\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[greek,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Post-Extubation Dysphagia and Dysphonia amongst Adults with COVID-19 in
the Republic of Ireland: a Prospective Multi-Site Observational Cohort
Study}



\author[1]{Julie Regan}%
\author[1]{Margaret Walshe}%
\author[2]{Sarah Lavan}%
\author[3]{Eanna Horan}%
\author[4]{Patricia Gillivan-Murphy}%
\author[5]{Anne Healy}%
\author[6]{Caoimhe Langan}%
\author[7]{Karen Malherbe}%
\author[8]{Breda Flynn Murphy}%
\author[9]{Maria Cremin}%
\author[10]{Denise Hilton}%
\author[11]{Jenni Cavaliere}%
\author[12]{Alice Whyte}%
\affil[1]{Trinity College Dublin}%
\affil[2]{St. James' Hospital}%
\affil[3]{Tallaght University Hospital}%
\affil[4]{Mater Misericordiae University Hospital}%
\affil[5]{Beaumont Hospital}%
\affil[6]{St Vincent's University Hospital}%
\affil[7]{Galway University Hospital}%
\affil[8]{Midland Regional Hospital Portlaoise}%
\affil[9]{University Hospital Kerry}%
\affil[10]{Cavan General Hospital}%
\affil[11]{University Hospital Waterford}%
\affil[12]{Naas General Hospital}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: This study aims 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
and (iii) establish SLT rehabilitation needs and services provided to
this cohort. Design: A multi-site prospective observational cohort study
Participants: 100 adults with confirmed COVID-19 who were intubated
across eleven acute hospital sites in ROI and who were referred to SLT
services between March and June 2020 inclusive. Main Outcome Measures:
Oral intake status, level of diet modification and perceptual voice
quality. Results: Based on initial SLT assessment, 90\% required altered
oral intake and 59\% required tube feeding with 36\% unable for oral
intake. Age (OR 1.064; 95\% CI 1.018-1.112), proning (OR 3.671; 95\% CI
1.128-11.943), and pre-existing respiratory disease (OR 5.863; 95\% CI
1.521-11.599) were predictors of oral intake status post-extubation.
Two-thirds (66\%) presented with dysphonia post-extubation. Intubation
injury (OR 10.471; 95\% CI 1.060-103.466) and pre-existing respiratory
disease (OR 24.196; 95\% CI 1.609-363.78) were predictors of
post-extubation voice quality. Thirty-seven percent required dysphagia
rehabilitation post-extubation whereas 20\% needed voice rehabilitation.
Dysphagia and dysphonia persisted in 27\% and 37\% cases respectively at
hospital discharge. Discussion: Post-extubation dysphagia and dysphonia
were prevalent amongst adults with COVID-19 across the ROI. Predictors
included iatrogenic factors and underlying respiratory disease. Prompt
evaluation and intervention is needed to minimise complications and
inform rehabilitation planning.%
\end{abstract}%



\sloppy


\textbf{Short running title:} Post-extubation dysphonia and dysphagia in
COVID-19

\textbf{Post-Extubation Dysphagia and Dysphonia amongst Adults with
COVID-19 in the Republic of Ireland: a Prospective Multi-Site
Observational Cohort Study}

\textbf{Disclosure statement:} Authors have no disclosures to report

\textbf{Conflicts of interest:} None

\textbf{Eight key words:} COVID-19; intubation; post-extubation;
dysphagia; swallowing; voice; dysphonia; speech and language therapy

\textbf{Abstract}

\textbf{Objectives:} This study aims 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 and (iii) establish SLT rehabilitation needs and
services provided to this cohort.

\textbf{Design:} A multi-site prospective observational cohort study

\textbf{Participants:} 100 adults with confirmed COVID-19 who were
intubated across eleven acute hospital sites in ROI and who were
referred to SLT services between March and June 2020 inclusive.

\textbf{Main Outcome Measures:} Oral intake status, level of diet
modification and perceptual voice quality.

\textbf{Results:} Based on initial SLT assessment, 90\% required altered
oral intake and 59\% required tube feeding with 36\% unable for oral
intake. Age (OR 1.064; 95\% CI 1.018-1.112), proning (OR 3.671; 95\% CI
1.128-11.943), and pre-existing respiratory disease (OR 5.863; 95\% CI
1.521-11.599) were predictors of oral intake status post-extubation.
Two-thirds (66\%) presented with dysphonia post-extubation. Intubation
injury (OR 10.471; 95\% CI 1.060-103.466) and pre-existing respiratory
disease (OR 24.196; 95\% CI 1.609-363.78) were predictors of
post-extubation voice quality. Thirty-seven percent required dysphagia
rehabilitation post-extubation whereas 20\% needed voice rehabilitation.
Dysphagia and dysphonia persisted in 27\% and 37\% cases respectively at
hospital discharge.

