in Stroke Patients. Arch Phys Med Rehabil. 2005;86(8):1516-20. http://dx.doi.org/10.1016/j.apmr.2004.11.049. PMid:16084801.
http://dx.doi.org/10.1016/j.apmr.2004.11... ) were used as a basis for the assessment, classification, and speech therapy diagnosis of swallowing for treated patients. Furthermore, the professional conduct suggested by PARD were also adapted according to safe food consistencies for the patient, following the standard of hospital diets: free diet - normal consistency and no restriction on the type or preparation of food; bland diet - food that is softened and low in residue, with no raw food, considered a transition diet; soft diet - food that is soft or in the form of puree, porridge or mashed potatoes, indicated for patients with chewing difficulties; pureed diet with free liquids - food that has been liquefied into a creamy consistency, with water and liquids not needing to be thickened; complete liquid - composed only of liquid food, not thickened.

The routine of the speech therapy interventions provided to the subjects of this study is shown in a flowchart (Figure 1). It should be noted that all assessments were carried out with the patient sitting, alert and responsive, with priority given to the patient offering the diet himself or, when this was not possible, with the help of a companion, aiming to stimulate independence and functionality of the patient.

Finally, we analyzed the collected data using the statistical software GraphPad Prism 5 (GraphPad Software Inc., San Diego, CA, USA). To assess the normality of the variables, we used the Shapiro-Wilk test. Continuous variables with a normal distribution and those with a non-normal distribution were presented, respectively, as mean (standard deviation) and median (interquartile range, IQR), while categorical variables were presented as frequencies and percentages. For correlations, we used the Pearson correlation coefficient (parametric data) or Spearman correlation coefficient (non-parametric data). The correlations were classified as weak (r values between 0.10 and 0.39), moderate (r values between 0.40 and 0.69), and strong (r values between 0.70 and 1.00). The significance level was 5% (p < 0.05).

RESULTS

The period corresponding to this study, 136 (20.48%) patients aged 18 years or older, hospitalized for COVID-19, and with records in their medical history, underwent speech therapy consultation (request for speech therapy assessment by the medical team), anamnesis, and/or evaluation, of which only 37 had information regarding the use of tracheostomy. Of these, 6 were excluded due to a lack of clinical outcome information regarding tracheostomy and oral feeding, with 2 patients who died during hospitalization, and 4 were transferred to another rehabilitation hospital; 1 was excluded due to prior permanent tracheostomy before admission due to tracheal stenosis, and the speech therapy intervention was solely for adapting the oral diet; 2 other patients were excluded because their hospitalization was not due to COVID-19 (severe traumatic brain injury and decompensated human immunodeficiency virus), resulting in the analysis of 28 medical records in this research (Figure 2).

Regarding the general characteristics of patients hospitalized for COVID-19 who underwent tracheostomy, there was a male prevalence (57.1%), with a mean age of 52 years and 1 month± 14 years and the main comorbidities were SAH in 15 cases, and obesity in 14 cases (Table 1).

Regarding hospitalization data, there was an average length of stay of 53.7 ± 20.0 days, with 53.6% of patients admitted under the medical specialty of Pulmonology (Table 2).

