Introduction
Many patients who underwent prolonged intubation [1] develop dysphagia after extubation, with an occurrence varying between 3% and 62%. The prevalence of swallowing disorders increases as the intubation period is extended [2]. Dysphagia predisposes to prolonged hospitalizations and to a worse prognosis due to the high risk of complications such as aspiration pneumonia, malnutrition and dehydration. The origin of post-intubation dysphagia derives from several factors: the endotracheal tube can cause trauma at pharynx or larynx [1] and can generate muscle atrophy due to disuse, aggravated by long sedation and the use of neuromuscular blockers. Such disuse of the swallowing mechanism may diminish its cortical representation and delay functional recovery in the long term. To these factors can be added changes in sensitivity, gastroesophageal reflux and breath-swallowing incoordination [3]. Recovery after post-intubation dysphagia is usually possible in a short period of time [2]. In patients with Acute Respiratory Distress Syndrome (ARDS), however, swallowing improvement appears slower, even longer than 6 months. The reason may lie in the severity of the pathology that often requires prolonged mechanical ventilation and long stays in intensive care unit.
A recent case-control study compared the trend of swallowing disorders after endotracheal tube removal in 101 Covid-19 patients and in 150 non-Covid-19 patients undergoing prolonged intubation. Although Covid-19 patients were intubated longer, they showed less swallowing disorders after extubation and required fewer re-education sessions [4]. However, there is no data about the incidence of dysphagia in these patients also owing to the reduction of diagnostic procedures such as Fiberoptic Endoscopic Evaluation of Swallowing (FEES) during Covid-19 pandemic because of the aerosol generating risk [5]. In May 2020 the first case report on oropharyngeal dysphagia associated with Sars-CoV-2 was published: the patient, a 70-year-old man, after an 11-day intubation developed dysphagia and a subsequent aspiration pneumonia. The instrumental evaluations evidenced bilateral absent GAG reflex, pyriform and vallecular salivary stagnation and silent aspiration. The patient received rehabilitative treatment with noticeable improvement of symptoms, without the need for nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG) positioning. The authors hypothesized the presence of a glossofaringeal and vagal neuropathy underlying the development of dysphagia [6]. Another newest Italian case report highlighted the possible involvement of the cranial nerves in dysphagia development during Covid-19 [7].
The purpose of the present case report is to describe the clinical history and the rehabilitation of a patient coming from Bergamo, Italy. Patient’s informed consent was obtained for data treatment.