What are the recommended physiotherapy outcome measures to use with Covid-19 patients in an out-patient post-COVID clinical setting?

Question

• What is the evidence to support high flow nasal oxygen in COVID-19 management?
• Does high flow nasal oxygen result in increased droplet dispersion and aerosol generation in COVID-19 patients?

Short Answer

High flow nasal oxygen for the management of COVID-19 is a controversial topic due to a lack of high-quality research into its efficacy and its potential as an aerosol-generating procedure. Systematic reviews commissioned by the World Health Organization found that high-flow nasal cannulas may reduce the need for invasive ventilation and the escalation of treatments over conventional oxygen therapy in COVID-19 patients. However, they caution that this potential advantage must be weighed against the currently unknown risk of droplet and aerosol transmission: there is currently no research evidence directly examining the consequent dispersion of COVID-19 virus for this procedure. A number of actions can reduce any potential risk: deliver HFNO in negative-pressure rooms and/or ensure proper ventilation; use an increased area of precaution; ensure staff have protective PPE; and place surgical masks on patients receiving the HFNO.

The content of this document is correct as of 04/12/20.

QUESTION

• Is there any evidence to suggest chest physiotherapy is an aerosol-generating procedure?
• Does the evidence compare different types of chest physiotherapy treatment techniques – and whether certain treatments may be more aerosol generating than others? (i.e. positive pressure devices, oscillating devices, cough assist, breathing techniques, patient coughing, suction etc).

SHORT ANSWER

There is insufficient evidence to state that chest physiotherapy is an aerosol-generating procedure. However, absence of evidence is not evidence of absence. International and national professional physiotherapy bodies have endorsed guidelines for physiotherapy management during COVID-19 which state that chest physiotherapy interventions are potentially aerosol-generating procedures and strongly recommend using airborne precautions when delivering these interventions. Furthermore, a recent systematic review classified chest physiotherapy interventions as potentially aerosol-generating and recommended, for the purposes of selecting personal protective equipment, that such procedures be treated as aerosol-generating.

The content of this document is correct as of 04/12/20.

Question

What is the latest evidence regarding conscious proning of COVID-19 patients?
At what level of oxygen is it best to commence proning?
When should you stop proning as the patient is improving?

Short Answer

The current evidence for conscious proning is of poor quality and fails to answer several key questions required to inform clinical practice, including the optimum conditions for commencing and ceasing proning. There are multiple RCTs underway that will address these gaps in knowledge over the coming months.

The content of this document is correct as of 27/11/2020.

Question

1.What is current guidance for cleaning a room after a hands-on physiotherapy session?

2.What are the current recommended products for effectively cleaning surfaces?

3.Do I have to wait a certain amount of time to clean my treatment room after a session?

Short answer

1.Clean with detergent and water followed by rinsing and drying. If a surface is suspected or known to have been contaminated by infectious material a disinfected should be used after cleaning.

2.A neutral detergent with water for cleaning and a chlorine-based product, such as sodium hypochlorite, for disinfecting.

3.HSPC cleaning protocols do not stipulate that a certain amount of time should be left between seeing a patient and cleaning. HSPC guidelines state that COVID-19 virus droplets produced by an infected patient will land on surfaces “within minutes” of production. They do not state how many minutes precisely. Research has found that large droplets fall within 1 second while smaller droplets can take up to 9 minutes to fall to the ground.

The content of this answer is correct as of 02/10/2020

QUESTION

What is the current guidance for Occupational Therapists practicing telehealth?

ANSWER

There are a number of best practice guidance documents currently available. We have summarised the information and guidance from the Irish COVID-19 Occupational Therapy in Acute Hospitals Interest Group, the Association of Occupational Therapists of Ireland, the World Federation of Occupational Therapists, the American Occupational Therapy Association and Occupational Therapy Australia (OTA).

Question

Can the below tests be administered via telepractice?

• Beery-Buktenica Developmental Test of Visual-Motor Integration
• Detailed assessment of speed of handwriting (DASH)

Answer

Yes, both Beery and the DASH have publisher recommendations for administration via telepractice. Detailed instructions for the DASH can be found here and detailed instructions for the Beery can be found here.

Both tests are published by Pearson. The DASH telepractice information is available on the Pearson UK website but it does not appear on their US website. For the Beery, vice versa, the telepractice information is available on the Pearson US website and does not appear on their UK website.

Question

What is the impact on return to work for patients with COVID-19 who have been hospitalised?