All patients hospitalized for COVID-19 in this study underwent OTI and progressed to tracheostomy in an average of 22.1 ± 6.4 days. Speech therapy interventions started after an average of 38.4 ± 17.4 days of hospitalization, with the patient on room air or Ayre's T-piece oxygen support (46.4%). Furthermore, speech therapy interventions were requested in 39.3% for the progression of tracheostomy and oral feeding, with an average of 10 (IQR 7.8-5) interventions during this process, tracheostomy cuff was kept deflated on the third (IQR 1°-4,5°) intervention, decannulation was suggested 7 (IQR 5-20,2) days after the start and the patient was given an oral diet after five (IQR 4-8,2) interventions (Table 3 and 4). All the patients (100%) had a phonoaudiological diagnosis of severe oropharyngeal dysphagia(18) and FOIS 1(¹⁹19 Crary MA, Mann GDC, Groher ME. Initial Psychometric Assessment of a Functional Oral Intake Scale for Dysphagia in Stroke Patients. Arch Phys Med Rehabil. 2005;86(8):1516-20. http://dx.doi.org/10.1016/j.apmr.2004.11.049. PMid:16084801.
http://dx.doi.org/10.1016/j.apmr.2004.11... ) at the first intervention, while at the last, 15 (53.57%) had functional swallowing(¹⁸18 Padovani AR, Moraes DP, Mangili LD, Furquim de Andrade CR. Protocolo Fonoaudiológico de Avaliação do Risco para Disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. http://dx.doi.org/10.1590/S1516-80342007000300007.
http://dx.doi.org/10.1590/S1516-80342007... ) and FOIS 6(¹⁹19 Crary MA, Mann GDC, Groher ME. Initial Psychometric Assessment of a Functional Oral Intake Scale for Dysphagia in Stroke Patients. Arch Phys Med Rehabil. 2005;86(8):1516-20. http://dx.doi.org/10.1016/j.apmr.2004.11.049. PMid:16084801.
http://dx.doi.org/10.1016/j.apmr.2004.11... ), 11 (39.29%) normal swallowing(¹⁸18 Padovani AR, Moraes DP, Mangili LD, Furquim de Andrade CR. Protocolo Fonoaudiológico de Avaliação do Risco para Disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. http://dx.doi.org/10.1590/S1516-80342007000300007.
http://dx.doi.org/10.1590/S1516-80342007... ) and FOIS 7(¹⁹19 Crary MA, Mann GDC, Groher ME. Initial Psychometric Assessment of a Functional Oral Intake Scale for Dysphagia in Stroke Patients. Arch Phys Med Rehabil. 2005;86(8):1516-20. http://dx.doi.org/10.1016/j.apmr.2004.11.049. PMid:16084801.
http://dx.doi.org/10.1016/j.apmr.2004.11... ) and only 2 (7.14%) mild oropharyngeal dysphagia(¹⁸18 Padovani AR, Moraes DP, Mangili LD, Furquim de Andrade CR. Protocolo Fonoaudiológico de Avaliação do Risco para Disfagia (PARD). Rev Soc Bras Fonoaudiol. 2007;12(3):199-205. http://dx.doi.org/10.1590/S1516-80342007000300007.
http://dx.doi.org/10.1590/S1516-80342007... ) and FOIS 5(¹⁹19 Crary MA, Mann GDC, Groher ME. Initial Psychometric Assessment of a Functional Oral Intake Scale for Dysphagia in Stroke Patients. Arch Phys Med Rehabil. 2005;86(8):1516-20. http://dx.doi.org/10.1016/j.apmr.2004.11.049. PMid:16084801.
http://dx.doi.org/10.1016/j.apmr.2004.11... ).

There was a strong positive correlation between the length of hospital stay and the time initiation of speech therapy interventions (r=0.808; p<0.0001) (Figure 3).

The number of speech therapy interventions showed a moderate positive correlation with the time of tracheostomy until decannulation (r=0.552; p=0.002) (Figure 4A). There was a moderate and positive correlation between the number of speech therapy interventions until clearance for oral feeding and the time of tracheostomy (r=0.533; p=0.004) (Figure 4B).

However, there was no correlation between the length of hospital stay and the total number of speech therapy interventions (r=0.372; p=0.051), the number of interventions until clearance for oral feeding (r=0.378; p=0.053), and until tracheostomy decannulation (r=0.154; p=0.444). Similarly, the length the start time before speech therapy interventions did not show a correlation with the number of interventions until occlusion (r=0.131; p=0.516) and decannulation of tracheostomy (r=0.111; p=0.580), as well as with the duration of tracheostomy use (r=0.115; p=0.305).

