The role of tracheostomy in coronavirus disease 2019 (COVID-19) is unclear, with several consensus guidelines advising against this practice. We developed both a dedicated airway team and coordinated ...education programme to facilitate ward management of tracheostomised COVID-19 patients. Here, we report outcomes in the first 100 COVID-19 patients who underwent tracheostomy at our institution.
This was a prospective observational cohort study of patients confirmed to have COVID-19 who required mechanical ventilation at Queen Elizabeth Hospital, Birmingham, UK. The primary outcome measure was 30-day survival, accounting for severe organ dysfunction (Acute Physiology and Chronic Health APACHE-II score>17). Secondary outcomes included duration of ventilation, ICU stay, and healthcare workers directly involved in tracheostomy care acquiring COVID-19.
A total of 164 patients with COVID-19 were admitted to the ICU between March 9, 2020 and April 21, 2020. A total of 100 patients (mean standard deviation age: 55 12 yr; 29% female) underwent tracheostomy; 64 (age: 57 14 yr; 25% female) did not undergo tracheostomy. Despite similar APACHE-II scores, 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals CI: 2.3–6.4); P<0.0001}. In patients with APACHE-II scores ≥17, 68/100 (68%) tracheotomised patients survived, compared with 12/64 (19%) non-tracheotomised patients (P<0.001). Tracheostomy within 14 days of intubation was associated with shorter duration of ventilation (mean difference: 6.0 days 95% CI: 3.1–9.0; P<0.0001) and ICU stay (mean difference: 6.7 days 95% CI: 3.7–9.6; P<0.0001). No healthcare workers developed COVID-19.
Independent of the severity of critical illness from COVID-19, 30-day survival was higher and ICU stay shorter in patients receiving tracheostomy. Early tracheostomy appears to be safe in COVID-19.
OBJECTIVES:Tracheostomy and dysphagia often coexist during critical illness; however, given the patient’s medical complexity, understanding the evidence to optimize swallowing assessment and ...intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.
DATA SOURCES:Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.
STUDY SELECTION:Two blinded reviewers determined eligibility according to inclusion criteriaEnglish-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.
DATA EXTRACTION:We extracted data using a form designed a priori and conducted descriptive analyses.
DATA SYNTHESIS:We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categoriesdysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.
CONCLUSIONS:The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.
Thousands of rescued harbor seals ( Phoca vitulina ) require rehabilitation worldwide. Many require resource intensive gavage feeding due to abandonment soon after birth. Little is known about seal ...swallowing, therefore, our primary objective was to determine the feasibility of conducting videofluoroscopic swallowing studies (VFS) on seal pups prior to their release. Secondarily, we propose swallowing phase descriptions. We adapted a VFS approach used in humans and our feasibility parameters included: bolus detection and consumption, and number of analyzable swallowing events. Unrestrained seals were imaged in a dry environment using a Siemens mobile c-arm fluoroscopy unit. Oral boluses were thawed herring injected with liquid barium suspension (105% w/v). Two independent raters described swallows using a standardized approach with results summarized descriptively. We successfully completed freely-behaving VFS with two infant seals (1 male: 8 wks, 3 d; 1 female: 5 wks, 3 d). Both consumed five boluses with six fully analyzable swallowing events. We describe four swallow phases: preparatory, prehension, oropharyngeal and esophageal. Airway protection likely occurs in two ways: (1) during the preparatory phase through modified corniculate cartilage contact with the glottis and (2) with soft palate contact to the base of tongue prior to swallow initiation. We have conducted a unique VFS approach on rehabilitated seals, prior to their release. We have described airway protection and suggest that swallowing is initiated earlier in the feeding process than described previously. This protocol success will afford: (1) collection of normative swallowing data, and (2) future knowledge translation from humans to seals.
Background
The autoimmune disease Sjogren's syndrome (SS) is often characterized by salivary changes that may affect swallowing. No known study has investigated the association between salivary ...biomarkers and perceptions of swallowing in individuals with SS. Our objectives were to explore: (1) the operational feasibility of investigating saliva volume and composition, along with perceptions of swallowing, in those with and without SS; and (2) the relationship between saliva composition and perceptions of oral dryness, swallowing, and quality of life.
Methods
We conducted a prospective, case–control feasibility study, collecting feasibility data (recruitment rate and optimal saliva collection methods) and whole mouth saliva samples (unstimulated and stimulated). We measured total protein content and conducted sialochemical (α‐amylase, cortisol, C‐reactive protein CRP, and mucins), sialometric (flow rate), and perceptual (oral dryness and swallowing‐related quality of life SWAL‐QOL) assessments. Our exploratory analyses focused on the main and fixed effects. We summarized all data descriptively, comparing: (a) outcomes between groups (t tests or Mann–Whitney U) and (b) salivary and perceptual data across participants (partial least‐squares correlation PLSC).
