Aerosol Generating Procedures (AGPs)

This guidance helps speech-language pathologists (SLPs) and related professionals make decisions about personal protective equipment (PPE) when performing tasks that may release respiratory aerosols and increase the risk of spreading respiratory infections.

Understanding the Risk of Aerosols

Aerosols are tiny particles that can carry viruses or bacteria. They can be released during certain medical procedures or during behaviors like coughing or sneezing.

How much aerosol is produced depends on

the type of procedure;
how forcefully a person breathes or coughs; and
whether devices like high-flow oxygen are being used (Chui et al., 2022).

Some evidence suggests that coughing and shouting can produce 10–300 times more aerosols than some medical interventions like high-flow nasal cannula or non-invasive ventilation (Hamilton et al., 2022; Wilson et al., 2021).

There’s no clear agreement on what counts as an aerosol generating procedure (AGP). Different professional guidelines use different definitions, and the level of risk can vary depending on the setting and the patient (Klompas et al., 2021).

Because of this uncertainty, it’s safest to use the highest level of infection control precautions available, especially when working with patients who may have airborne transmissible illnesses like measles or tuberculosis.

AGPs in Speech-Language Pathology Practice

Speech-language pathologists (SLPs) perform several activities that can generate aerosols, often by triggering coughing or causing the release of respiratory secretions. These activities include the following:

Dysphagia care

Non-instrumental swallowing assessment, which includes structural and functional assessment of the oral mechanism, testing oral reflexes (e.g., gag and cough reflexes), and clinical (bedside) administration of different food and liquid consistencies 
Instrumental assessment of swallowing, including flexible 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

Voice care, including the use of endoscopy or stroboscopy
Laryngectomy care, including (a) voice restoration using voice prostheses and (b) stoma care
Tracheostomy management with or without mechanical ventilation, including suctioning 
Routine patient behaviors can create aerosols—examples of such behaviors include coughing, sneezing, throat clearing, loud talking or shouting, and labored or forceful breathing.

These procedures and activities may not always be labeled as AGPs, but they can still raise the risk of spreading respiratory particles.

Protecting Yourself and Others

Professionals working with patients who have or may have an airborne transmissible illness are recommended to follow infection prevention guidance from local, state, and federal guidelines as well as facility policy.

Infection prevention for airborne illnesses typically includes the following:

N95 respirator (or facility equivalent)
Eye protection (goggles or face shield)
Gloves
Gown
Airborne infection isolation room (formerly referred to as “negative pressure isolation room”)

If the patient does not have a known infection, clinicians can adhere to the following guidelines and regulations:

Standard precautions
Facility policy
Local, state, and federal guidelines

Additional Resources

References

Chui, J., Hui, D. S., & Chan, M. T. (2022). How should aerosol generating procedures be defined? BMJ, 378, Article e065903. https://doi.org/10.1136/bmj-2021-065903

Hamilton, F. W., Gregson, F. K. A., Arnold, D. T., AERATOR Group, Bzdek, B. R., Reid, J. P., Maskell, N., & Dodd, J. W.. (2022). Aerosol emission from the respiratory tract: An analysis of aerosol generation from oxygen delivery systems. Thorax, 77(3), 276–282. https://doi.org/10.1136/thoraxjnl-2021-217577

Klompas, M., Baker, M., & Rhee, C. (2021). What is an aerosol-generating procedure? JAMA Surgery, 156(2), 113–114. https://doi.org/10.1001/jamasurg.2020.6643

Wilson, N. M., Marks, G. B., Eckhardt, A., Clarke, A. M., Young, F. P., Garden, F. L., Stewart, W., & Tovey, E. R. (2021). The effect of respiratory activity, non‐invasive respiratory support and facemasks on aerosol generation and its relevance to COVID‐19. Anaesthesia, 76(11), 1465–1474. https://doi.org/10.1111/anae.15475