Short Answer

In Ireland, 3,676 people have been hospitalised because of COVID-19. There is no information on the consequent work status of these individuals. This is also the case on the global stage. There are indications from small scale studies and research on similar diseases (SARS & MERS) that some individuals hospitalised with COVID-19 will experience delayed return to work. Fatigue and breathlessness are the most common post-discharge symptoms. Scientists and professional bodies are calling for occupational therapists and other allied health professionals to prepare for the surge in demand for services but more research is needed to determine the long-term consequences of a COVID-19 hospitalisation and its impact on return to work.

The content of this document is correct as of 08/10/2020.

Question

• What is the current best practice when working as a CBT therapist in primary care?
• In light of the new strains of Covid 19 and the most recent information, is it still recommended to wear a face shield and maintain 2 metres distance from the patient?
• What is a safe session duration?

Short Answer

Recent updates of Irish guidance have reiterated that masks must be worn in healthcare facilities when a distance of 2 metres cannot be maintained. However, the guidance does not specifically address if masks need to be worn if persons are greater than 2 metres apart. Surgical masks are recommended for health workers within primary care practices while face coverings are recommended for patients entering a primary care practice. An updated rapid evidence summary by the HSPC indicates that face coverings are preferable to visors/shields to reduce transmission of COVID-19, though the evidence is of low quality. However, there are circumstances where a face covering may not be appropriate and may affect quality of care. In these circumstances a visor/shield may be used provided that it extends from above the eyes to below the chin and from ear-to-ear. The role of room ventilation is increasingly acknowledged and some guidance exists on increasing ventilation though this is dependent on context. Recommendations are not made about safe session duration.

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The content of this document is correct as of 02/02/2021.

Question

How can a person who is a ‘close contact’ without their own transport safely travel to a COVID-19 testing centre? Are there any specific arrangements for students or healthcare workers? Can they use public transport, taxi or is there any arrangement with the ambulance centre to support this? 

Short Answer

A person who is a ‘close contact’, without their own car, should ask one person that they live with to drive them to the testing centre. If the ‘close contact’ does not live with anyone who has a car they should ask someone who they have been in close contact with very recently to drive them. They should follow the HSE guidance on how to safely travel in a car in such a circumstance. A person who is a close contact should not use public transport, this includes using a taxi service. There are no special arrangements in place for students or healthcare workers.

The content of this document is correct as of 10/11/2020.

QUESTION

Do I need to wear a mask if maintaining a 2m distance in a treatment room while delivering face-to-face CBT in Primary Care?

Short answer

The National Public Health Emergency Team (NPHET) has recommended that healthcare workers use a surgical mask for all patient care activities when a safe distance (2m) cannot be maintained. This implies that when a 2m distance can be maintained a mask is not necessary. However, the NPHET guidance does not state this explicitly and does not address the issues of room size/occupancy or duration of contact. The European Centre for Disease Prevention and Control considers maintaining a 2m distance in a closed environment, such as a treatment room, as low-risk for exposure to COVID-19. The HSE Health Protection Surveillance Centre state that in low-risk circumstances, where wearing a mask may impact on patient care, a clear face visor is an acceptable alternative.

The content of this document is correct as of 30/09/2020.

These documents were used to answer this question:

1. Health Protection Surveillance Centre (2020). Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. HSE: September 2020.
2. Health Protection Surveillance Centre (2020). Guiding principles for Infection Prevention and Control when returning to routine General Practice during pandemic COVID-19 v2.1. HSE: July 2020.
3. European Centre for Disease Prevention and Control (2020). Public health management of persons having had contact with cases of novel coronavirus in the European Union. ECDC: February 2020.

Dr Liz Kingston, member of the RapidInfo4U Panel of Experienced Clinicians and Lecturer at the University of Limerick, with a clinical speciality in infection prevention and control, was consulted to answer this question.

What is the impact of achieving adequate nutrition in the rehabilitation phase post COVID-19 infection?

Short Answer
At this time, there is no evidence on the impact of adequate nutrition in the rehabilitation phase post COVID-19. There is also limited evidence for the impact of adequate nutrition in the prevention and treatment of COVID-19. However, given the broader evidence on the impact of nutrition on recovery from infectious diseases, guidelines highlight the need to assess malnutrition in COVID-19 patients and to develop an appropriate plan to ensure necessary energy, protein, vitamin and mineral intakes.

How long do taste changes or loss remain post COVID-19? What is the impact of same?

