ASHA Guidance to SLPs Regarding Aerosol Generating Procedures

Updated January 18, 2022

COVID-19 typically presents as a respiratory illness accompanied by cough and "is transmitted by exposure to infectious respiratory fluids" (CDC, 2021). The Centers for Disease Control and Prevention (CDC) has indicated that "Exposure occurs in three principal ways: (1) inhalation of very fine respiratory droplets and aerosol particles, (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them.” (CDC, 2021)

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 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.” (Refer to CDC resource titled "Which procedures are considered aerosol generating procedures in healthcare settings?"). The CDC continues to encourage that “Procedures that pose such risk should be performed cautiously and avoided if possible. 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

These procedures may raise the risk for aerosolization when triggering patients’ reflexive coughs and sneezes.

ASHA supports CDC guidance to exercise appropriate caution and deliver services within the SLP scope of practice to patients and their families during the COVID-19 pandemic. Individual clinicians and facilities are encouraged to conduct their own risk assessment to initiate/re-initiate and provide SLP in-person services, including AGPs.

Health care workers, such as SLPs, who work in close patient proximity while performing AGPs, can be at increased risk for transmission of respiratory infections, such as COVID-19. Because of this, ASHA recommends that employers provide SLPs adequate protection during AGPs consistent with the CDC recommended guidelines for personal protective equipment (PPE), which state “N95 respirators or respirators that offer a higher level of protection should be used when performing or present for an aerosol generating procedure.”

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. We recommend the provision of highest level of safeguards available at the facility in accordance with CDC’s guidance.

Additional CDC guidelines for 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.