I work as a skilled speech therapist in home health. I had my first long-term covid client last week, a gentleman who has had difficulty swallowing and a raspy voice for weeks now. I expect more of them. I wish I didn’t have to.
One of the real problems is that this disease is so new that effective therapies for long covid have not yet been developed. One professional article I read in my research before working with this client stated rather boldly that because we don’t really know the extent of the damage or the longer prognoses, the best we can do is treat the symptoms. That’s not very encouraging.
While most of the public assumes that speech therapists work with stuttering, lisping, and r-problems, truth is that swallowing, voice, and cognitive impairments are also well within our scope of practice. Intubation for respiratory difficulty can damage vocal cords, and the effects of both the intubation and the disease itself can play havoc on one’s ability to swallow. We probably don’t need to rehash the “brain fog” that results from diminished oxygen uptake or the damage to the senses of taste and smell that are among the early symptoms.
Most of the guidelines published by the American Speech-Language and Hearing Association (ASHA) regarding dealing with covid patients are about how therapists should protect themselves while poking around in people’s mouths. The following quotes from the ASHA guidelines pages are full of medicalese, but they are really informative for those who do have to deal with long term as well as acute covid for themselves or their loved ones.
This one describes dealing with swallowing problems (dysphagia) and voice problems (dysphonia):
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“Since we are currently in the COVID-19 pandemic phase, even asymptomatic patients can be infected and contagious, and as false negatives from coronavirus diagnostic tests are frequent, the same precautions should apply to all patients” (p. 2).
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It is recommended that patients with swallowing disorders should only be assessed in cases of emergency that cannot be postponed and should only be conducted in a hospital environment. The following procedures should be considered very high risk for interpersonal contamination:
- clinical and flexible endoscopic swallowing assessments (especially since patients cannot wear a mask during food tests);
- flexible endoscopies;
- nasogastric tube insertions; and
- videofluoroscopic swallowing exams.
Clinical and flexible endoscopic assessments of swallowing are not routinely recommended because the patient is required to not wear a mask for tests involving food, because of the close proximity between the provider and the patient’s face, and because of high risk of projections of virus-laden droplets (e.g., during coughing, sneezing, spitting).
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When procedures cannot be postponed, it is recommended that the following personal protective equipment is provided and proper dressing and undressing is learned:
- protective glasses;
- FFP2 (N95) mask;
- cap;
- gloves; and
- gown.
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"In situations where urgent management of swallowing disorders is compulsory, as in some postoperative cases or in some patients with neurodegenerative diseases, tele-rehabilitation is preferable whenever it is technically possible and allowed by the current regulations" (p. 2).
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Laryngologists and speech pathologists may need to perform nasoendoscopies and laryngoscopies for recent dysphonia cases that cannot be postponed. If feasible, a teleconsultation is preferred.
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If the team decides that an in-person consultation for recent dysphonia is necessary and a flexible endoscopy is not required nor is the patient likely to have COVID-19, it recommended that the patient and provider wear a surgical mask during the examination. If a flexible endoscopy is performed, the following personal protective equipment is required:
- head cap;
- FFP2 (N95) mask;
- protective glasses and, if possible, full-face protection with protective visor;
- gloves; and
- gown.
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- “Vocal rehabilitation should not be considered urgent in the current epidemic context. If the patient has already been taken care of for such a rehabilitation, this can be continued by tele-rehabilitation" (p. 2).
And here is a little bit about treating the cognitive aspects of long covid.
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Children and adults with ongoing symptoms post COVID-19 or suspected post-COVID-19 syndrome should receive a holistic, person-centered assessment which includes:
- A comprehensive clinical history and assessment of physical, cognitive, psychological, and psychiatric symptoms, as well as functional abilities.
- Use a validated screening tool to measure the severity and impact of cognitive impairment to assess for new cognitive symptoms post COVID-19.
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Children and adults with acute or confirmed COVID-19 and their families/caregivers should receive counseling and written information on new or ongoing symptoms, including recovery and management of cognitive impairment (e.g., loss of concentration or memory issues) and ear, nose, and throat symptoms (e.g., tinnitus, dizziness).
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- Multidisciplinary rehabilitation, included speech-language pathology, should be provided as needed. A personalized rehabilitation plan should be developed based on assessment and presenting symptoms (e.g., cognitive impairment) with following and monitoring as needed.
Most of the people I have worked with have never expected to have to learn about how swallowing works. It can be pretty interesting but a bad swallow can force food into already damaged lungs, so swallowing therapy is also an important preventative measure for people who are in a weakened condition. I hope you are not one of them!