COVID Questions
COVID FAQs and answers from the front line.
George Barnes MS CCC-SLP
1/12/20
Are you seeing that the loss of taste and smell in patients is causing less intake, weight loss, or dehydration? How does this impact their recovery?
In short, no. I haven’t seen this symptom to cause any significant issues with our COVID-19 patients. In fact, I have found it to pale in comparison to other more severe symptoms that may cause decreased appetite and weight loss (i.e. shortness of breath, weakness, confusion, etc.). But this is only my experience and as much as I’d like my perspective to be the only one that exists there’s always more to the story. For one, I don’t see the mild cases. The patients I see in the hospital only come in if their symptoms are severe or critical (the hospital isn’t the most popular place to hang out these days). Further, I’m only seeing these patients short-term and the loss of taste and smell has been known to last long after the infection. So what about the mild patients or those who have fully recovered and still present with these symptoms over time? You know what they say: “When a question is too difficult to answer, let somebody else answer for you” (not a real quote).
Let’s look at the research. The tough thing about COVID-19 is that all the helpful studies we could use now haven’t been published yet. We are blazing our own trail here and so the only way to figure out where we are going is to look back to see where we’ve gone. For example, some studies simply say it’s too early to answer this question (Great, thanks) (Soler et al., 2020; Glazer et al., 2020).
*Side note- do take a look at those studies if you have time as they give a great overview of the science behind the loss of taste and smell.
Another study of 213 COVID-19 survivors found a definitive link between COVID-19 and weight loss, but seemed to reflect my findings- that the weight loss was secondary to the severity of the respiratory disease; not the loss of taste and smell (Di Filippo et al., 2020).
However, I did find one study (not peer-reviewed yet) which surveyed 9,000 people and reported that patients s/p COVID with loss of taste and smell experience loss of appetite, weight, and nutritional sufficiency (Watson et al., 2020). Interestingly, the study also finds a weight GAIN (COVID-19 15 anyone?). The study goes even further to say that as people lose their appetites they also lose social engagement and intimacy in their relationships. I think this reflects the bigger picture that eating and drinking are interwoven into our social lives. The less we enjoy eating, the less we enjoy socializing and vice versa.
So like all things COVID, it’s complicated. But it remains clear that there is a link between COVID and weight loss and taste and smell may play a significant role. Being that weight loss is directly tied to mortality and recovery, this is an issue that we should continue to follow closely. With this information, I know I for one won’t hesitate to consult the dietician with my patients with COVID to make sure they get the information and resources they need. I always want to be looking at the full picture and this is just another piece to the many puzzles of COVID-19.
Please note: This was by no means an official systematic review of the literature so I urge you to do your own research and PLEASE comment on what you’ve found or what your experience has been below.
References:
Burges Watson, D. L., Campbell, M., Hopkins, C., Smith, B., Kelly, C., & Deary, V. (2020). Altered Smell and Taste: anosmia,
parosmia and the impact of long Covid-19. MedRxiv, 1. https://doi.org/10.1101/2020.11.26.20239152
Di Filippo, L., De Lorenzo, R., D’Amico, M., Sofia, V., Roveri, L., Mele, R., Saibene, A., Rovere-Querini, P., & Conte, C. (2020).
COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-
hoc analysis of a prospective cohort study. Clinical Nutrition, 1. https://doi.org/10.1016/j.clnu.2020.10.043
Glezer, I., Bruni‐Cardoso, A., Schechtman, D., & Malnic, B. (2020). Viral infection and smell loss: The case of COVID‐19. Journal
of Neurochemistry, 1. https://doi.org/10.1111/jnc.15197
Soler, Z. M., Patel, Z. M., Turner, J. H., & Holbrook, E. H. (2020). A primer on viral‐associated olfactory loss in the era of COVID‐
19. International Forum of Allergy & Rhinology, 10(7), 814–820. https://doi.org/10.1002/alr.22578
“I am seeing patients with COVID-19 who have changes in vocal quality. Why is this happening and how can we treat it?”
COVID-19 loves the airways. It’s where it thrives. Upper AND lower- it doesn’t discriminate. So we shouldn’t be surprised when we start seeing patients with airway disorders. And what’s the dead center of that airway? The vocal folds. These two little pieces of fleshy tissue may not look important, but they are responsible not only for protecting and clearing the airways, but for complex language and social connection (What some people consider the most defining characteristic of our species- Drop the mic vocal folds!).
