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.