\textbf{Discussion:} Post-extubation dysphagia and dysphonia were
prevalent amongst adults with COVID-19 across the ROI. Predictors
included iatrogenic factors and underlying respiratory disease. Prompt
evaluation and intervention is needed to minimise complications and
inform rehabilitation planning.

\textbf{Key Points}

\begin{enumerate}
\tightlist
\item
  Post-extubation dysphagia and dysphonia are multifactorial and can
  lead to prolonged ICU stay, prolonged tube feeding, aspiration
  pneumonia and increased morbidity and mortality.
\item
  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.
\item
  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.
\item
  Over a third (37\%) required dysphagia rehabilitation post-extubation
  whereas 20\% needed voice rehabilitation.
\item
  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.
\end{enumerate}

\textbf{Background}

The SARS-CoV-2 virus (termed COVID-19) is a novel respiratory virus,
which has led to an international pandemic. COVID-19 has resulted in an
unprecedented number of critically ill adults, which has overwhelmed
intensive care unit (ICU) services worldwide. Endotracheal intubation
and mechanical ventilation have been a central management procedure for
critically ill patients with COVID-19 in ICU settings.

Post-extubation dysphagia (PED) and dysphonia are common post-extubation
in critical care patients (1-4). Iatrogenic causes include prolonged
intubation (5) and intubation injury including laryngeal oedema,
granulations, ulceration and vocal cord immobility (6). Other potential
factors are delirium (7), proning (8), disuse atrophy and critical
illness neuropathy or myopathy during ICU stay (9) and neurological
manifestations of COVID-19 (10). Also, tracheostomy insertion can lead
to aspiration risk and difficulties managing secretions (3). PED is
associated with worse outcomes in ICU including aspiration pneumonia,
prolonged tube feeding, delayed initiation of oral intake, prolonged
hospitalisation, and increased morbidity and mortality (11, 12).

Dysphonia is another recognised complication of intubation reported
amongst adults with COVID-19 (3). Post-extubation dysphonia results from
vocal cord immobility, laryngopharyngeal reflux, granuloma, reduced
breath support for phonation and vocal cord fatigue. Endotracheal tube
(ETT) size (13) and cuff pressure during intubation (14) have been
identified as risk factors for post-extubation dysphonia. Age and
duration of intubation has also been linked with prolonged dysphonia
post-extubation in previous critical care research (15).

The impact of intubation as part of COVID-19 management on swallowing
and voice is unclear internationally, as are the dysphagia and dysphonia
rehabilitation needs within this population (16). This study aims to
characterise the presence and degree of post-extubation voice and
swallowing difficulties amongst adults requiring intubation as part of
medical management of COVID-19 in the Republic of Ireland (ROI) during
the first wave of the pandemic. Specific research objectives are to (i)
explore the presence, degree and trajectory of dysphonia and dysphagia
post-extubation in adults with COVID-19 across the ROI between March and
June 2020 inclusive; (ii) identify variables, which predict
post-extubation oral intake status and voice quality, and (iii)
determine SLT evaluation and rehabilitation indicated and provided to
this cohort.

\textbf{Methods}

\textbf{Study Design}

This multi-site prospective observational cohort study is reported
according to the STROBE guidelines for observational cohort studies
(17). Ethical approval for this study was obtained from National
Research Ethics Committee (NREC).

\textbf{Settings}

In this multi-centre observational cohort study, speech and language
therapists from eleven acute hospitals across Ireland participated.

\textbf{Participants}

All adults admitted into a participating acute hospital in the ROI with
COVID-19 and referred to SLT were included. Inclusion criteria were (i)
confirmed COVID-19 positive based on polymerase chain reaction (PCR)
test; (ii) intubated during inpatient stay as part of COVID-19
treatment; (iii) referred to SLT during hospital admission and (iv)
consent obtained. Exclusion criteria were (i) age 16 years or younger
(ii) unconfirmed COVID-19; (iii) no consent (iv) intubation for reasons
other than COVID-19.

\textbf{Independent Variables}

Demographic data included age, gender, pre-admission medical
comorbidities and premorbid swallow status. During hospital admission,
data on neurological manifestations of COVID-19 were captured. The
patient's most recent chest x-ray at time of initial SLT assessment was
rated using a validated five-point ordinal scoring system (18).

Intubation variables collated from healthcare records were grade of
intubation (1-4), number of endo-tracheal tubes (ETT) used, maximum ETT
cuff pressure during intubation, number of failed extubations and
presence of intubation injury. Data on proning and proning-related
injury were collected. Tracheostomy insertion, tracheostomy type and
size, time to decannulation were also included. Length of ICU stay
(LOSICU) and hospital length of stay (LOS) were recorded.