A person’s vocal quality depends highly on the shape, symmetry, size, and texture of the vocal folds. If they are misshapen, asymmetrical, swollen, or injured… trust me, we will hear about it. Voice changes with COVID-19 range from mild to severe, usually corresponding with the severity of the disease itself. A mild cough might result in some mild hoarseness from inflammation/degeneration due to frequent coughing. A moderate case may also include shortness of breath which will affect the strength and volume of the voice. Whereas a severe case with intubation and tracheostomy may cause edema, abrasions, lesions, stenosis, tracheomalacia, granuloma, granulation tissue, and/or paralysis (Severe cases = more issues with bigger words).
Now, I’m not a voice specialist, and never have I claimed to be. I’m a dysphagia dude through and through. But being a “speech” pathologist means I should at least assess, monitor, and provide some referrals/treatment options for the voice. Like a good member of the speech community, if I hear something (e.g. hoarse, aphonia, breathy, etc.) I say something. First, I try to get the patient or family to compare their current vocal quality to their baseline. Then I educate on ways to prevent further damage (hydration, mucolytics, avoid straining etc.). Then, depending on the severity and significance to the patient, I consult with ENT and pulmonology to see if voice therapy and/or respiratory exercises are indicated.
Voice disorders are common in patients with COVID-19, as they are with any respiratory disease. While rarely urgent (especially in a pandemic), communication is still the foundation of our social framework (I’m a speech pathologist, I should know). Let’s do our part to give this issue the voice it deserves.
Have questions, comments, or just want to say hi? Comment below!
Reference:
Asiaee, M., Vahedian-Azimi, A., Atashi-Seyed, S., Karamtfar, A., Nourbakhsh, M. (2020). Voice
Quality Evaluation in Patients With COVID-19: An Acoustic Analysis. Journal of Voice.
https://doi.org/10.1016/j.jvoice.2020.09.024
“Why do people with COVID-19 have cognitive deficits and how can I help?”
Throughout this pandemic, I have been seeing a lot of people with COVID-19 who are going from a functional baseline to a level of confusion that mirrors dementia. It’s not the mild cases so much, but the severe and critically ill patients I’m finding we need to look out for.
COVID-19 is unique among infections in that it often results in systemic organ failure with central and peripheral nervous system involvement (Liotta et al., 2020). As you might imagine the disruption of essential neural communication can cause some issues, including cognitive deficits. Below are three main versions of this, their causes, and some ways we can help. Given the complexity of the disease process (and our bodies), some of the causes and management options overlap from category to category. Check it out:
Encephalopathy: A direct alteration of brain function is common with COVID-19, but the cause is still not well understood. It’s probably from a combination of possible factors including a breakdown in the blood-brain barrier, multi-organ failure, blood coagulation issues, inflammation, and/or a direct invasion of the virus into the brain (yikes!) (Liotta et al., 2020; Umapathi et al., 2020).
How can you help? Management often includes medication to target the virus and to suppress the immune system. Identifying the deficits and putting them on the interdisciplinary team’s (IDT) radar is the most important thing we can do. Basically, we want to catch it before it gets out of control.
CVA: The virus and immune response have been found to cause increased blood coagulation, vasculitis, cardiomyopathy (Spence et al., 2020), and reduced ability to lower blood pressure (Wang et al., 2020). What we are left with is a perfect storm for CVAs (As if these patients weren’t going through enough already).
How can you help? CVAs are not foreign to us SLPs so we can start by managing the speech, language, swallowing, and cognitive symptoms as we normally would. You got this one.
Delirium: It’s common with critical illness and may be caused by a myriad of factors, such as neurological changes, CVA, hypoxia, fever, dehydration, inflammation, medications, and metabolic changes (O’Hanlon & Inouye, 2020). Sorting out all these possible factors can cause delirium in itself!
How can you help? Again, the number one thing we can do is to frequently screen and monitor cognitive changes over time so our IDT is aware of what’s going on. Also, patients with COVID-19 aren’t physically seen by medical staff very often (We can’t just drop in to say hi when there’s a deadly disease on the loose). So while you are in the room you can address their immediate needs, provide cognitive stimulation, and allow them to communicate with their family if possible. You can also advocate for early mobility and normalizing the sleep/wake cycle with the IDT (Lahue et al., 2020).
With all of these ways to help, you can do wonders for the patient’s mental state and ward off a precipitous downturn. Aristotle told us that “the energy of the mind is the essence of life.” Let’s do whatever is in our power to keep that mind alive.
References:
Lahue, Sara C., et al. “Collaborative Delirium Prevention in the Age of COVID ‐19.” Journal of the American Geriatrics Society, vol.
