Successful treatment of intubation-induced severe neurogenic post-extubation dysphagia using pharyngeal electrical stimulation in a COVID-19 survivor: a case report

Abstract

Background: A significant portion of critically ill patients with coronavirus disease 2019 (COVID-19) are at high risk of developing intensive care unit (ICU)-acquired swallowing dysfunction (neurogenic dysphagia) as a consequence of requiring prolonged mechanical ventilation. Pharyngeal electrical stimulation (PES) is a simple and safe treatment for neurogenic dysphagia. It has been shown that PES can restore safe swallowing in orally intubated or tracheotomized ICU patients with neurogenic dysphagia following severe stroke. We report the case of a patient with severe neurogenic post-extubation dysphagia (PED) due to prolonged intubation and severe general muscle weakness related to COVID-19, which was successfully treated using PES.

Case presentation: A 71-year-old Caucasian female patient with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection developed neurogenic dysphagia following prolonged intubation in the ICU. To avoid aerosol-generating procedures, her swallowing function was evaluated non-instrumentally as recommended by recently published international guidelines in response to the COVID-19 pandemic. Her swallowing function was markedly impaired and PES therapy was recommended. PES led to a rapid improvement of the PED, as evaluated by bedside swallowing assessments using the Gugging Swallowing Screen (GUSS) and Dysphagia Severity Rating Scale (DSRS), and diet screening using the Functional Oral Intake Scale (FOIS). The improved swallowing, as reflected by these measures, allowed this patient to transfer from the ICU to a non-intensive medical department 5 days after completing PES treatment.

Conclusions: PES treatment contributed to the restoration of a safe swallowing function in this critically ill patient with COVID-19 and ICU-acquired swallowing dysfunction. Early clinical bedside swallowing assessment and dysphagia intervention in COVID-19 patients is crucial to optimize their full recovery. PES may contribute to a safe and earlier ICU discharge of patients with ICU-acquired swallowing dysfunction. Earlier ICU discharge and reduced rates of re-intubation following PES can help alleviate some of the pressure on ICU bed capacity, which is critical in times of a health emergency such as the ongoing COVID-19 pandemic.

Keywords: COVID-19 infection; Case report; Intensive care unit (ICU); Pharyngeal electrical stimulation (PES); Post-extubation dysphagia (PED).

Fig. 1

Description of Phagenyx^® system, a medical device comprising a base station with a touch screen user interface (a) and a sterile single-patient-use catheter (b) that can be used to deliver nutrition and hydration for up to 30 days after insertion

Fig. 2

Schematic timeline of events from hospital admission until recovery after PES treatment. BT body temperature (°C), HI Horowitz oxygenation index, HR heart rate (beats per minute), BP blood pressure (mean, mmHg), SpO₂ oxygen saturation (%)

Fig. 3

Gugging Swallowing Screen (GUSS) dysphagia assessments. A 20-point GUSS scale determining the dysphagia severity and the risk of aspiration (20 being the best score: no dysphagia and minimal aspiration risk) was used at baseline, day 4, day 7, and day 22 following the final PES treatment session

Fig. 4

Dysphagia Severity Rating Scale (DSRS) dysphagia assessments. A 12-point DSRS scale grading dysphagia severity based on fluid and diet modification, as well as supervision requirements for feeding (12 being the worst score: no oral fluids or feeding, even under supervision), was used at baseline, day 4, day 7, and day 22 following the final PES treatment session

Fig. 5

Functional Oral Intake Scale (FOIS) dysphagia assessments. A 7-point FOIS scale reflecting food and liquids intake by mouth on a consistent basis (7 being the best score: normal oral intake without any restrictions) was used at baseline, day 4, day 7, and day 22 following the final PES treatment session