\textbf{Swallow and Voice Outcomes}

Swallowing and voice outcomes were influenced by curtailed access during
COVID-19 to instrumental assessments typically used in intensive care
settings such as fibreoptic endoscopic evaluation of swallowing (FEES).
Presence and severity of PED was measured using the Functional Oral
Intake Scale (FOIS) (19). The FOIS is a validated 7-point ordinal rating
scale with high inter-rater reliability (19). A second proxy dysphagia
measure was food and fluid consistencies required for dysphagia
management, using the International Dysphagia Diet Standardisation
Initiative (IDDSI) (20). Voice quality was evaluated using the overall
Grade (G) score from the GRBAS scale (21). The scale has established
high rater reliability (21) and is widely used in clinical research
(12).

\textbf{Data Sources/Management}

One nominated speech and language therapist from each hospital site was
responsible for data entry at each location. A dataset and dataset
dictionary were emailed to named speech and language therapists from
each participating site. Speech and language therapists were instructed
to populate the dataset prospectively and return the anonymised data to
the first authors for analysis.

\textbf{Bias}

To minimise observer bias, all clinicians used outcome measures
routinely used in clinical practice with established rater reliability.
Clear rules and procedures were in place for data collection and data
were clearly defined in a data dictionary provided to all settings.
Merged data was anonymised to researchers.

\textbf{Study Size}

Any patients who meet the eligibility criteria over the three-month data
collection period were included in the study. The study size was
determined by the prevalence of cases, and in particular those needing
respiratory support. In the event, 100 participants were recruited with
the precision in the statistical estimates illustrating the observed
power.

\textbf{Statistical Analysis}

Descriptive statistics were reported using medians and interquartile
range (IQR) for continuous data. Categorical variables were presented as
frequency (percentage). Variables were tested for normality using the
Shapiro-Wilks test. To establish associations between dependent and
independent variables, Spearman's rho correlations were conducted. To
determine the trajectory of dysphagia and dysphonia from initial SLT
assessment to SLT discharge, medians of ordinal dependent variables at
both time points were compared using two-tailed Wilcoxon signed rank
tests.

To determine independent predictors of oral intake status at time of
initial SLT assessment, a binary logistic regression was used. The
seven-point ordinal FOIS rating scale was divided into feeding tube
reliant (FOIS Levels 1-3) and not tube feeding reliant (FOIS Level 4-7)
categories as the binary dependent variable. To prevent over-fitting the
model, six independent variables were selected for oral intake status
(age, duration of intubation, proning, neurological manifestations,
maximum cuff pressure, history of respiratory disease).

For voice quality, an ordinal logistic regression was completed with the
overall (G) four-point ordinal GRBAS rating as the dependent variable.
Six independent variables were selected for the voice regression model
(intubation injury, proning, maximum cuff pressure, duration of
intubation, number of comorbidities, and history of respiratory
disease).

For both regression models, independent variables were selected based on
evidence from previous research and a visual review of the data. Where a
significant association was identified between independent variables
(e.g., duration of intubation and presence of tracheostomy), only one
was selected for a model. Mean imputation was made for one independent
variable (maximum cuff pressure) as it was missing 24/100 cases. Model
fits were confirmed using likelihood ratio chi- squared tests. A
two-sided \selectlanguage{greek}α \selectlanguage{english}of less than 0.05 was considered statistically significant.
Statistical analyses were completed using the SPSS (v26) software.

\textbf{Results}

\textbf{Participants}

Data from 100 adults with PCR test confirmed COVID-19 who were intubated
across eleven acute hospitals in ROI and referred to SLT between March
and June 2020 inclusive were included in analysis. The 100 adults (69\%
male) had a mean age of 62 years (age range 17-88 years). Further
demographic details are in Table 1.

\textbf{TABLE 1 HERE}

Median duration of intubation was 14 days (IQR 8-19.5). Data on grade of
intubation, number of ET tubes, maximum cuff pressure (76/100), number
of failed extubations, proning and tracheostomy are captured in Table 1.
Missing data for some of these variables was due to limited access to
data across clinical settings.

\textbf{TABLE 2 HERE}

\textbf{Presence, Severity and Trajectory of Swallowing and Voice
Outcomes Post-Extubation}

Median time between extubation and initial SLT evaluation was 4 days
(IQR 2-11 days). Ninety percent (n=90) of patients presented with
dysphagia (FOIS Level 1-6) at initial SLT assessment with 36\% unable to
take any nutrition orally (FOIS Level 1) (Table 3). Median FOIS score at
initial SLT assessment was 2.5 (SD 2.139; range 1-7) (n=100). IDDSI
fluid and food consistency findings are detailed in Table 3. A
significant negative correlation was observed between oral intake status
at initial SLT assessment as rated by the FOIS and ICULOS (r=-.227;
p=0.028) and also between oral intake status and hospital LOS,
indicating that the lower the FOIS score, the longer the LOS (r=-.363;
p=0.000).