DISCUSSION

In this study, there was a prevalence of males among adult patients hospitalized for COVID-19 and subjected to tracheostomy, as other studies related to the topic also identified(⁴4 Rappoport WD, González AT, Capdeville FF, Valdés GF, Rojas PH, Zanolli DL, et al. Traqueostomía en pacientes con COVID-19: recomendaciones actuales. Rev Cir. 2020 Out;72(5):449-54. http://dx.doi.org/10.35687/s2452-45492020005870.
http://dx.doi.org/10.35687/s2452-4549202... ,⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,²⁰20 Tornari C, Surda P, Takhar A, Amin N, Dinham A, Harding R, et al. Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients. Eur Arch Otorhinolaryngol. 2021 Maio;278(5):1595-604. http://dx.doi.org/10.1007/s00405-020-06187-1. PMid:32740720.
http://dx.doi.org/10.1007/s00405-020-061... ). With the aim of evaluating this prevalence, the literature discourse about the biological differences related to sexual hormones that mediate innate immune cells, which can influence functional responses to SARS-CoV-2 infection differently in men and women(²¹21 Ten-Caten F, Gonzalez-Dias P, Castro Í, Ogava RLT, Giddaluru J, Silva JCS, et al. In-depth analysis of laboratory parameters reveals the interplay between sex, age, and systemic inflammation in individuals with COVID-19. Int J Infect Dis. 2021 Abr;105:579-87. http://dx.doi.org/10.1016/j.ijid.2021.03.016. PMid:33713813.
http://dx.doi.org/10.1016/j.ijid.2021.03... ,²²22 Fabião J, Sassi B, Pedrollo EF, Gerchman F, Kramer CK, Leitão CB, et al. Why do men have worse COVID-19-related outcomes? A systematic review and meta-analysis with sex adjusted for age. Braz J Med Biol Res. 2022 Fev 16;55:e11711. http://dx.doi.org/10.1590/1414-431x2021e11711. PMid:35195196.
http://dx.doi.org/10.1590/1414-431x2021e... ). A systematic review and meta-analysis confirmed that COVID-19 severity and mortality are higher in men, but age was not an important factor in modulating these interactions(²²22 Fabião J, Sassi B, Pedrollo EF, Gerchman F, Kramer CK, Leitão CB, et al. Why do men have worse COVID-19-related outcomes? A systematic review and meta-analysis with sex adjusted for age. Braz J Med Biol Res. 2022 Fev 16;55:e11711. http://dx.doi.org/10.1590/1414-431x2021e11711. PMid:35195196.
http://dx.doi.org/10.1590/1414-431x2021e... ).

A greater involvement was observed in younger patients, with an average age of 52 years and 1 month, similar to other studies conducted in Brazil(⁵5 Oliveira JSD, Quaresma TK, Dornelles S, Berwig LC, Scheeren B. Comparação dos marcadores de alteração na deglutição entre pacientes com e sem COVID-19 pós-intubação orotraqueal. Audiol Commun Res. 2023;28:e2692. http://dx.doi.org/10.1590/2317-6431-2022-2692pt.
http://dx.doi.org/10.1590/2317-6431-2022... ,⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.), with a possible variation in the literature, reaching an average age of 65 years in an Australian study(²³23 Clayton NA, Walker E, Freemane-Sanderson A. Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW. Aust Crit Care. 2023 Mar;36(2):262-8. http://dx.doi.org/10.1016/j.aucc.2022.01.001. PMid:35177342.
http://dx.doi.org/10.1016/j.aucc.2022.01... ).

The presence of SAH and obesity as pre-existing comorbidities and exacerbating factors for COVID-19 symptoms is frequently presented in the literature(⁴4 Rappoport WD, González AT, Capdeville FF, Valdés GF, Rojas PH, Zanolli DL, et al. Traqueostomía en pacientes con COVID-19: recomendaciones actuales. Rev Cir. 2020 Out;72(5):449-54. http://dx.doi.org/10.35687/s2452-45492020005870.
http://dx.doi.org/10.35687/s2452-4549202... ,²³23 Clayton NA, Walker E, Freemane-Sanderson A. Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW. Aust Crit Care. 2023 Mar;36(2):262-8. http://dx.doi.org/10.1016/j.aucc.2022.01.001. PMid:35177342.
http://dx.doi.org/10.1016/j.aucc.2022.01... ,²⁴24 Rocha LFI, Motter AA. Correlação entre a obesidade e o COVID-19: revisão integrativa. ASSOBRAFIR Ciênc. 2021;12:e43015. http://dx.doi.org/10.47066/2177-9333.AC.2020.0019.
http://dx.doi.org/10.47066/2177-9333.AC.... ), with SAH being considered the most frequent(⁴4 Rappoport WD, González AT, Capdeville FF, Valdés GF, Rojas PH, Zanolli DL, et al. Traqueostomía en pacientes con COVID-19: recomendaciones actuales. Rev Cir. 2020 Out;72(5):449-54. http://dx.doi.org/10.35687/s2452-45492020005870.
http://dx.doi.org/10.35687/s2452-4549202... ), as we also observed in this research. Regarding obesity, in addition to predisposing individuals to the development of other cardiovascular and metabolic diseases, its negative interference with the immune system is evident, increasing inflammation with the potential exacerbation of SARS-CoV-2 infection, the need for IMV and admission to the ICU(²⁴24 Rocha LFI, Motter AA. Correlação entre a obesidade e o COVID-19: revisão integrativa. ASSOBRAFIR Ciênc. 2021;12:e43015. http://dx.doi.org/10.47066/2177-9333.AC.2020.0019.
http://dx.doi.org/10.47066/2177-9333.AC.... ).

