MB, a 60 year old male with a J-tube &  diagnosis of stomach CA had just received his surgery for the latter with a gastric pull up pouch. He was to begin PO trials with the SLP at the SNF,  but she was  concerned about aspiration as well as digestion issues. The staff was unaware the patient was going to have secondary surgery to close the fistula at the site of the pull up surgery which had a catchment bag attached to it. (The site had not completely healed yet and was draining.) Unless you knew to examine the area of surgery this may have been missed.  The LTC SLP intelligently requested a FEES for this patient, whose presentation you do not see every day. The patient was alert, oriented as well as in excellent physical condition despite his primary diagnosis. He was to be returning home shortly.

The patient easily participated in the exam. He was trialed with very small amounts of thin liquids, puree and dissolvable cracker. In terms of the oral pharyngeal component, nothing of clinical significance was noted. However to a trained therapist, a small hiss and splash under the patient’s clothes was heard. Yes……………….the food and drink – everything was coming through the wall of the gastric pouch into the bag!  Had someone been performing the exam who had not seem complex cases like this over the years, this could have been missed.

The SDX FEES Specialist paged the surgeon, the situation was explained and the patient was allowed to have thin liquids as long as the bag was changed regularly and the site remained clean. The patient was given a post op surgery re-consult date before he went home. He hadn’t remembered that the surgery was 2 parts and that the fistula had to be closed. This decreased the patient’s anxiety ten-fold as he was terrified of what was washing through his bag. He plans to be discharged home, complete his second surgery to close the pouch wound, begin slowly transitioning back to small portions of regular foods and decrease or possibly eliminate his J tube feeds.

SDX prides itself on our hand-selection & thorough training of SLPs who have demonstrated excellence in long-term and medical therapy settings.  It’s not always just about the exam, sometimes it’s the expertise AND ACCESSIBILITY of our FEES Specialists that lets you SEE the FEES difference!   

Let’s face it, in our profession we can’t even agree if we should call a swallowing problem dys-fay-gia or dys-fah-gia, so how is it that we should agree on a single instrumental exam?

Well, the answer is we shouldn’t.

We should have both FEES and MBS available for instrumental testing.  We should be free to choose the exam that gives the answers to the questions we are asking.  If I’m wondering why Mr. Smith is coughing during and after his meals, let’s FEES away…concerns for chronic coughing, secretion management, changes in vocal quality and complaints of globus sensation warrant that.  Now if Mrs. Smith is showing me she has food getting stuck in the mediastinal region and she has a history of esophageal difficulties, MBS makes sense.  One of my favorite docs breaks it down like this…bigger concerns with liquids, FEES them.  Dysphagia to solids?  Lean on MBS.  I’m not saying it’s black or white…like an MBS.  Really, swallowing usually deserves a BRIGHTER, more colorful assessment like the FEES.  Consider factors like how quickly testing needs to be completed, if you are concerned for fatigue, if you want to train the patient using biofeedback…then scoping away will make your day.  FEES gives you all those advantages!

Looking at the typical SNF roster, 75% of those residents with dysphagia needing an instrumental swallow test would be best serviced with FEES at the bedside in their typical eating position swallowing actual food served from the kitchen, like rice, salad, spaghetti, sandwiches…not barium coated crackers.  #FEESadvantage!   If we are testing swallow function for a meal, then let’s keep it real!  Order up a regular meal from the kitchen and let’s see during the FEES how those cabbage rolls or meatballs actually go down.

Did I mention radiation typically cuts off my view of an MBS at 3 minutes?  And that’s if I’m lucky to record that much footage!  I mean, that’s like paying MOVIE PRICES to see just a PREVIEW!  Well, when it comes to my older patients, I want to know what happens at minute 12, 15, 18, 25…I need to see the impact of fatigue on bolus control and pharyngeal clearance!  Again, point to the challenger, FEES.  No  time limits with FEES, so I can view that entire meal.

I am so thankful that I was taught by open-minded, savvy SLPs in a strong rehab environment with MD support.  I’m fortunate that I came into SLP-ing at a time when clinical practice was not as constricted by financial resources as it is today.  Back in the day, the only question was “What instrumental study does the patient need?” not “How much will the test cost?” or worse yet “Can’t you just leave them on a modified diet?”

We should always focus on evidenced-based practice and best practices for patient care. 

Be sure to take the time and THINK about the test you need based on your therapy goals, questions and concerns…make sure you are getting the best value for your therapy dollars!   #FEESadvantage #sdxslps #dysphagianerd

We had an SDX FEES patient last week who was in a predicament. He had been scheduled for an MBS who was scheduled a week out. Overall he had debility, end stage renal disease and coughing when eating a regular diet texture with thin liquids. However, it was found before the exam he was actually allergic to barium contrast used in an MBS procedure. Also his renal doctor also became involved and preferred he did not have any barium contrast whatsoever even if he wasn’t allergic. The FEES exam was scheduled and performed within 48 hours. The patient was anxious about the exam as he was prepared for an MBS and somewhat apprehensive regarding scope placement. However, after explaining the FEES exam and participating easily in the exam for 18 minutes, the scope was removed and he couldn’t believe “How easy and painless it was.”  He stated he would recommend a FEES to anyone he knew with a swallowing problem. He also appreciated that he was seen upright in bed without having to go outside of the facility as this is where he prefers to eat. The report and video was available in the SDX-FEES.COM secure e-cloud by the end of day for professional and SLP viewing.  #madeadifferencetothatone #nailedit!

The Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues in Feeding and Hydration discusses the importance of a supportive interdisciplinary effort using a culturally respectful approach to support families and caregivers through their decision making process.  It emphasizes the individual’s “right to request or withhold nutrition or hydration as medical treatment.”

