European Journal of Neurology ( IF 4.5 ) Pub Date : 2020-05-27 , DOI: 10.1111/ene.14367 R Dziewas 1 , T Warnecke 1 , P Zürcher 2 , J C Schefold 2
We read with great interest the article ‘COVID‐19: what if the brain had a role in causing the deaths?’ by Tassorelli and co‐workers, in which the authors generate and summarize hypotheses as to how severe acute respiratory syndrome coronavirus‐2 may enter the peripheral and central nervous system and cause life‐threatening complications [1]. With this letter, we would like to contribute to this discussion by highlighting how different complications of COVID‐19 may result in damage to central and peripheral parts of the swallowing network leading to dysphagia in critically ill COVID‐19 survivors.
As demonstrated by a recent survey, dysphagia is a key concern in intensive care units (ICUs) [2]. According to the DYnAMICS trial, dysphagia affects more than 10% of patients after extubation, about half of whom remain dysphagic on hospital discharge [3]. Importantly, in this study, the incidence of dysphagia was even higher in specific subgroups, in particular in emergency admissions (18.3%) and in patients with acute neurological conditions, and was independently associated with overall disease severity and with increased length of mechanical ventilation (MV). Dysphagia in the critically ill has been identified as a key predictor of pneumonia, extubation failure, need for tracheostomy and prolonged MV, increased length of stay and overall adverse outcome and mortality [4].
The coronavirus disease 2019 (COVID‐19) pandemic is spreading worldwide with more than 3 million cases to date and growing numbers of ICU admissions. According to recent publications, around 5% of patients require ICU treatment with a high proportion in need of prolonged MV due to acute respiratory distress syndrome and vasopressor treatment for septic shock [5]. In addition to these conditions, which were identified as key risk factors for the development of critical illness polyneuropathy and myopathy, other neurological complications such as stroke, encephalitis, skeletal muscle injury and Guillain–Barré syndrome have also been reported in COVID‐19 [6].
The act of swallowing is coordinated and executed by a widely distributed network that incorporates cortical, subcortical and brainstem structures as well as downstream peripheral nerves and muscles. As summarized in Fig. 1, all mentioned complications of COVID‐19 target this network at different levels and critically ill patients are therefore prone to dysphagia. Although this goes unnoticed and is of less relevance during the period of MV, dysphagia and related complications enter the scene when patients have been extubated or, in case of previous tracheostomy, the question of possible decannulation arises after successful weaning from MV. At this critical juncture, careful assessment of safety and efficacy of swallowing including management of pharyngeal secretions seems of utmost importance in COVID‐19 survivors, as these patients are, due to the severity of lung disease, particularly prone to suffering from respiratory complications subsequent to tracheal aspiration.
The diagnostic workup in this context usually comprises an aspiration screening (e.g. water swallow test as implemented in the Bernese ICU Dysphagia Algorithm [4]) and, in case of screening abnormalities, a full dysphagia assessment, including, where appropriate, instrumental testing with fiberoptic endoscopic evaluation of swallowing [4]. Importantly, the respective diagnostic steps are likely aerosol‐generating procedures, as patients, in particular those with severe dysphagia and aspiration, regularly cough during these tests. Because of the involved risks of virus transmission through aerosol emissions, dysphagia experts should wear appropriate personal protective equipment when approaching patients with COVID‐19. Subsequent to the initial dysphagia assessment and implementation of first therapeutic interventions like dietary modifications and simple compensatory maneuvers, more refined treatments should be decided on a case‐by‐case basis with the option to postpone these until the patient has tested negative.
Disclosure of conflicts of interest
R.D. and T.W. declare no financial or other conflicts of interest. P.Z. reports (full departmental disclosure) grants from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestlé, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lily and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien and Nycomed outside the submitted work. J.C.S. reports (full departmental disclosure) grants from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestlé, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lily and Company, Baxter, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien and Nycomed outside the submitted work.