The average length of hospital stay for the patients in this study was 53.7 days, with the vast majority undergoing IMV on the day of admission. The length of time of orotracheal tube until the implementation of tracheostomy during this period was an average of 22 days, which is longer than the majority of studies in the literature, which vary between ten(⁵5 Oliveira JSD, Quaresma TK, Dornelles S, Berwig LC, Scheeren B. Comparação dos marcadores de alteração na deglutição entre pacientes com e sem COVID-19 pós-intubação orotraqueal. Audiol Commun Res. 2023;28:e2692. http://dx.doi.org/10.1590/2317-6431-2022-2692pt.
http://dx.doi.org/10.1590/2317-6431-2022... ), 15(²⁵25 Archer SK, Iezzi CM, Gilpin L. Swallowing and voice outcomes in patients hospitalized with COVID-19: an observational cohort study. Arch Phys Med Rehabil. 2021;102(6):1084-90. http://dx.doi.org/10.1016/j.apmr.2021.01.063. PMid:33529610.
http://dx.doi.org/10.1016/j.apmr.2021.01... ), 19(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.), and 24(⁶6 Rouhani MJ, Clunie G, Thong G, Lovell L, Roe J, Ashcroft M, et al. A prospective study of voice, swallow, and airway outcomes following tracheostomy for COVID-19. Laryngoscope. 2021;131(6):e1918-25. http://dx.doi.org/10.1002/lary.29346. PMid:33341953.
http://dx.doi.org/10.1002/lary.29346... ) days. The initial guidelines recommended performing tracheostomy later, after 21 days, assuming that the delay would allow a reduction in viral load and the amount of disseminated aerosols, as well as reducing the possibility of patients not tolerating apnea during the procedure(²⁶26 Schultz MJ, Teng MS, Brenner MJ. Timing of tracheostomy for patients with COVID-19 in the ICU-setting precedent in unprecedented times. JAMA Otolaryngol Head Neck Surg. Oct 146(10):887-8. http://dx.doi.org/10.1001/jamaoto.2020.2630. PMid: 32880624.
http://dx.doi.org/10.1001/jamaoto.2020.2... ). However, a more recent meta-analysis study showed that early tracheostomy (up to 14 days of OTI), when compared to late tracheostomy, was associated with shorter length of stay in IMV and ICU, without changing the mortality rate of COVID-19 patients(⁷7 Ji Y, Fang Y, Cheng B, Li L, Fang X. Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis. Crit Care. 2022 Fev 8;26(1):40. http://dx.doi.org/10.1186/s13054-022-03904-6. PMid:35135597.
http://dx.doi.org/10.1186/s13054-022-039... ).

Regarding the importance of speech therapy performance as part of the multi-professional team in the management of tracheostomized patients in the context of COVID-19(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹⁰10 Cerqueira SBG, Teixeira JP, Carneiro TC, Ferreira GP, Silva JHSD, Graça LOD, et al. Manejo fonoaudiológico do paciente traqueostomizado no contexto da COVID-19: uma revisão do conhecimento atual. Distúrb Comun. 2021;33(1):178-85. http://dx.doi.org/10.23925/2176-2724.2021v33i1p178-185.
http://dx.doi.org/10.23925/2176-2724.202... ), a large portion of the interventions recorded in this study were requested for progression in the decannulation process and consequently rehabilitation of the swallowing function in order to resume oral feeding. They started an average of 38.4 days after hospitalization, close to another recently published study(²³23 Clayton NA, Walker E, Freemane-Sanderson A. Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW. Aust Crit Care. 2023 Mar;36(2):262-8. http://dx.doi.org/10.1016/j.aucc.2022.01.001. PMid:35177342.
http://dx.doi.org/10.1016/j.aucc.2022.01... ).