Results
We enrolled 12 (N) participants (6 per group), all providing analyzable saliva. Cases had lower flow rate (p = 0.003) and higher total protein, cortisol, and CRP concentrations (p < 0.02) than controls. PLSC revealed inverse covariance between sialochemical and SWAL‐QOL data across participants.
Conclusion
Our study was feasible as designed. We explored novel relationships between salivary outcomes and participant‐reported perceptions, distinguishing individuals with and without SS. Our findings support further study of saliva's role in perceptions of swallowing, specifically analytes with lubricative properties.
We distinguished novel relationships between salivary properties and participant‐reported perceptions of swallowing in those with and without Sjogren's syndrome. Our findings support the feasibility of further study of saliva's role and analytes with lubricative properties during swallowing. Utilizing salivary investigations along with other swallowing diagnostics, salivary analyte profiling may enable biomarker‐based diagnostic and treatment approaches for dysphagia and autoimmune diseases.
Key points
Our successful feasibility study distinguished individuals with and without Sjogren's syndrome (SS) according to novel relationships between salivary properties and participant‐reported perceptions of swallowing.
Salivary analyte profiling in SS may enable biomarker‐based approaches to early identification, differential diagnosis, and bespoke treatment of dysphagia, while also informing the diagnostic process for SS and other chronic, autoimmune conditions.
This research was initiated to explore the experiences and important elements of swallow therapy in patients after surgery for treatment of head and neck cancer (HNC).
One-to-one, face-to-face ...interviews were conducted with patients with HNC 7 to 14 days after oral reconstructive surgery (free, pedicled, or bony flap). Analysis was conducted by using interpretive phenomenology.
Analysis of interviews from 15 patients identified 2 overarching themes: “I never dreamt” and “They look at you, and they speak to you.” There was no way for patients to be adequately prepared for the enormity of the surgery and its consequences; however, the way health care professionals interacted and communicated with the person, rather than the altered and disfigured self, was healing and therapeutic.
There is a need for novel ways to prepare patients for HNC surgery and to support them in recovery, including ways to connect and help patients feel human again.
Abstract
AIMS
Awake craniotomy (AC) with language mapping facilitates maximal safe intracranial tumour resection whilst preserving neurological function 1, and is associated with increased ...postoperative patient satisfaction and quality of life 2, 3. We examine patients’ preoperative language assessment scores, alongside cultural and sociodemographic information to consider the impact on surgical planning and patient outcomes.
METHOD
A service evaluation of assessment tools was undertaken using clinical note audit and clinician reflections. Retrospective data collection from 48 patients assessed for AC with language mapping included language assessment scores, cultural and sociodemographic data, and surgical plan for awake or asleep tumour resection.
RESULTS
Analysis suggests language assessment scores may be influenced by a range of patient factors outside of the lesion location and its associated language deficits, including native language, age, ethnicity and religion.
CONCLUSION
Assessment scores influence a patient’s suitability for AC with language mapping and subsequent morbidity and mortality outcomes. Culture and sociodemographic background are integral to daily language use, and can therefore be expected to influence scores on language assessment tasks. This evaluation highlights the necessity for diversity of language use to be reflected in assessment tools used within an AC pathway.
REFERENCES
1. Hervey-Jumper, S.L. and M.S. Berger, Maximizing safe resection of low- and high-grade glioma. JNO, 2016.
2. Wahab, S.S., P.L. Grundy, and C. Weidmann, Patient experience and satisfaction with awake craniotomy for brain tumours. BJNS, 2011.
3. Coello, A.F., et al., Selection of intraoperative tasks for awake mapping based on relationships between tumor location and functional networks: A review. JNS, 2013.
Tracheostomy and dysphagia often coexist during critical illness; however, given the patient's medical complexity, understanding the evidence to optimize swallowing assessment and intervention is ...challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.
Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.
Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.
We extracted data using a form designed a priori and conducted descriptive analyses.
We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.
The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.