Two-thirds (66\%; n=99) of participants presented with post-extubation
dysphonia (GRBAS 1/+) with 14\% in severe (rating 3) category (Table 3).
A weak positive association was detected between GRBAS rating and LOS
(r=.235; p=022), indicating that the higher the GRBAS score (poor vocal
quality), the longer the hospital LOS. Voice quality was not associated
with ICULOS (r=.084; p=0.428).

Oral intake status (median FOIS score) altered significantly from
initial SLT assessment (FOIS score 2.5) to time of SLT discharge (median
FOIS score 7) (z=-7.322; p=0.000). A significant change was also
observed in IDDSI fluid (z=-6.023; p=0.000) and food (z=-7.52; p=0.000)
consistencies within the participant group from initial assessment to
discharge (Table 3).

\textbf{Table 3 here}

Median voice quality rating also altered significantly from initial SLT
assessment (GRBAS score 1) to SLT discharge (GRBAS score 0) (z=-5.619;
p=0.000). Details regarding alteration in swallow and voice outcomes are
in Table 3.

\textbf{Variables Predicting Dysphagia and Dysphonia at Initial SLT
Assessment}

\textbf{Table 4 here}

In a multivariate model, statistically significant predictors of
post-extubation oral intake status included age (OR 1.064; 95\% CI
1.018-1.112; p=0.006), proning (OR 3.671; 95\% CI 1.128-11.943; p=.031),
and history of respiratory disease (OR 5.863; 95\% CI 1.521-22.599;
p=.010) (Table 4).

\textbf{Table 5 here}

In a multivariate model, statistically significant predictors of
post-extubation voice quality were intubation injury (OR 10.471; CI
1.060-103.466; p=.044) and history of respiratory disease (OR 24.196;
95\% CI 1.609-363.78; p=.021) (Table 5).

\textbf{SLT Rehabilitation Needs and Services Provided}

Over a third (n=37/100) of patients required dysphagia rehabilitation
post-extubation (Table 6). In 70\% (26/37) of these cases, dysphagia
rehabilitation was implemented, although 19\% (7/37) had it provided in
adapted form due to infection risk related to the pandemic. In 11\%
(4/37) of cases, dysphagia rehabilitation was indicated but could not be
provided at point of service delivery due to the pandemic service
constraints. A fifth (20\%; n=20/100) of participants required voice
rehabilitation post-extubation. Within this subgroup, 55\% (11/20)
received standard voice rehabilitation and 15\% (3/20) received it in
adapted form (Table 6). In 30\% (6/20) cases, voice rehabilitation was
indicated but could not be implemented also due to pandemic service
constraints.

\textbf{Table 6 here}

\textbf{Discussion}

In this study, 90\% of patients intubated as part of COVID-19 management
across the ROI who were referred to SLT presented with new onset PED
based on oral intake status. Over half (59\%) required tube feeding
based on SLT assessment and over a third were unable for any nutrition
orally post-extubation. This high rate of PED compares with recent
research (3, 4). Post-extubation oral intake status was associated with
length of ICU stay and hospital stay duration in this study.

There was a threefold increase in impact on oral intake status with
proning in this study. Lower cranial nerve paralysis and oropharyngeal
oedema have previously been linked to proning, and cranial nerves IX to
XII are hypothesised to be affected by proning (7, 23). Pre-existing
respiratory disease was also identified as a predictor of PED in this
study. Adults with respiratory disease may already have altered
respiratory swallow coordination, which could be exacerbated
post-extubation. There was approximately a 6\% increase in the relative
odds of oral intake status change per year of age in this study. Older
people may have a pre-existing presbyphagia, which pre-disposes them to
PED. Furthermore, frailty and sarcopaenia may also be prevalent amongst
older people, which could contribute towards PED. In contrast to
previous research (5), duration of intubation was not predictive of oral
intake status in this study. This may be due to the fact that patients
with tracheostomy were not excluded in this study, as researchers aimed
to capture all adults with COVID-19 post extubation. Additionally,
prolonged intubation duration with COVID-19 may explain contrasting
findings to previous PED research.

There was a tenfold increase in impact on voice quality for those with
intubation injury, which aligns with previous research (15). This
highlights the importance of post-extubation endoscopy to evaluate vocal
cord function in the ICU setting. Those with a history of respiratory
disease were at threefold risk of impact on voice quality. Dysphonia is
prevalent in adults with COPD which is due, in part, to altered
pulmonary function (24). This alteration may be exacerbated
post-extubation, which may negatively impact on voice. In contrast to
previous research (14), endotracheal cuff pressure was not associated
with post-extubation dysphonia in this study.