Short Answer:
Research indicates that about 1 in 3 COVID-19 patients will experience taste changes or loss and that for the majority this dysfunction will last 7 to 14 days. It is not yet clear how long it will take those patients with persistent taste dysfunction to recover. Research to date has included only short-term follow-up protocols, following patients for four to eight weeks. As with everything in the COVID-19 era evidence is constantly accruing and more research is needed to determine both the average length of recovery time for persistent taste dysfunction as well as the impact of such a dysfunction overtime on the patient. Existing literature on taste dysfunction (unrelated to COVID-19) has found that loss of taste can be detrimental to both the physical and mental health of a patient. There are currently no treatments recommended by researchers for loss of taste produced by the COVID-19 virus.

Question

When cleaning areas between patients are detergent wipes (e.g. Sanicloths) required or will a general detergent spray and disposable tissue suffice?

When disinfecting areas between patients are disinfectant wipes required or can we use disinfectant spray and disposable tissues? 

Short answer

The HSE Health Protection Surveillance Centre guidelines do not stipulate that wipes are required to clean or disinfect areas between patients. Disposable tissues, cloth, or paper towels are sufficient to use in conjunction with the appropriate detergent solution and disinfectant.

The content of this document is correct as of 06/11/2020.

This response was based on HSE Health Protection Surveillance Centre Interim Guidance on Infection Prevention and Control for the Health Service Executive 2020 v1.2. Available here.

Question

Is there sufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19?

Short answer

No, there is insufficient evidence to warrant a change in the established position (i.e. NICE guidelines of June 2020) regarding vitamin D for the prevention or treatment of COVID-19. Best practice remains maintaining recommended levels of Vitamin D, which may include supplementation of vitamin D in groups at high-risk of deficiency.

The content of this document is correct as of 17/09/2020.

Question

Essential oils have been use for decades for the treatment of minor ailments. Each particular essential oil has their specific properties from antiviral, antimicrobial, anti-fungicide, antibacterial and so on. Is there any evidence that essential oils ease respiratory symptoms or respiratory distress for patients with COVID-19 if used alongside or in conjunction with medical treatment?

Short Answer

Research on the antiviral properties of essential oils are at the early stages. Recent reviews have found no trials that evaluated the clinical efficacy of essential oils on respiratory symptoms caused by coronavirus in humans. Additionally, current studies fail to provide adequate information on the toxicity of essential oils and safe dose information.

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The content of this document is correct as of 28/01/2021.

Are visors a safe alternative to face masks for patients who cannot communicate with healthcare professional who is using a face mask?

QUESTION

Is there a mandatory requirement to set aside vacant rooms to be utilised in the event of a COVID-19 outbreak in a residential care facility?
Will there be financial provision or grant to the centre to cover the cost of having vacant rooms for this purpose?

Haines, J, Esposito, K, Slinger, C, et al. UK consensus statement on the diagnosis of inducible laryngeal obstruction in light of the COVID‐19 pandemic. Clin Exp Allergy. 2020; 00: 1– 7.

Laryngoscopy is the mandatory gold standard for the accurate assessment and diagnosis of inducible laryngeal obstruction. However, it is considered an aerosol‐generating procedure and so in the context of COVID-19 the availability of laryngoscopy is reduced. 

This consensus statement aims to guide clinicians working with inducible laryngeal obstruction (ILO) patient populations in the context of COVID-19. It provides an agreed, recommended strategy for presumptive diagnosis in patients who cannot have laryngoscopy performed due to pandemic restrictions.

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Tohidast, S. A., Mansuri, B., Bagheri, R., & Azimi, H. (2020). Provision of speech-language pathology services for the treatment of speech and language disorders in children during the COVID-19 pandemic: Problems, concerns, and solutions. International journal of pediatric otorhinolaryngology, 138, 110262.

COVID-19 has interrupted the provision of Speech-Language Pathology (SLP) services to children due to the need for face-to-face communication between Speech and Language Pathologists (SLPs) and children during the evaluation and treatment processes.

This article describes the negative effects of COVID-19 on the provision of SLP services and discusses concerns raised by the families, the importance of providing SLP services during the critical period of speech and language development, telepractice services, the roles of speech-language-hearing related scientific associations, and the roles of SLPs during the COVID-19 crisis.

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Brodsky, M. B., & Gilbert, R. J. (2020). The Long-Term Effects of COVID-19 on Dysphagia Evaluation and Treatment. Archives of Physical Medicine and Rehabilitation.

This short editorial in the Archives of Physical Medicine and Rehabilitation discusses aerosol-generating procedures. Published June 10th, 2020.

