Fear of the viral syndrome severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
termed COVID-19 (ie, coronavirus disease 2019)
is real. Government mandates intended to reduce the rate of transmission, such as
social distancing (read as physical distancing), community lock-downs, and public
masking, are the only options available for containment.2, 3, 4 This new normal, amid
the constant threat of COVID-19, has led to an upheaval in rehabilitation care, forcing
us to rethink the manner in which we deliver it.
Aerosol generating procedures + vulnerabilities = opportunities
The virus is with us and will likely remain so, even when the more stringent methods
of disease mitigation have been lifted. Rehabilitation professionals work physically
close with patients, caregivers too. Health care professionals who make a living assessing
and treating the oropharynx, nasopharynx, larynx, and upper and lower airways, the
anatomical epicenters of the SARS-CoV-2 virus, share the responsibility for constructive
clinical engagement. Specific to dysphagia assessment, highly affected geographical
regions have limited use of the gold standards—videofluoroscopic swallow study (VFSS)
and flexible endoscopic evaluation of swallowing (FEES). Less affected regions have
adjusted practice to address safety concerns. Under the current regime, guided by
professional societies down to departments of clinicians, VFSS and FEES are considered:
(1) aerosol generating procedures5, 6, 7 and (2) elective procedures (defined as neither
emergent nor urgent for medical care7, 8, 9). The irony is that patients with COVID-19,
especially those postextubation from mechanical ventilation in intensive care units,
may be among those who need these procedures most.
Moreover, if we take the perspective that all patients with a potentially compromised
(ie, vulnerable) airway may be carriers of SARS-CoV-2 (ie, person under investigation
), determining a safe swallow of foods and liquids may be less relevant than quantifying
the degree of airway risk. In this light, VFSS and FEES are both insufficient and
unsafe. We are caught in a clinical time warp, assessing patients with little more
than clinical examinations. How do we resume evaluations of swallowing and airway
protection in this post-COVID-19 world?
We could consider risk stratification of airway vulnerability with noninvasive imaging
and noninvasive metrics. Assessments could include such swallowing characteristics
as laryngeal structure and dynamics, lingual deformation during swallowing, airway
compromise during swallowing, and efficiency of swallowing physiology. Among the methods
that address these characteristics are noninvasive imaging,
strength or somatosensory testing,15, 16, 17, 18, 19 patient-reported symptoms,20,
21, 22, 23, 24 accelerometry,25, 26, 27, 28, 29 cervical auscultation,30, 31, 32,
33 and swallowing frequency.34, 35, 36, 37 Still largely being developed and what
many might consider not ready for prime time, none of these methods have been substantively
tested in the clinical setting. Characterizing pathology across the spectrum of diseases,
distinguishing macroscale from microscale aspiration, and quantitative assessment
of airway vulnerability and its risk of pneumonia using tools with translatable and
reproducible metrics to clinical outcomes are needed—now more than ever.
We must embrace noninvasive testing of swallowing and airway safety. Combining a detailed
medical history, validated patient-reported symptoms inventory, and cranial nerve
examination are a good start, but with variable reliability,
but this cannot be all there is. We need to work constructively with industry and
regulatory bodies to develop and test inventions for routine, value-based care. Health
care, especially rehabilitation, is dynamic. This necessitates continued engagement
with third-party payors, including state and federal governments, to welcome and respond
to these changes. Skepticism and reluctance need to be quelled when innovation and
onboarding must be the ever-present themes. “We’ve always done it that way” never
was an acceptable ideology.
Directing different resources differently
Outpatient visits have been severely restricted, redirecting resources to address
acute care hospitalization demands. This will continue for some time after the curve
has been flattened. In the months and years that follow, when supplies are restored
and personnel resume business as usual, we will endeavor to overcome the economic
burden of this medical tragedy. Stimulus packages to individuals will not make a dent
in the medical bills many thousands of patients face posthospitalization needing rehabilitation.
The rehabilitation burden is only at the beginning, severely lagging the onslaught
of hospitalizations climbing as high as 31% in the United States.39, 40, 41, 42 Worse,
the economics of rehabilitation are far-reaching, impacting many professions and patients,
all with no end in sight.
Strokes, for example, have not stopped since the pandemic began; rather, they have
Dysphagia is no different,
never mind the ongoing threat of airway invasion in the context of weakness from both
SARS-CoV-2 and acute care hospitalization. Patients need follow-up, but we must mitigate
the challenges of treating patients when physical contact may be harmful for all involved.
Creativity and resourcefulness are needed to meet patients’ needs. Enter telehealth.
Various applications, including electronic medical records systems and video conferencing
platforms, are being used to deliver health care, many long before the SARS-CoV-2
outbreak. Remote methods of assessing or treating dysphagia are nearly 20 years old.48,
49, 50 Such methods may not be standardized or generally implemented in clinical settings
due to technological insufficiencies, lack of training, and issues related to billing
and reimbursement. Moreover, telehealth may not be a panacea or used for all patient
populations.51, 52, 53 Despite these apparent limitations, patients are still able
to follow-up with providers and at least receive limited care where they would otherwise
be refused care until systems for reentry and clinical pathways are more established.
At the time of printing, specifically in the United States, Medicare temporarily waived
requirements in 42 CFR §484.55(a)(2) and §484.55(b)(3), permitting speech-language
pathologists to remotely evaluate and treat speech production and fluency, language
comprehension, and voice (CPT 92507-08, 92521-24),
yet clinical swallowing evaluations (CPT 92610) and swallowing treatment (CPT 92526)
remain not covered.
Medicare beneficiaries, 64 million in 2019,
have a forced choice: (1) suffer with dysphagia while hoping for spontaneous recovery
and fear the worst-case scenario of being rehospitalized with pneumonia due to impaired
airway safety, or (2) pay out-of-pocket for telehealth services that—currently—will
not be reimbursed, further straining personal economics and still risk rehospitalization
with pneumonia due to impaired airway safety. All of these limitations now can be
reconsidered. Wearable technologies allow clinicians to remotely assess minute-to-minute
physiological performance (eg, swallowing frequency) or monitor physiochemical components
of exhaled air as a metric of aspiration. These technologies for dysphagia are not
clinical realities; telehealth is the best we have.
In the end, distinguishing between clinical practice and innovation is a false choice.
Clinicians are responsible for meeting the challenge of COVID-19 by identifying new
methods wherever they exist. Researchers must strive to find clinical relevance to
match their innovations. SARS-CoV-2 has dictated that those who manage dysphagia must
evolve. And so, we shall.