The number of adults receiving SLT rehabilitation during hospital stay
appeared low in this study and some adults did not receive dysphagia and
dysphonia intervention when indicated. Concerns regarding aerosol
generated procedures as well as lack of instrumental evaluations may
have influenced the amount and type of intervention being offered during
the first pandemic wave (16). Other influencing factors may be access to
personal protective equipment, SLT services in ICU settings across ROI,
and local dysphagia training.

The rates of persistent dysphagia and dysphonia at hospital discharge
mirrors previous COVID-19 research (3, 4). These subgroups may require
long term rehabilitation due to ICU acquired weakness, post-intensive
care syndrome (PICU) or neurological deficits. These figures are clear
evidence that speech and language therapists should be core members of
outpatient multidisciplinary COVID-19 clinics.

Limitations to this study included missing data on oral health,
delirium, grade of intubation and endotracheal tube size. Missing data
was particularly difficult to access from intensive care records due to
transmission risk. Patient reported outcomes would have been beneficial
but not feasible post-extubation given how medically unwell this cohort
were. Validated scales to measure frailty and sarcopaenia amongst adults
intubated may have been useful but again this was not feasible in the
context of this study.

FEES was not available in ICU settings during the first wave of the
pandemic due to concerns regarding transmission risk (16). FEES provides
physiological data on secretions, pharyngeal sensation and aspiration or
residue. However, it could be argued that oral intake is a more
meaningful outcome from the patient perspective. Nevertheless,
endoscopic assessment of intubation injury would be valuable to ensure
the presence and nature of laryngeal injuries are accurately identified
(25).

Post-extubation dysphonia and dysphagia research is needed from future
pandemic waves to establish the impact of evolving intensive care
management and mutating virus variants on voice and swallowing outcomes.
Post-discharge timepoints to capture longer term voice and swallowing
difficulties would guide multidisciplinary service delivery in the
community.