Effective 'valving' in the upper aerodigestive tract (UAT) is essential to temporarily separate the digestive and respiratory pathways. Marine mammals are largely dedicated to feeding underwater, and ...in many cases swallowing prey whole. In seals, little work has been done to explore the anatomy and function of the UAT in the context of valving mechanisms that function to separate food and air pathways. Here we use videofluoroscopy, gross dissection, histology and computed tomography (CT) renderings to explore the anatomy of the larynx and soft palate in the harbour seal (
), and generate models for how valving mechanisms in the head and neck may function during breathing, phonating, diving and swallowing. Harbour seals have an elevated larynx and the epiglottis may rise above the level of the soft palate, particularly in pups when sucking. In addition, the corniculate and arytenoid cartilages with associated muscles form most of the lateral margins of the laryngeal inlet and vestibule, and move independently to facilitate airway closure. The corniculate cartilages flex over the laryngeal inlet beneath the epiglottis to completely close the laryngeal vestibule and inlet. The vocal folds are thick and muscular and the medial margin of the folds contains a small vocal ligament. The soft palate has well-defined levator veli palatini muscles that probably function to elevate the palate and close the pharyngeal isthmus during feeding. Our results support the conclusion that harbour seals have evolved UAT valving mechanisms as adaptations to a marine environment that are not seen in terrestrial carnivores.
Abstract only
In North America, wild harbor seal neonates and pups (
Phoca vitulina
) are among the most common marine mammals admitted to rescue centers. Nutritional support is typically via gavage ...as most are admitted prior to weaning. In order to advance seal feeding and swallowing rehabilitation, we require a comprehensive understanding of their upper aerodigestive tract (UAT) as it applies to swallowing physiology. Anatomical studies of the harbor seal UAT are limited, and standardized UAT measurements for neonates and pups have not yet been determined. Our objective is to design a systematic method to measure their UAT structures and then obtain quantitative values. During post mortem examination, we photographed UAT structures using scalars. Structures included: tongue, vocal folds, cricoid cartilage, trachea, and epiglottis.
A priori
, we developed a manual outlining measurement start and endpoints using ImageJ (NIH, 2010). Following measurements, we summarized results with means (standard deviations, SD) and medians (interquartile ranges, IQR) as appropriate and explored correlations (Pearson’s correlation coefficient, one‐tailed) between UAT structures and other body measurements. We used IBM SPSS analytical software version 26 (IBM Corporation, 2019) for analyses with significance of p<.05. Our specimens included 14 deceased harbor seal neonates or pups (9 males, 5 females) aged between three days and 2 months old at the time of death. Causes of death were either: spontaneous, congenital, or due to infectious, metabolic or malnutrition disorders, or by euthanasia after a humane endpoint was reached. On admission to rehabilitation, body measurement ranges included: 46.0 to 57.0 (body length cm), 36.0 to 59.0 (axillary girth cm) 5.8 to 12.6 (weight kg). Post‐mortem UAT measurements (mm, mean ± SD) included: 1) tongue tip to epiglottis base: 82.7 ± 6.9, 2) vocal fold length: 13.9 ± 2.0, 3) tracheal diameter: 10.3 ± 1.4, and 4) epiglottic length: 20.0 ± 2.8. Correlations between seal body length and UAT dimensions were not statistically significant. In conclusion, we have developed a systematic method to measure harbor seal neonate and pup UAT structures. To the best of our knowledge, these measurements, as they relate to swallowing, have not been previously reported. These findings expand the seal macroscopic anatomy knowledge base and contribute to cross‐species conceptual convergences between human and seal swallowing physiology and its rehabilitation.
Support or Funding Information
Supported by a UBC Faculty of Medicine Summer Student Research Program 2019 award to Hirad Nourbakhsh, UBC Faculty of Medicine Start‐up grant to Stacey A. Skoretz and by a Natural Sciences and Engineering Research Council of Canada (NSERC) Discovery Grant to A. Wayne Vogl (RGPIN‐2018‐03727).
Purpose of Review
To provide an overview of current concepts and considerations in the measurement of dysphagia-related quality of life (QoL) for people with head and neck disease. We describe key ...psychometric and other tool properties that are important to consider when deciding which dysphagia QoL tool to use in practice. The review seeks to establish which tool/s best meet the required properties.
Recent Findings
Currently, no single dysphagia QoL tool meets all criteria. However, a few (SWAL QoL, MDADI, SOAL) meet several parameters and we highlight the current evidence base for these assessments.
Summary
QoL is essential to providing holistic clinical care and could also be an important outcome in research when evaluating interventions. Existing tools may benefit from re-validation studies which take account of progress made in the fields of instrument development, cross-cultural validity and patient centredness. It is also crucial to recognise that the value of capturing QoL in clinical practice is only realised by subsequent follow-up with the individual patient.
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