JCPSLP Vol 23 No 3

(Wijeratne & Crewther, 2020). Of significance from an SLP perspective, S.R.’s COVID-19 related complications also included swallowing and communication impairments. S.R.’s family was provided a guarded prognosis initially, given the uncertain nature of the virus and the initial dependence on life support apparatuses. A complete timeline of S.R’s admission is detailed in Table 1. Assessment and interventions Initially, S.R. was tracheostomy-dependent and presented with dysphagia, dysphonia and cognitive communication impairment. These deficits were in the setting of both his prolonged ICU admission, generalised critical illness myopathy and fatigue, and as a result of COVID-19 related neurological sequelae of hypoxic ischaemic encephalopathy and subsequent multiple intracranial bleeds. S.R.’s deficits necessitated extensive SLP involvement which was significantly different to the usual standard of care. Later research has described the significant variability in clinical practice modifications from setting to setting early in the pandemic (Kearney et al., 2021). A summary of the modifications implemented in S.R.’s care is outlined in Table 2. Tracheostomy weaning was led by SLP and physiotherapy (PT). Due to severe fatigue, the initial weaning regime involved intensive input requiring multiple short cuff deflations, starting at 15 minutes, twice per day, progressing to 40 minutes, and eventually to 24-hour cuff deflations led by nursing staff. Due to S.R.’s high respiratory requirements, digital occlusion trials ranged from 30 seconds to a maximum of two 1-minute trials within a 15-minute cuff deflation. S.R.’s initial tolerance of the Passy Muir Valve (PMV) fluctuated from 20 to 40 minutes on a given day due to onset of fatigue, reduced oxygen saturation and diaphoresis. S.R. progressed to nurse-led PMV use within 6 days. The SLP attended routine multidisciplinary team (MDT) tracheostomy meetings to discuss progress, concerns and medical updates, and facilitated extensive education and upskilling in tracheostomy management to redeployed ward nursing staff involved in S.R.’s care who had limited tracheostomy experience. This was considered an indirect SLP intervention. S.R.’s oropharyngeal dysphagia was characterised by reduced frequency of spontaneous swallows, poor secretion management, and immediate reflexive coughing post trials of thin fluids from a swab. The treating clinician relied on clinical (bedside) swallowing examinations due to the cessation of instrumental swallowing assessments in accordance with organisation directives and national guidelines (Speech Pathology Australia, 2020). This was consistent with effective COVID-19 practice patterns noted in more recent research (Archer et al., 2021; Dawson et al., 2020). S.R. progressed from being nil by mouth to commencing oral intake with intensive SLP interventions including repeated swallow trials, texture modified diet, thickened fluids, and compensatory strategies. S.R.’s diet and fluid recommendations as per the International Dysphagia Diet Standardisation Initiative (IDDSI) terminology are outlined in Table 1. Compensatory strategies included reducing bolus volume, rate of presentation and postural adaptations. Dysphagia rehabilitation exercises were not implemented as swallow physiology was unable to be examined through instrumental swallowing assessments. S.R.’s primary goal ‘to eat and drink’ was thought to reflect the importance placed on nutrition in S.R.’s culture, and therefore, extensive emotional support and encouragement was provided as an adjacent intervention to achieving this shared goal.

S.R.’s dysphonia was of moderate severity and was characterised by breathiness, roughness, and reduced vocal loudness. The Grade Roughness Breathiness Aesthenia Strain (GRBAS) scale was used for perceptual voice assessment, with an initial score of G2R2B2A0S0. Due to S.R.’s concomitant cognitive communication deficits, he was initially unable to participate in impairment-based voice rehabilitation. Instead, indirect voice therapy was implemented, which involved vocal hygiene strategies. As S.R.’s cognitive status and medical presentation continued to improve, he was able to engage in voice therapy exercises, which improved his voice quality significantly. To promote communication access, multiple attempts at implementing alternative and augmentative communication (AAC) systems were trialled. This included the use of a whiteboard, alphabet board, 2x2 cell picture communication board and a yes/no board. Where possible, AAC systems were translated into Maltese. The functional application of AAC was significantly limited by S.R.’s impaired cognition, upper limb weakness and fatigue. For some time during his admission, S.R. had limited access to functional communication which resulted in aggressive and distressed behaviour (code grey). Following this, the treating clinician prioritised access to communication by training all staff involved with S.R.’s care, which later became a hospital-wide project during the pandemic. S.R.’s cognitive communication skills were initially assessed with informal measures and observations due to the severity of his illness and rapid onset of fatigue. His communication profile consisted of significantly reduced spontaneous verbal output, inability to follow single stage commands, high distractibility, impulsivity and impaired visuospatial skills including scanning. At day 66 of his admission, S.R. completed the CLQT with a Maltese phone interpreter. S.R. scored an overall moderate severity rating, with severe impairments in executive functions, and moderate impairments across attention, memory, language, and visuospatial domains. Cognitive rehabilitation techniques included supported communication strategies, ongoing trials of AAC and later, functional communication-based tasks. Follow-up and outcomes Table 2 highlights the adaptations made by SLP in response to developing clinical practice guidelines around clinical safety and best practice. Regardless of these changes, our intervention supported successful decannulation; complete resolution of all swallow, cognitive communication and voice deficits; and contributed to the patient’s discharge to independent living at his home, with no further SLP follow up required. Due to the high acuity of S.R.’s case and the priorities of our organisation at the time, pre and post data was unable to be collected. In this instance, resolution of deficits was defined by the patient and his family’s impression of returning to baseline level of function. A high prevalence of dysphagia, dysphonia and cognitive changes in patients with COVID-19 has now been reported; however, at the time of data collection, evidence was largely limited to expert consensus recommendations for modifying clinical practice (Archer et al., 2021; Daroische et al., 2021; Regan et al., 2021; Rouhani et al., 2020). S.R.’s clinical presentation is consistent with the findings of later cohort studies which suggest complete recovery of dysphagia and dysphonia is expected in most COVID-19 patients who receive intensive SLP intervention (Dawson et al., 2020; Regan et al., 2021; Rouhani et al., 2020). The extent of recovery of cognitive changes post COVID-19 has been reported to vary from person to person given

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JCPSLP Volume 23, Number 3 2021

Journal of Clinical Practice in Speech-Language Pathology