In relation to tracheostomy, a scientific publication prior to the pandemic described as parameters considered predictive for the decannulation process the clinical and hemodynamic stability, favorable pulmonary functional condition, good secretion management, airway protection with effective cough, tolerance to cuff deflation and tracheostomy occlusion(¹⁶16 Medeiros GCD, Sassi FC, Silva CL, Andrade CRFD. Critérios para decanulação da traqueostomia: revisão de literatura. CoDAS. 2019;31(6):e20180228. http://dx.doi.org/10.1590/2317-1782/20192018228. PMid:31800881.
http://dx.doi.org/10.1590/2317-1782/2019... ). However, after noting the lack of studies on the detailed analysis of the decannulation process of patients with tracheostomy and COVID-19, researchers created a protocol, adapted from an existing one and developed for patients with severe acquired brain injury, in order to achieve best practices in terms of safety and prevention of tracheostomy complications(²⁷27 Cavalli E, Belfiori G, Molinari G, Peghetti A, Zanoni A, Chinelli E. Does a decannulation protocol exist in COVID-19 patients? The importance of working in a multiprofessional team. Discov Health Systems. 2023;2(1):14. http://dx.doi.org/10.1007/s44250-023-00031-z. PMid:37520514.
http://dx.doi.org/10.1007/s44250-023-000... ). Its phases correspond to: 1) cuff deflation; 2) assessment of oropharyngeal secretion management (Blue Dye Test carried out by the speech therapist); 3) assessment with an otolaryngologist for fibrobronchoscopy and replacement of the tracheostomy tube (fenestrated or not, with or without cuff); 4) 5-minute tracheostomy occlusion test (adaptation or not of a speech valve); 5) tracheostomy occlusion for 48-72 hours for decannulation.

In this study, recorded an average of ten speech therapy interventions. The tracheostomy cuff was kept deflated on the third day, there was a seven day progression until decannulation was suggested and five interventions until the oral diet was released (data represented as median - interquartile range). In the end, all the patients were receiving exclusive oral feeding (no alternative route of complementary feeding). The literature, which is still scarce and has very varied results, reports the need for between five and 37 speech therapy interventions to complete these stages, with the cuff being deflated within 22 days of accompaniment, decannulation suggested between seven and 59 days of using the tracheostomy and the oral diet being released between six and 62 days of hospitalization, without presenting the number of sessions for this(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,¹¹11 Santos TDS, Gomes FML, Gomes DC, Taquemori LY, Tonelotto A. Speech therapy and tracheostomy rehabilitation in COVID 19: five preliminary case reports. SN Comprehensive Clinical Medicine. 02 Apr 2021. Preprint. http://dx.doi.org/10.21203/rs.3.rs-320075/v1.
http://dx.doi.org/10.21203/rs.3.rs-32007... ).

In this research, the duration of the tracheostomy until decannulation was approximately 30 days, agreeing with the literature(⁹9 Rocha ACA, Gardenghi G. Perfil fonoaudiológico de pacientes infectados por coronavírus decanulados em um hospital público: série de casos. RESC - Revista Eletrônica Saúde e Ciência. 2021;11(1):45-60.,²⁸28 Osbeck Sandblom H, Dotevall H, Svennerholm K, Tuomi L, Finizia C. Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study. PLoS One. 2021 Jun 4;16(6):e0252347. http://dx.doi.org/10.1371/journal.pone.0252347. PMid:34086717.
http://dx.doi.org/10.1371/journal.pone.0... ). Studies show that patients with tracheostomies after COVID-19 can have sequelae in different organs, physical conditions (long immobilization in pronation causing muscle and pharyngeal weakness, fatigue) and mental conditions (due to isolation from family and work, delirium) that result in the need for longer periods of rehabilitation, including a greater number of speech therapy interventions(⁶6 Rouhani MJ, Clunie G, Thong G, Lovell L, Roe J, Ashcroft M, et al. A prospective study of voice, swallow, and airway outcomes following tracheostomy for COVID-19. Laryngoscope. 2021;131(6):e1918-25. http://dx.doi.org/10.1002/lary.29346. PMid:33341953.
http://dx.doi.org/10.1002/lary.29346... ,²⁹29 Dawson C, Capewell R, Ellis S, Matthews S, Adamson S, Wood M, et al. Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience. J Laryngol Otol. 2020 Nov;10(11):1-6. http://dx.doi.org/10.1017/S0022215120002443. PMid:33168109.
http://dx.doi.org/10.1017/S0022215120002... ).Furthermore, authors found an association between the presence of tracheostomy and the severity of dysphagia, as well as the time for the initiation of rehabilitation and resolution of the condition. This association also extended to the initiation of oral feeding and the duration of enteral nutrition(²³23 Clayton NA, Walker E, Freemane-Sanderson A. Clinical profile and recovery pattern of dysphagia in the COVID-19 patient: A prospective observational cohort within NSW. Aust Crit Care. 2023 Mar;36(2):262-8. http://dx.doi.org/10.1016/j.aucc.2022.01.001. PMid:35177342.
http://dx.doi.org/10.1016/j.aucc.2022.01... ).

