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COVID-19 Information and Resources: Risk Management of AGPs for Dysphagia Care [Updated May 6, 2020]

The Dysphagia Research Society is a multidisciplinary society of researchers and clinicians (speech-language pathologists, swallowing scientists, physicians, engineers, physical therapists, occupational therapists, dietitians and others) with expertise in swallowing disorders (dysphagia). DRS is organized exclusively for scientific, charitable, and educational purposes. The main purposes of the society are to enhance and encourage interdisciplinary research pertinent to normal and disordered swallowing, and to promote the dissemination of this knowledge into clinical practice. 

The following guidance has been prepared by the DRS COVID-19 Task Force in response to clinician concerns and requests for support related to the use of personal protective equipment (PPE), oropharyngeal dysphagia management during COVID-19 and aerosol generating procedures (AGPs).

An aerosol generating procedure is a procedure that may stimulate coughing, sneezing and/or result in nasal, nasopharyngeal or pharyngolaryngeal secretions becoming particalized, resulting in the release of airborne particles [aerosols].1,2 Whereas the transmission of respiratory pathogens is thought to occur mainly through respiratory droplets (contact, airborne or droplet) generated by coughing and sneezing, and through contact with contaminated surfaces, international and national COVID-19 policy and practice recommendations highlight that AGPs cause increased risk of aerosol spread, thus increasing the risk of airborne transmission of COVID-19.1-5

Special precautions must be implemented to protect healthcare workers performing AGPs on patients with potential viral respiratory infections, as recommended by the CDC4. For those with known or suspected COVID-19, including high risk individuals who may be asymptomatic, specific precautions are required. In addition to proper hand hygiene and gloves, airborne precautions include gowns, N95 masks or powered air-purifying respirator (PAPR), and face shields. Government and / or local Infection control recommendations MUST be sought and followed before commencing any of these procedures. A patient’s COVID-19 status should be established prior to contact wherever possible, and if unknown, the patient should be treated as potentially infected. Minimal and essential personnel presence should be present in the vicinity when performing the AGP procedures, while maintaining permissible social distancing between the members during such procedures. All clinicians performing AGPs must have access to appropriate personal protection equipment (PPE) and equipment sanitation. All clinicians must be educated on COVID-19 risk assessment in their patients and appropriate use of PPE4-9

It is the recommendation of the Dysphagia Research Society that the following procedures should be considered as AGPs and require airborne PPE precautions to be in place:

Any examination or procedure performed on the aerodigestive tract (middle ear, nose, pharynx, oral cavity, oropharynx, hypopharynx or esophagus)10-12 including: 

  1.  clinical evaluation of swallowing, including oro-motor/cranial nerve examination2,13-17

  2.  cough reflex testing2,13-17

  3.  oral care2,13-17

  4.  endoscopy, including SLP-led flexible endoscopic evaluation of swallowing (FEES)2,10-17

  5.  laryngoscopy, stroboscopy, or transnasal endoscopy (TNE)2,10-17

  6. videofluoroscopic swallow study (VFSS)2,13-17

  7. laryngectomy care and management2,10-17 including:

                       i. surgical voice restoration (voice prosthesis changes; and open stoma inspection)

                       ii. communication management/assessment with laryngectomy patients due to risk of coughing

  1.   intubation, tracheostomy care and management2,10-17

                         i. with or without mechanical ventilation

                         ii. suctioning procedures

                         iii. deflating cuff, digital occlusion and speaking valve use

  1. non-invasive ventilation (NIV) and high-flow nasal oxygen (HFNO)2,10-17

  2. respiratory support2,10-17 via nasal cannulae, high flow nasal cannulae, and face mask

  3. transnasal endoscopic procedures10-12

  4. respiratory muscle strength training (expiratory muscle strength training [EMST], inspiratory muscle strength training [IMST]) 

  5. pharyngeal-esophageal manometry and pH-MII procedures 

  6. dysphagia interventions requiring close proximity to / contact with the aerodigestive tract.2,13-17


In summary, there is consensus and agreement across the healthcare and infection control community that aerosol generating procedures place the healthcare professional at greater risk of infection. In the context of the available evidence and expert consensus, healthcare providers and infection control policy makers should take precautionary steps to reduce the risk of COVID-19 transmission and infection, while undertaking the aforementioned dysphagia assessment and treatment procedures.

