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ASHA Guidance to SLPs Regarding Aerosol Generating Procedures

April 22, 2020

COVID-19 typically presents as a respiratory illness accompanied by cough and is mainly spread via droplets (aerosols) produced when an infected person coughs or sneezes. The following guidance has been prepared by the American-Speech-Language Hearing Association (ASHA) to help speech-language pathologists (SLPs) and related personnel make informed decisions about personal protective equipment (PPE) needed while engaging in procedures within the SLP scope of practice that may produce aerosols. 

On April 13, 2020, the Centers for Disease Control (CDC)  updated their guidance to indicate that aerosol generating procedures (AGPs) are medical procedures that are “more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing” and result in “uncontrolled respiratory secretions.” AGPs produce airborne particles (aerosols/droplets) that can lead to the spread of respiratory infections. SLPs may perform several procedures that can result in generation of aerosols, specifically by the trigger of the cough reflex, that can result in production of uncontrolled respiratory secretions. These include (but are not limited to): 

  • Dysphagia care: 
  • Non-instrumental swallowing assessment, which includes structural and functional assessment of oral mechanism, testing oral reflexes (e.g., gag and cough reflexes), and clinical (bedside) administration of different diet and liquid consistencies 
  • Instrumental assessment of swallowing, which includes fiberoptic endoscopic evaluation of swallowing (FEES)—with or without sensory testing, and videofluoroscopic swallowing study (VFSS), among others
  • Dysphagia treatment, which includes rehabilitative and compensatory approaches
  • Instrumental assessment of voice via endoscopy, with or without stroboscopy 
  • Assessment and management of laryngectomy, including voice restoration using voice prosthesis and stoma care
  • Assessment and treatment of tracheostomies, with or without mechanical ventilation, including suctioning 
  • Non-invasive ventilation such as high-flow nasal oxygen and nasal cannulae 

Specific to the COVID-19 pandemic, the CDC states that “current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with the virus that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity.”  

This indicates that health care workers, such as SLPs, who work in close patient proximity while performing AGPs, can be at risk for transmission of respiratory infections, such as COVID-19. Because of this, ASHA recommends that employers provide SLPs adequate protection from droplet transmission during AGPs consistent with the CDC recommended guidelines for personal protective equipment (PPE), which state that  

Some procedures performed on patient with known or suspected COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible. If performed, the following should occur:

  • HCP [Healthcare Personnel] in the room should wear an N95 or higher-level respirator, eye protection, gloves, and a gown.
  • The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.
  • AGPs should ideally take place in an AIIR [Airborne Infection Isolation Rooms].
  • Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below.

During the pandemic, ASHA’s guidance is to use CDC-recommended PPE for all AGPs, regardless of the symptom presentation of the patient—specifically because of the transmission risk of the novel coronavirus from asymptomatic or pre-symptomatic carriers. While we acknowledge there is a national shortage of PPEs, we still recommend the provision of highest level of safeguards available at the facility in accordance with CDC’s guidance

Additional CDC guidelines for environmental infection control and related frequently asked questions, strategies for optimizing PPE, and criteria for return to work for health care personnel with confirmed or suspected COVID-19 are also available. See also ASHA’s guidance regarding limited access to PPE

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