This is a petition requesting action from ASHA regarding The ASHA Leader article, Safely Assess Swallowing During Covid? It’s Complicated, specifically the section by Renee Kinder titled SNFs: Stringent Precautions and COVID Complications.

Principle I of ASHA’s Code of Ethics states, “Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.” Rule B under this principle states, “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”

It is our understanding that during a global pandemic those who hold a Certificate of Clinical Competency are still expected to adhere to ASHA’s Code of Ethics, which is why we were shocked to see these statements published in the article, SNFs: Stringent Precautions and COVID Complications. The author indicated that FEES should be prohibited from SNFs due to it being an aerosol generating procedure and because of these prohibitions, clinical assessments should be used effectively to determine patients’ swallowing function and to make dietary recommendations. This opinion is misinformed and potentially harmful to the population we serve. 

First, we should understand what the term “aerosol generating procedure” means. FEES and MBSS are no more aerosol generating than a bedside swallow examination. This is due to the fact that it is the cough that is aerosol generating, not the instrumentation. Providers across the nation have worked diligently to safely provide these instrumental swallowing assessments to the fragile SNF population. It is absolutely possible to safely provide these assessments and it is unreservedly necessary to provide these services to these patients, as they deserve the highest quality care. For more information regarding endoscopy from the American Academy of Otolaryngology and Head and Neck Surgery, visit: Guidance for Return to Practice

Moving on the to the topic of identifying swallowing deficits at the bedside: would you allow a surgeon to fix your grandmother’s fractured hip without first completing imaging? Of course not! The surgeon cannot fix the hip unless they know the exact nature of the injury. Assessment of the mechanism using medical imaging is necessary prior to the initiation of a rehabilitative treatment plan. It is widely understood that this is necessary prior to initiating voice treatment. 

This applies to swallowing, as well. An important role in improving the public health of all populations, including residents in SNF, is the application of these same standards of medical imaging in the form of instrumental swallowing studies being universally applied to the evaluation and treatment of dysphagia. It is impossible for an SLP to identify underlying physiology without instrumentation. At ASHA conventions, we often hear “we cannot treat what we cannot see” and “we need to know the why”, so it is disheartening to read contrary information from this publication. These statements are foundational. We need to know why the patient cannot safely or comfortably swallow in order to provide a targeted, patient-centered intervention program. We can actually do harm by initiating an intervention program without understanding the underlying deficits. Dysphagia diagnostics are not simply for the detection of aspiration, but rather to assess swallow safety and efficiency and to identify any underlying physiological deficits and apply an appropriate treatment plan.

In most cases, making significant diet changes without first providing instrumentation is unethical. Consumption of thickened liquids can actually result in an increased risk for aspiration pneumonia over time. Altering food and liquid textures can impact a patient’s quality of life in addition to putting a person who is already medically compromised at risk for malnutrition and dehydration. The bedside swallow study is a valuable and necessary starting point in identifying dysphagia, yet clinical findings are not sufficient in evaluating dysphagia. Research has suggested that a patient is less likely to cough when aspirating nectar thick liquids than when aspirating thin liquids. If diets are changed based on the absence of a cough, we could be putting patients at increased harm. A diminished cough could mean diminished clearance of the aspirate, thus an increased likelihood of developing aspiration pneumonia. Finally, NPO status does not necessarily eliminate aspiration and negatively impacts quality of life.

In summary, imaging is essential. We are bound by ASHA’s Code of Ethics to provide quality services. We must take additional precautions during the COVID era to keep our patients, ourselves, and our families safe; however, this does not make these services less essential. The ASHA Leader is the voice of ASHA, thus it is responsible for promoting the highest standard of care as best practice. Please publish a piece correcting the misinformation in the article.

References:

Carnaby, G.D. & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia 28: 567-574.

Garand KL, McCullough G, Crary M, Arvedson JC, Dodrill P (2020). Assessment across the lifespan: The clinical swallow evaluation. American Journal of Speech-Language Pathology 29, 919-933. 

Langmore, SE, Skarupski, KA, Park, PS,  &Fries, BE. (2002) Predictors of aspiration in nursing home residents. Dysphagia, Fall; 17(4) 298-307.

Langmore, SE, Terpenning, MS, Schork AS, Yinmiuao, C, Murray, J, Lopatin, D, Loesche, WJ. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13 69-81.

Leder, S.B. (2015). Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluations of Swallowing: Findings and Consequences. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). ASHA Volume 24, February 2015

Leder, S.B, Sasaki, C.T., & Burrell, M.I. (1998). Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration. Dysphagia, (13),19-21

Leder, S. B., Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia, 17, 214-218.

Lim, S. H., Lieu, P. K., Phua, S. Y., Seshardri, R., Venketasubramanian, N., Lee, S. H., et al (2001). Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia, 16(1), 1-6.

Logemann, J. A.,  Gensler, G., Robbins, J., Lindblad, A. S., Brandt, D., Hind, J., et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Journal of Speech Lang Hearing Research, 51, 173-183.

Miles A, Moore S, McFarlane M, Lee F, Allen J, Huckabee ML. Comparison of cough reflex test against instrumental assessment of aspiration. Physiol Behav. 2013;118:25‐31. doi:10.1016/j.physbeh.2013.05.004

Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11(2), 99-103.

Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., et al. (2008) Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med, 148(7) 509-518.

Takahashi, N., Kikutani, T., Tamura, F., Groher, M., & Kuboki, T. (2012). Videoendoscopic assessment of swallowing function to predict the future incidence of pneumonia of the elderly. Journal of Oral Rehabilitation, 39, 429-437.

Vose, A.K., Kesneck, S., Sunday, K., Plowman, E., & Humbert, I. (2018). A survey of clinician decision making when identifying swallowing impairments and identifying treatment. AJSLHR 61(11), 2735-2756