 


Created by the DRS COVID-19 Taskforce on May 4, 2020. Updated on May 6, 2020.
This is a multidisciplinary taskforce of academic and healthcare professionals with expertise in Speech-Language Pathology, Otolaryngology, Critical/Intensive Care, Infectious Diseases and Respiratory Care. The Task Force has also created a COVID-19 Resource Page to guide service delivery related to dysphagia management during the global COVID-19 pandemic. 

Co-chairs of the DRS COVID-19 Taskforce
Anna Miles PhD and Rinki Desai MS, CCC-SLP, CBIS, CDP 

Members of the DRS COVID-19 Taskforce

Susan Langmore PhD, CCC-SLP, BCS-S, Nadine Connor PhD, CCC-SLP, Martin Brodsky PhD, ScM, CCC-SLP, Georgia Malandraki PhD, CCC-SLP, BCS-S, Tim McCulloch MD, FACS, Sudarshan Jadcherla MD, DCH, FRCP (Irel), AGAF, Jacqui Allen MBChB, FRACS, Kendrea L. (Focht) Garand PhD, CScD, CCC-SLP, BCS-S, CBIS, CCRE, Joe Murray PhD, CCC-SLP, BCS-S, Luis Riquelme PhD, CCC-SLP, BCS-S, Mike Pulia MD, MS, and Mark Moss MD



References


  1. Aerosol Generating Procedures (AGPs). Health Protection Scotland (link) Published 2020. Accessed May 6, 2020.

  2. Royal College of Speech Language Therapists (RCSLT): Report on aerosol generating procedures, dysphagia assessment and COVID-19 (link) Accessed May 4, 2020

  3. 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):e35797. doi:10.1371/journal.pone.0035797

  4. Centers for Disease Control and Prevention (CDC). Coronavirus disease 2019 (COVID-19) interim infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in healthcare settings. (link) Accessed on May 4, 2020.

  5. Syamal M. Literature-guided recommendations for otolaryngologists during the COVID-19 pandemic: A contemporary review.  Laryngoscope. 2020. doi:10.1002/lio2.389

  6. Balakrishnan K, Schechtman S, Hogikyan ND, Teoh AYB, McGrath B, Brenner MJ. COVID-19 Pandemic: What Every Otolaryngologist–Head and Neck Surgeon Needs to Know for Safe Airway Management.Otolaryngology Head & Neck Surgery. 2020, 1-5. doi:10.1177/0194599820919751

  7. Kowalski LP, Sanabria A, Rodge JA, Ng WT, de Bree R, et al., COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head & Neck. 2020; 1-9. doi: 10.1002/hed.26164

  8. Infection prevention and control and preparedness for COVID-19 in healthcare settings. Second update - 31 March 2020. European Centre for Disease Prevention and Control (link) Published 2020. Accessed May 6, 2020.

  9. World Health Organization. Infection prevention and control of epidemic and pandemic prone acute respiratory infections in health care. WHO guidelines (link) (2014). Accessed May 6, 2020.

  10. American Academy of Otolaryngology-Head & Neck Surgery (linkAccessed on May 4, 2020.

  11. Australasian Society of Otolaryngology-Head & Neck Surgery (link) Accessed on May 4, 2020.

  12. ENT UK (link) Accessed on May 4, 2020.

  13. American Speech-language-hearing Association (ASHA). Guidance to SLPs regarding aerosol generating procedures (link) Accessed on May 4, 2020.

  14. New Zealand Speech-Language Therapists' Association (NZSTA). Information regarding COVID-19 (link) Accessed on May 4, 2020.

  15. Speech Pathology Australia (SPA) Speech Pathology Australia guidance for service delivery, clinical procedures and infection control during COVID-19 pandemic. (link) Accessed on May 4, 2020.

  16. Speech-Language & Audiology Canada (SAC) COVID-19 Update: Speech-Language Pathology Services in Healthcare Settings During the COVID-19 Pandemic (link) Accessed on May 4, 2020.

  17. Irish Association of Speech-language Therapists. COVID-19 Guidance for IASLT members (link) Accessed on May 4, 2020.

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