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ASHA Guidance to SLPs Regarding Aerosol Generating Procedures

Updated October 8 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 Centers for Disease Control and Prevention (CDC) has indicated that “Pathogens that are mainly transmitted through close contact (i.e., contact transmission and droplet transmission) can sometimes also be spread via airborne transmission under special circumstances”. 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. 

Guidance from the Centers for Disease Control and Prevention (CDC) states 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.” AGPs produce infectious particles (aerosols/droplets) that can lead to the spread of respiratory infections. As the CDC notes, “There is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of AGPs for healthcare settings.” 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 

Current evidence is inconclusive to determine whether procedures themselves raise the risk for aerosol generation or if they increase the risk of patients’ reflexive coughs and sneezes that can result in aerosolization. Specific to the COVID-19 pandemic, the CDC states that “COVID-19 is primarily transmitted from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes, coughs, or talks. Infectious droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.”

The guidance also clarifies that “short-range inhalation of aerosols is a possibility for COVID-19, as with many respiratory pathogens. However, this cannot easily be distinguished from ‘droplet’ transmission based on epidemiologic patterns. Short-range transmission is a possibility particularly in crowded medical wards and inadequately ventilated spaces. Certain procedures in health facilities can generate fine aerosols and should be avoided whenever possible.”

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 and aerosol transmission during AGPs consistent with the CDC recommended guidelines for personal protective equipment (PPE), which state 

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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