68, no. 5, 2020, pp. 947–949., doi:10.1111/jgs.16480.
Liotta, Eric M., et al. “Frequent Neurologic Manifestations and Encephalopathy‐Associated Morbidity in Covid‐19 Patients.” Annals
of Clinical and Translational Neurology, vol. 7, no. 11, 2020, pp. 2221–2230., doi:10.1002/acn3.51210.
Umapathi, Thirugnanam, et al. “Encephalopathy in COVID-19 Patients; Viral, Parainfectious, or Both?” ENeurologicalSci, vol. 21,
2020, p. 100275., doi:10.1016/j.ensci.2020.100275.
O’Hanlon, Shane, and Sharon K Inouye. “Delirium: a Missing Piece in the COVID-19 Pandemic Puzzle.” Age and Ageing, vol. 49,
no. 4, 2020, pp. 497–498., doi:10.1093/ageing/afaa094.
Spence, J. David, et al. “Mechanisms of Stroke in COVID-19.” Cerebrovascular Diseases, vol. 49, no. 4, 2020, pp. 451–458.,
doi:10.1159/000509581.
Wang, Zilan, et al. “COVID-19 Associated Ischemic Stroke and Hemorrhagic Stroke: Incidence, Potential Pathological Mechanism,
and Management.” Frontiers in Neurology, vol. 11, 2020, doi:10.3389/fneur.2020.571996.
”How do I advocate for performing instrumental swallow studies for patients with COVID-19?”
COVID-19 is a novel virus and so the approach we need to take when managing the disease must be novel as well. This pandemic has changed so many things about healthcare and the field of speech pathology has not been spared. Now more than ever we must be extra careful about who we are physically seeing and how we are managing their care.
This disease spreads quickly and easily. Even brief interactions bring on a high chance of spreading the virus. For the sake of clarity, it’s beneficial to see the amount of risk of a specific action on a spectrum. There are high-risk situations and there are low-risk situations. Visiting your family in the park while standing 10 feet away with your mask on? Low risk. Administering PO trials to a patient with an active virus without proper PPE? High risk.
It also helps to think of each decision we make in terms of the risks and benefits involved. The risks we take as healthcare professionals in this pandemic don’t only impact ourselves. They impact our other patients, our families, our friends, and the community as a whole. In other words, the risks of seeing our patients are unusually high right now. These risks have to be met with an equal or greater benefit to the patient we are recommending the swallow study for.
The final decision will also vary depending on your facility. For example, in the acute hospital, we are doing instrumental studies with stricter protocols (e.g. masking the patient during transport, minimizing the number of people in the room, cleaning the room after use, etc.). On the other hand in the rehab setting, we are waiting for a negative COVID-19 result. The stakes tend to be higher in acute care and the patients less stable. Thus, having the additional information a swallow study provides can make a huge difference in the overall outcome for that patient.
Before you can accurately assess the risks specific to your facility, you need to ask yourself a few questions. Is accurate COVID-19 screening available? Does everybody have the necessary PPE? What are the policies and procedures for transporting the patient (in the case of an MBSS)? These questions will help you decide what level of risk is involved with the swallow study.
The best way to advocate for a swallow study would be to advocate for the person that needs it. Why is this exam important and why is it worth the extra exposure to yourself, transport, and radiology? What information are you looking to find in this exam? How will this information change the course of care for the patient? There are MANY reasons why a swallow study might be needed for your patient, but you need to be able to justify why this benefit will ultimately be worth the risk.
About George:
George Barnes MS CCC-SLP has clinical experience in a variety of settings including acute care, acute rehab, skilled nursing, and long-term acute care. This variety has developed his specialization in dysphagia management with a focus on diagnostics through instrumental swallow evaluations. His concentration is on geriatric patients with complex medical status. He is the co-founder of FEESible Swallow Solutions, a mobile speech pathology company dedicated to improving access to high-quality dysphagia services for patients in the skilled nursing setting.
George has a track record of supporting the field of speech pathology by paying his knowledge forward to other professionals via graduate-level education, clinical fellowship and student supervision, the Student to Empowered Professional (STEP) mentorship program, The Medical SLP Collective mentorship service, ASHA special interest groups, peer review for ASHA course material, the SIG13 dysphagia editorial committee, and participation in various interdisciplinary teams and committees in the hospital setting. He is a multiple ASHA ACE Award recipient for his dedication to continuing education. George actively conducts and supports new research aimed to improve efficiency and accuracy in dysphagia diagnostics, management, and care.
