Speech-Language InstituteIn continuation of Better Hearing and Speech Month (BHSM), an annual nationwide campaign aimed to raise awareness about communication disorders, and in light of the ongoing coronavirus outbreak, Kelly Salmon, SLPD, CCC-SLP, BCS-S, CLT-LANA, assistant professor in the University’s Speech-Language Pathology (SLP) program, explains the role of an SLP in the rehabilitation of coronavirus patients after prolonged ventilator use. 
 
The Q&A is based on a recent CBS report, “Coronavirus Patient’s Fight Doesn’t End After Getting Off a Ventilator, Speech Pathologists Say.” Click here to watch the video
 
Q: Can you explain the process of being placed on a ventilator?
A: 
The vocal folds (also referred to as the vocal cords) are the key muscles involved in the production of voice and play an important role in protecting the airway and lungs. However, they can be sensitive to injury during the process of being placed on a ventilator. In order to be placed on a ventilator, a tube called an endotracheal tube, commonly referred to as a breathing tube, needs to be passed from the mouth, into the throat, and between the vocal folds to be positioned within the trachea (windpipe). The ventilator is then attached to the tube to assist the individual with breathing. Injury to the vocal folds can occur during this process, known as intubation, or injury can occur over time as the tube remains in place for days or sometimes weeks at a time. 
 
Q: For someone who has never been on a ventilator, what’s it like? 
A: 
Typically, when an individual is intubated and on a ventilator, they are sedated or placed in a medically-induced coma to allow the body to rest and work toward recovery. When intubated and on a ventilator, an individual is typically confined to their hospital bed and unable to get up and move around. Because there is a tube that is placed within their mouth, throat and airway, they are not able to use their voice or speech to communicate. They are also not able to eat or drink when the breathing tube is in place. Generally, because the person is sedated and on multiple medications to try and improve their medical condition, they are not experiencing discomfort or pain with the tube in place. 
 
Q: In terms of speech, language and communication, what types of challenges are recovered coronavirus patients experiencing after prolonged ventilator use?
A: 
The most common difficulties experienced after being on a ventilator for a prolonged period of time are difficulties with breathing (usually fatiguing quickly), using the voice, trouble swallowing and trouble with thinking and memory. Typically, the longer that a person is on a ventilator, the weaker the muscles used to speak and swallow become over time because they are not being used. As a result, if there is weakness or injury to the vocal folds, an individual may have a weak, “breathy” or “hoarse (rough)” voice quality. They may also experience difficulty with swallowing because the muscles of the throat that are involved in this process have weakened. In addition, newer information speaks to difficulties with thinking processes as a result of battling the coronavirus. There has been speculation that the virus may also have an impact on the brain itself. Therefore, some individuals experience confusion, disorientation or trouble with thinking or memory following their battle with the virus. Voice, swallowing and cognition are all areas that a SLP would be called upon to rehabilitate among individuals experiencing these effects of COVID-19. 
 
Q: The story mentions that SLPs are finding it necessary to use a new type of rehabilitation to help patients regain essential functions. What factors caused by COVID-19 are influencing the need for a new rehabilitation approach and can you explain any new approaches?
A: 
I think the SLPs mentioned in this story were referring to finding creative ways to address the needs of individuals with COVID-19 in an environment where our resources, such as personal protective equipment (PPE), are limited. In most cases, the number of healthcare team members allowed in the patient’s room to provide care is also limited. This has led to the use of technology, like tablets and other teleconference technologies to be used to assist with evaluation of the patient. For example, the nurse may be the only person entering the patient’s room during a shift. If the patient requires evaluation of their swallowing function to determine whether they are able to safely eat and drink, the nurse may take the tablet or conferencing platform into the patient’s room while the SLP remains outside, instructing the patient and nurse on the activities necessary to complete a swallowing examination. 
 
Q: According to the story, strained for resources due to the outbreak, SLPs have to rely on clinical exams versus more precise testing. What does that mean for coronavirus patients and can you give any examples of the methods being used versus typical treatment?
A: 
SLPs usually have many tools available to them to get a clear picture of what is happening with the structures of the mouth and throat, including the vocal folds. These tools include use of instrumental examinations, such as endoscopic techniques (passing a small tube containing a camera through the nose and into the throat) and video X-rays to evaluate the structures involved in speaking and swallowing. Given the unique characteristics of the coronavirus, many endoscopic procedures have been put on hold and the use of video X-ray is a resource that is much less available given the additional precautions needed for COVID-19 patients, availability of PPE and prioritization of critical procedures. As a result, SLPs are instead relying on their clinical skills to evaluate voice and swallowing. This means that we are evaluating patients without the assistance of technology. We have patients complete various tasks and use our interviewing skills as well as our visual and listening skills to evaluate an individual’s voice and swallow function. It is well established that clinical assessment and instrumental assessment need to go hand-in-hand in order to make the most accurate assessment and to develop the best treatment plan; however, at this time, we are relying much more heavily on our clinical skills to develop treatment plans for our patients until we are able to resume instrumental testing. In general, I think the use of telehealth technologies and a high degree of collaboration amongst all of the healthcare team members are the two biggest approaches that have moved to the forefront during this time.
 
Q: The story mentions the challenges faced by the SLP community as well as opportunities. Can you explain what type of opportunities this presents for not only the SLP community-at-large, but also the University's SLP community, in terms of being in an academic setting and educating SLP students?
A: First and foremost, this crisis has demonstrated the importance of SLPs as an integral part of the multidisciplinary team caring for individuals with COVID-19. Opportunities to find creative ways to serve our patients at this time have also presented themselves. Telehealth has become a priority across the board – from hospitals to outpatient and university clinics, private practices and school systems. 
 
The Speech-Language Institute (SLI) here at Salus has been quick to upgrade our telehealth infrastructure to allow us to continue to serve our pediatric and adult clients during this upcoming summer semester. The entire team has rallied to work on training to become proficient in the use of telehealth technology to provide services to our clients and supervision and guidance to our student clinicians. Rehabilitation and education specialists, like SLPs, are known for being creative, flexible and able to adapt to changing situations and environments. I think that the therapy landscape will be changed for many years to come, with patients and families actively seeking opportunities to engage in teletherapy. We are in an excellent position to provide these services through the SLI.  
 
As far as teaching, there has definitely been a period of adjustment since transitioning from classroom to online instruction. Both faculty and students have had to work hard to find the right balance between “live” and recorded class meetings. In my opinion, we have done an excellent job in maintaining our faculty-student-clinical educator connections despite the distance between us. I think that there will be long-lasting changes to the institutions of healthcare and education that will influence the way that we practice as SLPs. I look forward to working with the students and my fellow colleagues at Salus to find creative and innovative solutions to the many clinical and professional challenges that we are likely to face in the years to come!