References中文翻译：
COVID-19 中的吞咽困难 - 对吞咽网络的多级损害？
我们非常感兴趣地阅读了文章“COVID-19：如果大脑在导致死亡中发挥了作用怎么办？” 由 Tassorelli 及其同事撰写，其中作者提出并总结了关于严重急性呼吸综合征冠状病毒-2 可能如何进入外周和中枢神经系统并导致危及生命的并发症的假设 [ 1 ]。在这封信中，我们希望通过强调 COVID-19 的不同并发症如何导致吞咽网络的中央和外围部分受损，从而导致危重 COVID-19 幸存者吞咽困难，从而为这一讨论做出贡献。
正如最近的一项调查所表明的，吞咽困难是重症监护病房 (ICU) [ 2 ] 的一个关键问题。根据 DYnMICS 试验，超过 10% 的患者在拔管后出现吞咽困难，其中约一半的患者在出院时仍存在吞咽困难 [ 3 ]。重要的是，在这项研究中，吞咽困难的发生率在特定亚组中甚至更高，特别是在急诊入院（18.3%）和急性神经系统疾病患者中，并且与整体疾病严重程度和机械通气时间增加独立相关。 MV）。重症患者吞咽困难已被确定为肺炎、拔管失败、需要气管切开术和延长 MV、住院时间延长以及总体不良结果和死亡率的关键预测因素。4 ]。
2019 年冠状病毒病 (COVID‐19) 大流行正在全球蔓延，迄今已有超过 300 万例病例，入住 ICU 的人数不断增加。根据最近的出版物，大约 5% 的患者需要 ICU 治疗，其中高比例的患者因急性呼吸窘迫综合征而需要延长 MV 和感染性休克的升压药治疗 [ 5 ]。除了这些被确定为重症多发性神经病和肌病发展的关键风险因素的疾病之外，COVID-19 还报告了其他神经系统并发症，如中风、脑炎、骨骼肌损伤和格林-巴利综合征 [ 6 ]。
吞咽动作由一个广泛分布的网络协调和执行，该网络包含皮质、皮质下和脑干结构以及下游的周围神经和肌肉。如图 1 所示，所有提到的 COVID-19 并发症均针对不同水平的该网络，因此重症患者容易出现吞咽困难。尽管这在 MV 期间没有引起注意并且相关性较小，但当患者拔管时，吞咽困难和相关并发症会出现，或者在先前的气管切开术的情况下，在成功脱离 MV 后会出现可能拔管的问题。在这个关键时刻，仔细评估吞咽的安全性和有效性，包括管理咽分泌物似乎对 COVID-19 幸存者至关重要，因为这些患者是，
在这种情况下，诊断检查通常包括抽吸筛查（例如，在伯尔尼 ICU 吞咽困难算法 [ 4 ] 中实施的吞水测试），以及在筛查异常的情况下，全面的吞咽困难评估，包括在适当情况下使用光纤进行仪器测试吞咽的内镜评估 [ 4]。重要的是，相应的诊断步骤可能会产生气溶胶，因为患者，特别是有严重吞咽困难和误吸的患者，在这些测试期间经常咳嗽。由于涉及通过气溶胶排放传播病毒的风险，吞咽困难专家在接近 COVID-19 患者时应穿戴适当的个人防护设备。在最初的吞咽困难评估和实施第一个治疗干预措施（如饮食调整和简单的代偿性动作）之后，应根据具体情况决定更精细的治疗方法，并可选择将这些治疗推迟到患者检测结果为阴性。
披露利益冲突
RD 和 TW 声明没有财务或其他利益冲突。PZ 报告（全部门披露）来自 Orion Pharma、Abbott Nutrition International、B. Braun Medical AG、CSEM AG、Edwards Lifesciences Services GmbH、Kenta Biotech Ltd、Maquet Critical Care AB、Omnicare Clinical Research AG、雀巢、Pierre Fabre Pharma AG 的赠款, 辉瑞, Bard Medica SA, Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lily and Company、Baxter、Astellas、Astra Zeneca、CSL Behring、Novartis、Covidien 和 Nycomed 在提交的作品之外。JCS 报告（全部门披露）来自 Orion Pharma、Abbott Nutrition International、B. Braun Medical AG、CSEM AG、
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