Conclusions

This study highlights the prevalence of post-extubation dysphagia and
dysphonia amongst adults intubated with COVID-19. Awareness of the
predictors of altered swallowing and voice quality post-extubation will
promote early in-depth evaluation and monitoring during hospital stay.
Prompt dysphagia and dysphonia evaluation and management is needed to
minimise clinical and quality of life complications.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Brodsky, M. B., Nollet, J. L., Spronk, P. E., \& Gonz\selectlanguage{ngerman}ález-Fernández,
  M. (2020). Prevalence, Pathophysiology, Diagnostic Modalities and
  Treatment Options for Dysphagia in Critically Ill
  Patients.~\emph{American Journal of Physical Medicine \&
  Rehabilitation} .
\item
  Hamdan, A. L., Sibai, A., Rameh, C., \& Kanazeh, G. (2007). Short-term
  effects of endotracheal intubation on voice.~\emph{Journal of Voice}
  ,~\emph{21} (6), 762-768.
\item
  Archer SK, Iezzi CM, Gilpin L, Swallowing and voice outcomes in
  patients hospitalised with COVID-19: An observational cohort study,
  ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2021) Brodsky, M.
  B., Gellar, J. E., Dinglas, V. D., Colantuoni, E., Mendez-Tellez, P.
  A., Shanholtz, C., \ldots{} \& Needham, D. M. (2014). Duration of oral
  endotracheal intubation is associated with dysphagia symptoms in acute
  lung injury patients.~\emph{Journal of critical care} ,~\emph{29} (4),
  574-579.
\item
  Dawson, C., Capewell, R., Ellis, S., Matthews, S., Adamson, S., Wood,
  M., \ldots{} \& Sharma, N. (2020). Dysphagia presentation and
  management following COVID-19: an acute care tertiary centre
  experience.\emph{The Journal of Laryngology \& Otology} , 1-6.
\item
  Brodsky, M. B., Levy, M. J., Jedlanek, E., Pandian, V., Blackford, B.,
  Price, C., \ldots{} \& Akst, L. M. (2018). Laryngeal injury and upper
  airway symptoms after oral endotracheal intubation with mechanical
  ventilation during critical care: a systematic review.~\emph{Critical
  care medicine} ,~\emph{46} (12), 2010.
\item
  O'Hanlon S, Inouye SK. Delirium: a missing piece in the COVID-19
  pandemic puzzle. Age and ageing. 2020 May 6.
\item
  Brugliera L, Filippi M, Del Carro U, Butera C, Bianchi F, Castellazzi
  P, Cimino P, Capodaglio P, Monti G, Mortini P, Pradotto LG. Nerve
  Compression Injuries After Prolonged Prone Position Ventilation in
  Patients With SARS-CoV-2: A Case Series. Archives of Physical Medicine
  and Rehabilitation. 2021 Jan 1.
\item
  Ponfick M, Linden R, Nowak DA. Dysphagia---a common, transient symptom
  in critical illness polyneuropathy: a fiberoptic endoscopic evaluation
  of swallowing study. Critical care medicine. 2015 Feb 1;43(2):365-72.
\item
  Dziewas, R., Warnecke, T., Zürcher, P., \& Schefold, J. C. (2020).
  Dysphagia in COVID\selectlanguage{english}-19--multilevel damage to the swallowing
  network?~\emph{European journal of neurology} .
\item
  McGrath BA, Brenner MJ, Warrillow SJ, Pandian V, Arora A, Cameron TS,
  Anon JM, Martinez GH, Truog RD, Block SD, Lui GC. Tracheostomy in the
  COVID-19 era: global and multidisciplinary guidance. The Lancet
  Respiratory Medicine. 2020 May 15.
\item
  Macht, M., King, C. J., Wimbish, T., Clark, B. J., Benson, A. B.,
  Burnham, E. L., \ldots{} \& Moss, M. (2013). Post-extubation dysphagia
  is associated with longer hospitalization in survivors of critical
  illness with neurologic impairment. \emph{Critical Care} ,\emph{17}
  (3), 1-9.
\item
  Brodsky, M. B., Huang, M., Shanholtz, C., Mendez-Tellez, P. A.,
  Palmer, J. B., Colantuoni, E., \& Needham, D. M. (2017). Recovery from
  dysphagia symptoms after oral endotracheal intubation in acute
  respiratory distress syndrome survivors. A 5-year longitudinal
  study.~\emph{Annals of the American Thoracic Society} ,~\emph{14} (3),
  376-383.
\item
  Krisciunas, G. P., Langmore, S. E., Gomez-Taborda, S., Fink, D.,
  Levitt, J. E., McKeehan, J., \ldots{} \& Vojnik, R. (2020). The
  Association Between Endotracheal Tube Size and Aspiration (During
  Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory
  Failure Survivors.~\emph{Critical Care Medicine} ,~\emph{48} (11),
  1604-1611.
\item
  SAMY, A., NEFISSA, A., \& AZZAM, A. E. A. (2018). Voice Disorders
  after Intubation: The Importance of Intra-Operative Monitoring and
  Controlling of Endo-Tracheal Tube Cuff Pressure in Reducing
  Intubation-Related Complications.~\emph{The Medical Journal of Cairo
  University} ,~\emph{86} (September), 2849-2860.
\item
  Yamanaka, H., Hayashi, Y., Watanabe, Y., Uematu, H., \& Mashimo, T.
  (2009). Prolonged hoarseness and arytenoid cartilage dislocation after
  tracheal intubation. \emph{British journal of anaesthesia} ,\emph{103}
  (3), 452-455.
\item
  Freeman-Sanderson A, Ward EC, Miles A, de Pedro Netto I, Duncan S,
  Inamoto Y, McRae J, Pillay N, Skoretz SA, Walshe M, Brodsky MB. A
  consensus statement for the management and rehabilitation of
  communication and swallowing function in the ICU: A global response to
  COVID-19. Archives of physical medicine and rehabilitation. 2020 Nov
  7.
\item
  Von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gotzsche, P. C.,
  Vandenbroucke, J. P., \& Strobe Initiative. (2014). The Strengthening
  the Reporting of Observational Studies in Epidemiology (STROBE)
  Statement: guidelines for reporting observational
  studies.\emph{International journal of surgery} , \emph{12} (12),
  1495-1499.
\item
  Taylor, E., Haven, K., Reed, P., Bissielo, A., Harvey, D., McArthur,
  C., \ldots{} \& Wilson, F. (2015). A chest radiograph scoring system
  in patients with severe acute respiratory infection: a validation
  study.~\emph{BMC medical imaging} ,~\emph{15} (1), 61.
\item
  Crary, M. A., Mann, G. D. C., \& Groher, M. E. (2005). Initial
  psychometric assessment of a functional oral intake scale for
  dysphagia in stroke patients. \emph{Archives of physical medicine and
  rehabilitation} , \emph{86} (8), 1516-1520.
\item
  Cichero, J. A., Lam, P., Steele, C. M., Hanson, B., Chen, J., Dantas,
  R. O., \ldots{} \& Stanschus, S. (2017). Development of international
  terminology and definitions for texture-modified foods and thickened
  fluids used in dysphagia management: the IDDSI
  framework.\emph{Dysphagia} , \emph{32} (2), 293-314.
\item
  Hirano M. Clinical examination of voice. New York: Springer Verlag,
  1981:81-4
\item
  Karnell, M. P., Melton, S. D., Childes, J. M., Coleman, T. C., Dailey,
  S. A., \& Hoffman, H. T. (2007). Reliability of clinician-based (GRBAS
  and CAPE-V) and patient-based (V-RQOL and IPVI) documentation of voice
  disorders. \emph{Journal of Voice} , \emph{21} (5), 576-590.
\item
  Le MQ, Rosales R, Shapiro LT, Huang LY. The Down Side of Prone
  Positioning: The Case of a COVID-19 Survivor. American Journal of
  Physical Medicine \& Rehabilitation. 2020 Jul 9.
\item
  Hassan MM, Hussein MT, Emam AM, Rashad UM, Rezk I. Is insufficient
  pulmonary air support the cause of dysphonia in chronic obstructive
  pulmonary disease? Auris Nasus Larynx. 2018 Aug 1;45(4):807-14.
\item
  Naunheim, M. R., Zhou, A. S., Puka, E., Franco Jr, R. A., Carroll, T.
  L., Teng, S. E., \ldots{} \& Song, P. C. Laryngeal complications of
  COVID\selectlanguage{english}-19.~\emph{Laryngoscope Investigative Otolaryngology} .
\end{enumerate}