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Patterson, J. M., Govender, R., Roe, J., Clunie, G., Murphy, J., Brady, G., … & Carding, P. (2020). COVID‐19 and ENT SLT services, workforce and research in the UK: A discussion paper. International journal of language & communication disorders.

The aim of this article is to discuss the threats and opportunities from the COVID-19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership.

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Soldatova, L., Williams, C., Postma, G.N., Falk, G.W. and Mirza, N., 2020. Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic. Otolaryngology–Head and Neck Surgery

With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to  resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a speciality faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.

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Dimer, N. A., Canto-Soares, N., dos Santos-Teixeira, L., & de Goulart, B. N. G. (2020). The Covid-19 pandemic and the implementation of telehealth in speech-language and hearing therapy for patients at home: an experience report.

This is an experience report on the implementation of real-time telehealth in speech-language and hearing therapy for patients during the COVID-19 pandemic who were previously seen on an outpatient basis in a primary health care service.

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Aoyagi, Y., Ohashi, M., Funahashi, R., Otaka, Y. and Saitoh, E., 2020. Oropharyngeal Dysphagia and Aspiration Pneumonia Following Coronavirus Disease 2019: A Case Report. Dysphagia, pp.1-4.

Cranial nerve involvement is a finding often observed in patients infected with severe acute respiratory syndrome. To our knowledge, this is the first report of oropharyngeal dysphagia associated with COVID-19.

A 70-year-old male developed dysphagia and consequent aspiration pneumonia during recovery from severe COVID-19. He had altered sense of taste and absent gag reflex. Videoendoscopy, videofluorography, and high-resolution manometry revealed impaired pharyngolaryngeal sensation, silent aspiration, and mesopharyngeal contractile dysfunction. These findings suggested that glossopharyngeal and vagal neuropathy might have elicited dysphagia following COVID-19. The current case emphasizes the importance of presuming neurologic involvement and concurrent dysphagia, and that subsequent aspiration pneumonia might be overlooked in severe respiratory infection during COVID-19.

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Julie Regan, Margaret Walshe, Sarah Lavan, et al. Post-Extubation Dysphagia and Dysphonia amongst Adults with COVID-19 in the Republic of Ireland: a Prospective Multi-Site Observational Cohort Study. Authorea. March 22, 2021.

This study aimed to:

(i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020;

(ii) identify variables predictive of post-extubation oral intake status and dysphonia

(iii) establish SLT rehabilitation needs and services provided to this cohort.

Key Points

1. Post-extubation dysphagia and dysphonia are multifactorial and can lead to prolonged ICU stay, prolonged tube feeding, aspiration pneumonia and increased morbidity and mortality.
2. In this multi-site prospective cohort study across eleven acute hospitals, 90% of adults required an altered oral diet post-extubation and 36% were unable for any oral intake based on SLT evaluation. Sixty-six percent presented with post-extubation dysphonia.
3. Age, proning and pre-existing respiratory disease were predictors of post-extubation oral intake status, whereas intubation injury and pre-existing respiratory disease were predictors of post-extubation dysphonia.
4. Over a third (37%) required dysphagia rehabilitation post-extubation whereas 20% needed voice rehabilitation.
5. Dysphagia and dysphonia persisted in 27% and 37% cases respectively at hospital discharge, indicating that SLTs should be included in outpatient multidisciplinary COVID clinics in the community.

Access the paper here

Dawson, C., Capewell, R., Ellis, S., Matthews, S., Adamson, S., Wood, M., … & Pracy, P. (2020). Dysphagia presentation and management following coronavirus disease 2019: an acute care tertiary centre experience. The Journal of Laryngology & Otology, 1-13.

This paper describes dysphagia as a sequela of of COVID-19, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.

The paper concludes that dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with COVID-19 Including therapeutic respiratory weaning for those with a tracheostomy.

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Ku, P. K., Holsinger, F. C., Chan, J. Y., Yeung, Z. W., Chan, B. Y., Tong, M. C., & Starmer, H. M. (2020). Management of dysphagia in the patient with head and neck cancer during COVID‐19 pandemic: Practical strategy. Head & Neck.

Despite significant limitations in clinical service provision during the pandemic of COVID‐19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.

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Feldstein, L. R., Rose, E. B., Horwitz, S. M., Collins, J. P., Newhams, M. M., Son, M. B. F., … & Singh, A. R. (2020). Multisystem inflammatory syndrome in US children and adolescents. New England Journal of Medicine, 383(4), 334-346.

Understanding the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C) and its temporal association with coronavirus disease 2019 (Covid-19) is important, given the clinical and public health implications of the syndrome.

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