Position Statement regarding the use of PPE for SLTs performing aerosol generating procedures as part of dysphagia management of individuals with COVID-19 (positive, suspected or non-COVID)

Position Statement regarding the use of PPE for SLTs performing aerosol generating procedures as part of dysphagia management of individuals with COVID-19 (positive, suspected or non-COVID)

The IASLT holds the position that clinical dysphagia assessment is an Aerosol Generating Procedure (AGP). Full risk assessment and identification of required levels of PPE should apply whilst conducting clinical dysphagia assessments with all individuals who present with COVID-19(positive, suspected or non-COVID). Current HSE Guidance for AGPs in the management of COVID-19 does not acknowledge clinical dysphagia assessments as an AGP.

The World Health Organisation (WHO) recently concluded that, based on the current evidence, transmission of COVID-19 is primarily through respiratory droplets and contact. 1 International and national COVID-19 policy and practice recommendations consistently highlight the emission of aerosols (very small droplets) from COVID-19 positive patients as increasing the risk of the airborne transmission (11  12).  Aerosols may remain suspended in the air for a period of time, travel over a distance and may cause infection if inhaled. Respiratory droplet emissions when coughing or sneezing have been widely acknowledged as important routes of COVID-19 transmission. Aerosols generated by speech are also proposed to be a potential source for transmission (5, 6).

Coughing and particularly saliva droplets emitted during coughing have been highlighted as an important route for virus transmission. The infective potential of aerosols depends on the anatomical origin of the fluids, the viral load, and the force of aerosol generation.

The IASLT holds the position that clinical dysphagia assessment is an Aerosol Generating Procedure (AGP).

Clinical Dysphagia Assessments:

Coughing is commonly generated during clinical dysphagia assessment which comprises several components, including assessment of voluntary cough and swallowing trials with samples of fluid and food. Reflexive coughing, secondary to aspiration is a common occurrence during the assessment procedure and may be forceful, prolonged and not easily suppressed. Coughing is an unpredictable risk, inherent to specialist dysphagia evaluations undertaken by Speech and Language Therapists.

Clinically, many patients presenting with (suspected) COVID-19 and dysphagia are predisposed to coughing during dysphagia assessments as a result of their concomitant respiratory conditions; upper respiratory tract symptoms of the COVID-19 infection, respiratory support requirements, post-acute respiratory distress syndrome or other comorbidities (e.g. chronic obstructive pulmonary disorder). Dysphagia itself may have resulted in an aspiration pneumonia while oral, pharyngeal and laryngeal weakness (secondary to intubation, intensive care unit (ICU) acquired weakness or neurological conditions) reduces the patients’ ability to manage oral secretions and protect the airway. Patients presenting with (suspected) COVID-19 and dysphagia are predisposed to a heightened and more frequent cough reflex through aspiration of saliva, food or liquids.

Appropriately timed and planned dysphagia assessments are essential for all patients but particularly those with (suspected) COVID-19 in avoiding complications of aspiration, contributing to the differential diagnosis of pneumonia, guiding palliative eating or drinking decisions and facilitating patient flow (2).

Typically undertaken by SLTs <1 metre of the patient, dysphagia assessments last at least 15 minutes. Ear, nose and throat (ENT) surgeons are reported to be at high risk of exposure and infection from COVID-19 due to close proximity to the patients’ upper respiratory mucosa and interventional procedures that induce cough. (3, 4) Given the nature of dysphagia assessment SLTs are likely to be at a similarly high level of risk of COVID-19 infection.

There is no current consensus internationally on a definitive list of healthcare procedures that are AGPs. The evidence base which is used to support classification of AGPs by healthcare bodies is limited however and biased in the selection of procedures investigated as sources of transmission (7), later synthesised in reviews and meta-analyses and in turn, underpinning clinical recommendations. The research evidence on risk of infection and transmission rate has focused on pre-defined AGPs, with dysphagia assessment not explicitly investigated (7) and/or unlikely to be represented given the nature of the setting (8).

 

IASLT acknowledges that there is an absence of definitive evidence linking dysphagia assessment to higher risk of COVID-19 infection but not evidence of an absence of risk.

Clinical dysphagia assessment, as a procedure resulting in prolonged exposure or contact by close proximity to respiratory, oral or aerodigestive tract secretions, should be considered an AGP.

PPE appropriate for airborne precautions should be provided to Speech and Language Therapists when required for conducting clinical dysphagia assessments with COVID-19 infection, suspected COVID-19 infection and non-COVID-19 infection.

  1. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. World Health Organization (WHO). https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations. WHO 2020.  [Accessed 20 May 2020].
  2. Royal College of Speech and Language Therapists (2020_
  3. Lu D, Wang H, Yu R, Yang H, Zhao Y. Integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ENT healthcare workers. J Hosp Infect. 2020:2019-2020. doi:10.1016/j.jhin.2020.02.018 19. 
  4. Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol - Head Neck Surg. 2020;1:1-6. doi:10.1001/jamaoto.2020.0780
  5. Asadi S, Bouvier N, Wexler AS, Ristenpart WD. The coronavirus pandemic and aerosols: Does COVID-19 transmit via expiratory particles? Aerosol Sci Technol. 2020;0(0):1-4. doi:10.1080/02786826.2020.1749229 
  6. 6. Anfinrud P, Stadnytskyi V, Bax C, Bax A. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering. N Engl J Med. 2020:1-2. doi:10.1056/NEJMc2007800
  7. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One. 2012;7(4). doi:10.1371/journal.pone.0035797
  8. Radonovich LJ, Simberkoff MS, Bessesen MT, et al. N95 respirators vs medical masks for preventing influenza among health care personnel: A randomized clinical trial. JAMA - J Am Med Assoc. 2019;322(9):824-833. doi:10.1001/jama.2019.11645
  9. British Association of Stroke Physicians (BASP) Statement about personal protective equipment for healthcare workers performing swallow assessments and nasogastric tube insertion. BASP 2020. 
  10. Irish Association of Speech and Language Therapists (IASLT) COVID-19 updated guidance for IASLT members (3rd update). IASLT 28th April 2020. 
  11. Infection prevention and control and preparedness for COVID-19 in healthcare settings. Second update - 31 March 2020. European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/sites/default/files/documents/Infectionprevention-control-for-the-care-of-patients-with-2019-nCoV-healthcaresettings_update-31-March-2020.pdf. Published 2020. Accessed May 20, 2020.
  12. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf;jses sionid=2120F3F2D118041F9C1BE4D6A065696D?sequence=1. Published 2014. Accessed April 20, 2020.