\textbf{Table 1. Demographic Data}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
\textbf{Age}\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
Mean Range\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
62 years 17-88 years\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Males Females\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
69 males 31 females\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Source of admission}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Home Residential setting Transfer from other hospital Transfer from
rehab setting Unknown\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
81\% 2\% 14\% 1\% 2\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Co-morbidities}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
None Minimum one comorbidity: One comorbidity Two Three Four Five
Mean/median no of comorbidities: \emph{Medical comorbidities:}
Respiratory disease (COPD/other respiratory disease) Cardiology Stroke
Progressive neurological Dementia Mental health condition Head and neck
cancer Cancer outside of head and neck Diabetes Obesity Intellectual
disability Other\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
6\% 94\% 34\% 28\% 20\% 9\% 3\% 2 21\% 34\% 0\% 1\% 0\% 10\% 0 10\% 22\%
29\% 1\% 46\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Pre-admission swallow status}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Normal diet (FOIS Level 7) FOIS Level 5 FOIS Level 1\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
96\% 3\% 1\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{COVID-19 Neurological manifestations}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Total: Stroke n=2 Seizures n=1 Impaired consciousness n=20 Delirium
n=8\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
37\% (34/96)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Most recent} \textbf{Chest x-ray at time of SLT initial
assessment}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Abnormal \emph{Chest x-ray classification (Taylor et al, 2015):} Patchy
atelectasis and/bronchial wall thickening Focal consolidation Multifocal
consolidation Diffuse alveolar changes Unknown\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
99\% 8\% 8\% 74\% 2\% 1\%\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Ventilation Data}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Intubation details (where data is missing it is because data could not
be obtained from local healthcare records) &
\vtop{\hbox{\strut \textbf{Intubation} Median duration of intubation
Median grade of intubation (n=48) Median no. of endotracheal tubes
(n=87) Median max cuff pressure (n=76) Median no failed extubations
(n=92) Intubation injury
\emph{Oedema}}\hbox{\strut \emph{Stridor}}\hbox{\strut \emph{Vocal cord
immobility}}\hbox{\strut \emph{Other} \textbf{Proning} Proning completed
Median Proning duration (days) Proning related injury \emph{Tongue lip
or facial swelling}}\hbox{\strut \emph{Pressure
sores}}\hbox{\strut \emph{Lip laceration}}\hbox{\strut \emph{Herpes rash
around mouth}}\hbox{\strut \emph{Ulcer on chin/around mouth}
\textbf{Tracheostomy} Tracheostomy insertion (n=100) Percutaneous
Surgical Median Tracheostomy size Mean time to decannulation (n=34; 2
pts still with trach excluded) \textbf{Length of Stay} Median Length of
ICU Stay Median Length of Hospital Stay}} & 14 days (IQR 8-19.5) (range
1-49) 1 (IQR) (range 1-2) 1 (IQR 1-2) 30mmHg (IQR 30-35) (range 22-60) 0
(range 0-2) 22/100 11/22 3/22 1/22 7/22 61\% (61/100) 4 days (IQR 2-11
days) 26\% (16/61) n=9 n=4 n=1 n=1 n=1 36\% 27 9 8 (range 6-9) 24 days
(SD: 16.11; range 3-71 days) 20 days (IQR 11-34) 38 days (IQR
28-68)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3.}