The positive correlation between the length of stay of the tracheostomy and the number of speech therapy interventions during hospitalization, as well as with the number of interventions until the release of the oral diet, highlighted in this study, is in line with the suggestion that professionals should take a more cautious approach to the process of weaning from the tracheostomy, with appropriate interventions for a safe return to oral feeding(²⁸28 Osbeck Sandblom H, Dotevall H, Svennerholm K, Tuomi L, Finizia C. Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study. PLoS One. 2021 Jun 4;16(6):e0252347. http://dx.doi.org/10.1371/journal.pone.0252347. PMid:34086717.
http://dx.doi.org/10.1371/journal.pone.0... ).

Furthermore, it is important to mention the high incidence of laryngeal injury among patients undergoing OTI and tracheostomy during the COVID-19 pandemic(⁶6 Rouhani MJ, Clunie G, Thong G, Lovell L, Roe J, Ashcroft M, et al. A prospective study of voice, swallow, and airway outcomes following tracheostomy for COVID-19. Laryngoscope. 2021;131(6):e1918-25. http://dx.doi.org/10.1002/lary.29346. PMid:33341953.
http://dx.doi.org/10.1002/lary.29346... ), which highlights the importance of a careful evaluation of the safety and efficacy of swallowing, as these patients are particularly prone to experiencing respiratory complications subsequent to laryngotracheal aspiration, due to the severity of the disease(³⁰30 Dziewas R, Warnecke T, Zürcher P, Schefold JC. Dysphagia in COVID-19 -multilevel damage to the swallowing network? Eur J Neurol. 2020 Set;27(9):e46-7. http://dx.doi.org/10.1111/ene.14367. PMid:32460415.
http://dx.doi.org/10.1111/ene.14367... ).

In addition to collaborating with recommendations for safer practices(⁶6 Rouhani MJ, Clunie G, Thong G, Lovell L, Roe J, Ashcroft M, et al. A prospective study of voice, swallow, and airway outcomes following tracheostomy for COVID-19. Laryngoscope. 2021;131(6):e1918-25. http://dx.doi.org/10.1002/lary.29346. PMid:33341953.
http://dx.doi.org/10.1002/lary.29346... ,²⁸28 Osbeck Sandblom H, Dotevall H, Svennerholm K, Tuomi L, Finizia C. Characterization of dysphagia and laryngeal findings in COVID-19 patients treated in the ICU-An observational clinical study. PLoS One. 2021 Jun 4;16(6):e0252347. http://dx.doi.org/10.1371/journal.pone.0252347. PMid:34086717.
http://dx.doi.org/10.1371/journal.pone.0... ,³⁰30 Dziewas R, Warnecke T, Zürcher P, Schefold JC. Dysphagia in COVID-19 -multilevel damage to the swallowing network? Eur J Neurol. 2020 Set;27(9):e46-7. http://dx.doi.org/10.1111/ene.14367. PMid:32460415.
http://dx.doi.org/10.1111/ene.14367... ), this study showed that the sooner speech therapy was started for patients hospitalized for COVID-19 and submitted to tracheostomy, the quicker their discharge from hospital. The influence of speech therapy performance in the rehabilitation of these patients on the length of hospital stay can be used as a reference to encourage the early insertion of the professional, both in the hospital routine and in patient care in the face of new public health emergencies with an impact similar to the COVID-19 pandemic. No other studies were found in the current literature with analysis and results equal to or close to this one, justifying its scientific and clinical contribution.

The limitations of this study include the lack of information in medical records and progress notes for characterizing each speech therapy intervention. Additionally, it was not possible to classify the hospital unit according to the severity of the patient when interventions started, as all patients were in a unit called COVID-19 ICU.

New retrospective and meta-analysis studies on speech therapy performance in tracheostomized patients are strongly suggested, given the recent pandemic context and the scarcity of evidence in the literature on the subject, most of which are case studies.

CONCLUSION

Speech therapy performance contributed to the swallowing rehabilitation of patients hospitalized for COVID-19 and undergoing tracheostomy, helping in the process of progression and decannulation of tracheostomy and release of oral feeding, in a safer way, in addition to possibly having an impact on the on the length of hospital stay.

REFERÊNCIAS

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