As the first wave of the coronavirus disease (COVID-19) pandemic unfolded in New York City, specialists at NYU Langone’s Voice Center responded to a rapidly evolving healthcare paradigm—shifting course in patient evaluations and treatments that routinely involve a high exposure risk through aerosolization. With real-time innovation in patient management, redesigned guidelines, and an emphasis on maintaining standards of care throughout a dynamic situation, a multidisciplinary team collaborated to ensure care continuity while navigating pandemic-associated complexity.

Innovating Beyond Guidelines Yields Early Tracheostomy Evidence

Among care teams across NYU Langone collaborating to implement best practices for patients with COVID-19, concerns mounted regarding the complications associated with long-term ventilation. “The guidelines concerning delay of tracheostomies in these patients to the 21-day mark were built on fear of transmission, rather than good evidence,” says Milan R. Amin, MD, professor in the Department of Otolaryngology—Head and Neck Surgery and director of the Voice Center. “The delay was recommended by researchers who hadn’t yet seen a wave of COVID-19, and we knew we had to actively evolve previous understanding in the context of our highly complicated patients.”

While the theoretical risk of early tracheostomy at first prevented its use, the risks associated with an endotracheal tube in place for longer than 10 to 14 days—including tracheal stenosis and narrowing, mucosa injury, and larynx erosion—are well documented. Dr. Amin and colleagues have seen these impacts at the center at an increasing rate, with patients experiencing shortness of breath, diminished voices, and permanent scarring.

With those long-term consequences anticipated, a multidisciplinary team including otolaryngology, pulmonology, and thoracic specialists created a strategy to reduce the time to tracheostomy based on prognosis. For those patients with a good prognosis and most likely to recover, tracheostomy was provided at day 5; for those with a poorer prognosis, tracheostomy remained delayed.

A retrospective review led by Paul E. Kwak, MD, assistant professor in the Department of Otolaryngology—Head and Neck Surgery, published in August 2020 in Otolaryngology–Head and Neck Surgery, analyzed 148 adult patients infected with COVID-19. The review found safety equivalence between the two timelines, and early tracheostomy was associated with positive outcomes including significantly shorter length of stay. A survival rate of 90 percent was observed in patients who received the earlier intervention, compared with the 20 to 50 percent estimated survival rate among critically ill patients.

“Our position as some of the first U.S. care teams treating COVID-19 patients focused us on the problem and how to help these patients in the most effective ways,” says Dr. Amin. “When you’re confronted with so many patients at once, there’s no time to try to glean protocols from prior studies that probably aren’t relevant anyway; you have to follow your instincts.”

Data Inform Guidelines to Keep Performers Singing

While evolving protocols improved COVID-19 care, other measures centered on prevention. Aaron M. Johnson, PhD, a speech–language pathologist and associate professor in the Department of Otolaryngology—Head and Neck Surgery, and also a trained classical singer, turned his focus to elucidating how singing, an inherently aerosol-producing event, could contribute to the spread of COVID-19. “The performing arts community represents a significant part of the New York City economy and a significant subset of our own patient population,” he notes. “Since we ask performers to sing and project their voices during treatment, it was important for us to determine how that could be done safely.”

Dr. Johnson and a consortium of co-investigators conducted a retrospective literature review to document how singing could be made safer in both treatment and performance capacities. Published in July 2020 in the Journal of Voice, this research defines the mechanism of singing as a “superspreader” event, stratifies risk based on environment and performance type, and outlines evidence-based guidelines to enhance singing safety. “We’ve had to reexamine all of the traditional ways we make music with others—really high-risk activities for disease transmission,” adds Dr. Johnson. “Other than staying home and not singing, we wanted to mitigate the risks of vocal training, voice therapy, and performing.”

A challenge associated with reliance on technology for singing is the latency of audio traveling across broadband signals—creating lags that interrupt fluidity of voices. One recommended approach to mitigate this effect is the adoption of low-latency audio systems within institutions. Other recommendations for reduced COVID-19 risk during in-person performances include relying on outdoor settings, rehearsing in shifts, and changing repertoires to accommodate singers in separate locations.

Additional research underway includes a survey of performers, in New York City and nationwide, to evaluate and quantify the economic and health impacts of COVID-19 that they have experienced.

An Evolution in Patient Management

The sharp rise in COVID-19 cases also demanded shifts in patient management. Voice Center patients typically begin with an endoscopic laryngeal evaluation, which substantially exposes providers to aerosolization—but was found in previous research, co-authored by Dr. Amin, to be an important part of a comprehensive voice patient intake. “Listening to the voice remotely is just not as accurate,” notes Dr. Amin.

Dr. Amin and the Voice Center team took a deliberate approach to fine-tune safety protocols, focusing on both infrastructure and patient flow. The resulting changes included enhanced filtration, more robust cleaning protocols and personal protective equipment (PPE) requirements, and an overhaul of patient intake, moving aerosol-producing exams to a central location.

Although these measures enabled safer in-person initial evaluations, voice rehabilitation care continues to be provided through video visits. “We have found that if patients wear a headset, we can get good enough audio fidelity to provide the same quality care,” notes Dr. Johnson. He and his team are developing a patient questionnaire to evaluate the quality of telemedicine care, and have been invited by other centers to lend their expertise in reducing risk and enhancing patient care, in a worldwide effort to help improve overall COVID-19 outcomes.

“With collaboration, we were able to actively enhance quality care while managing highly complicated patients,” concludes Dr. Amin. “It was about balancing patient management and safety so we could deliver the kind of care we’d want for ourselves and our families.”