\textbf{Trajectory of Swallow and Voice Outcomes from Initial Assessment
to SLT Discharge}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Oral Intake Status (Functional Oral Intake Scale)}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Initial SLT Assessment (n=100)}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Discharge (n=95)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{1: Tube dependent. Nothing by mouth.}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
36\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{2: Tube dependent with minimal attempts at food or or
liquid.}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{3: Tube dependent with consistent oral intake of food or
liquid.}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{4: Total oral diet of a single consistency}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{5: Total oral diet with multiple consistencies, but requiring
special preparation or compensations.}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{6: Total oral diet with multiple consistencies without special
preparation, but with specific food limitations.}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{7: Total oral diet with no restrictions}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
73\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Median (IQR)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
2.5 (1-5)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7 (7-7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Z score (p value)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-7.322 (p=.000)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-7.322 (p=.000)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Fluid Consistency} \textbf{(IDDSI Fluid Consistencies)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Initial SLT Assessment (n=100)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Discharge (n=91)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{0: Thin fluid}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
43\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
85\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{1: Slightly thick fluid}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{2: Mildly thick fluid}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{3: Moderately thick fluid}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{4: Extremely thick fluid}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{5: No fluids}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Median (IQR)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1 (0-5)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0-0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Z score (p value)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-6.023 (p=.000)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-6.023 (p=.000)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Food consistency} \textbf{(IDDSI Food Consistencies)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Initial SLT Assessment (n=100)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Discharge (n=91)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{4: Puree}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{5: Minced and moist}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{6: Soft \& bite sized}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{7: Regular}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
78\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{0: (none)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
40\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Median (IQR)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
4 (0-5)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7 (7-7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Z score (p value)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-8.976 (p=.000)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-8.976 (p=.000)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Voice Quality} \textbf{(GRBAS- G)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Initial SLT Assessment (n=99)}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Discharge (n=83)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{0: No abnormality detected}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
63\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{1: Mild}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{2: Moderate}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{3: Severe}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Median (IQR)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1 (0-2)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0-0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Z score (p value)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-5.619 (p=.000)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
-5.619 (p=.000)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4. Independent Variables Predictive of Post-Extubation
Oral intake status}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Independent Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{B}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{SE}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Odds ratio}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{95\% CI for OR} \textbf{Lower Upper}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{95\% CI for OR} \textbf{Lower Upper}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{P value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Age}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.062\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.0225\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.064\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.018\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.112\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.006*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Maximum cuff pressure\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.001\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.0448\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.999\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.915\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.091\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.988\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Proning}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.300\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.6019\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.671\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.128\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.943\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.031*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Neurological manifestations\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.049\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.5804\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.2856\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.915\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8.907\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.071\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{History of respiratory disease}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.769\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.6884\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5.863\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.521\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.599\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.01*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Duration of intubation\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.860\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.5381\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.423\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.147\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.215\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.110\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 5. Independent Variables Predictive of Post-Extubation
Voice Quality}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Independent Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{B}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{SE}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Odds ratio}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{95\% CI for OR} \textbf{Lower Upper}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{95\% CI for OR} \textbf{Lower Upper}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{P value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Intubation injury}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.349\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.1687\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10.471\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.060\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
103.466\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.044*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Number of comorbidities\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.310\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.5136\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.733\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.268\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.007\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.546\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Proning\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.328\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.9441\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.775\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.593\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24.015\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.159\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Maximum cuff pressure\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.087\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.0697\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.916\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.799\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.050\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.209\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Duration of intubation\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.113\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.0668\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.893\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.784\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.018\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.091\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{History of respiratory disease}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.186\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.3829\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24.196\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.609\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
363.78\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.021*\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 6. SLT Rehabilitation}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& \textbf{Dysphagia Intervention} & \textbf{Number of participants
implemented} & \textbf{Voice Intervention} & \textbf{Number of
participants implemented}\tabularnewline
\midrule
\endhead
\textbf{1} & Oro-facial exercises & 3 & Vocal cord adduction exercises &
4\tabularnewline
\textbf{2} & Sensory stimulation & 2 & Vocal function exercises &
5\tabularnewline
\textbf{3} & Masako manoeuvre & 10 & Vocal hygiene & 9\tabularnewline
\textbf{4} & Effortful swallow & 12 & Respiratory support for phonation
& 9\tabularnewline
\textbf{5} & Supraglottic swallow & 0 & EMST & 1\tabularnewline
\textbf{6} & Pitch glide & 3 & Other & 2\tabularnewline
\textbf{7} & Mendelsohn manoeuvre & 5 & &\tabularnewline
\textbf{8} & Postural strategy & 6 & &\tabularnewline
\textbf{9} & Chin tuck against resistance & 1 & &\tabularnewline
\textbf{10} & EMST & 1 & &\tabularnewline
\textbf{11} & NMES & 0 & &\tabularnewline
\textbf{12} & Other & 17 & &\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: EMST= Expiratory muscle strength training, NMES=
neuromuscular electrical stimulation

\selectlanguage{english}
\FloatBarrier
\end{document}