It is our professional and ethical responsibility, and well within our scope of practice as SLPs working with long-term care residents, to document not only what is safest for a resident but to additionally comment on (1) the resident’s prognosis for developing aspiration complications and (2) quality of life considerations.  Dementia is commonly considered in the research to be a terminal illness, and as such, it is appropriate for an SLP to explain in documentation that while there is risk of prandial aspiration with oral feedings, that the placement of a PEG tube will further increase the resident’s risk of developing complications like aspiration pneumonia.  Furthermore, nonoral nutrition is shown in the research to have no positive impact on quality of life in residents with dementia.  In a time where the focus is on evidence-based practice, it is important to be well-versed in the current research about PEG tubes and dementia, and to be able to fluently discuss both the pros and cons with residents, their caregivers, and other professionals.

SLPs have the power to be the voice of reason when PEG tubes are discussed for residents with dementia.  Rely on the research to guide your professional judgment and step up in the discussion for your residents and for their dignity.

Stated with love for quality of life & liberalized diets, Katrina Woodward, MS, CCC-SLP SDX Scope Squad Leader & Certified Dementia Practitioner

Mrs. M had been on a modified diet texture at her nursing home since her admission from the acute care hospital last week.  She had eaten regular foods with thin liquids her whole life.  Her primary diagnosis was exacerbation of COPD and a sensation of “globus” or a “lump in her throat.”  She was conservatively downgraded at bedside by the hospital SLP to nectar liquids and moist fork-mashable foods with sides of extra gravies and sauces due.  She was restricted from thin liquids due to a suspicious chronic cough that was “concerning for possible aspiration.”

Her acute stay was too short to complete an instrumental dysphagia exam before hospital discharge.  She was sent to a SNF for rehab on the modified diet recommend by the hospital SLP and sure enough, she started to refuse most meals.  The facility SLP noted that even though she was drinking nectar, she was still coughing intermittently when she ate, and also coughing even when she wasn’t eating.  The facility SLP requested a FEES in order to get to the bottom of the suspicious chronic cough and her physician agreed and ordered the exam.

SDX arrived on-site the next day.  Upon scoping Mrs. M, the FEES exam revealed severe signs and symptoms of laryngopharyngeal reflux (LPR). She scored above an 11 (!!!) on the Reflux Finding Score which is indicative of such significant LPR that an ENT and or GI consult is indicated.  She had severe edema and erythema to her arytenoid/interarytenoid space as well as bilateral vocal fold edema.  She was deemed appropriate for thin liquids and a soft chopped diet texture with sides of gravies and sauces on the side to alleviate the discomfort in the lower pharynx. Her cough was not related to food or liquid aspiration after all.  Mrs.  M was seen for outpatient GI as well as ENT consultations and was placed upon an aggressive short-term PPI (proton pump inhibitor) BID and an anti-reflux regiment.  Pulmonary was also consulted and indicated that there was some suspected backflow of reflux into the upper airway, potentially exacerbating some of her overall lung health issues.

Mrs. M continued to rehabilitate at the SNF prior to being ready to return home with family support. A second FEES prior to her discharge home was ordered and completed.  The results of this repeat FEES only 4 weeks after the initial FEES revealed decreased respiratory incoordination, as the exacerbation of COPD had resolved, plus a decrease in laryngeal edema and erythema at the arytenoid/interarytenoid space.  She reported easier transit of boluses and the chronic cough she had for many years had finally subsided with the LPR treatment. She was ready for diet advancement since she had successfully regained coordination of her swallow-breathe cycle.  

If Mrs. M hadn’t been seen on a FEES, her issues including LPR and chronic cough would have resulted in an unnecessarily restricted diet.  A FEES is your best tool for viewing the glottis and top of the esophagus and airway over longer periods of time, in color and in real-time. It is the ideal instrumental exam for patients with COPD and chronic cough issues of questionable etiology.  Mrs. M returned home on a regular diet texture and will continue to see her specialists to wean reflux medications if/when indicated and to provide ongoing support for her lung health.  See the FEES difference with SDX!

We continue with Part 3 of “The Proof is in the Pudding” by Karen Sheffler.

Special Considerations with FEES 

Use of Blue or Green Dye During FEES to Detect Aspiration

In 2005, Leder and his fellow researchers stated that the depth of bolus flow, bolus residue, laryngeal penetration and aspiration are reliably detected without dying foods and liquids blue or green (i.e., using white skim milk and yellow pudding)(17). This was good news; no more need for St Patrick’s Day jokes to convince the patient to drink green water! (Read more about testing with blue and green dyes).

However, in a larger and more recent study by Marvin et al (2016), researchers found that deeper airway invasion (i.e., noting aspiration versus just penetration) was detected more often when green-dye was used instead of plain white milk (29). They noted that the use of only white milk may under-identify penetration and aspiration, particularly when a patient has significant white secretions pooled in the pharynx and larynx prior to oral intake. One reason for the contradicting findings may be due to the volume of boluses tested. Marvin’s study tested up to 90ml, whereas Leder’s study tested only 3-5cc boluses. 

Marvin and colleagues suggested that green-dyed foods and liquids may be additionally beneficial for patients with mild-moderate dysphagia, who may have less frequent airway compromise and may penetrate and aspirate in trace amounts. 

Identifying and Rating Residue

Langmore, et al (1991) noted that the clinician can visualize and localize the residue better with the FEES versus the VFSS (2,31). Leder and Murray reminded us that Kelly et al found FEES to be more sensitive than VFSS in detecting residue, trace penetration and aspiration (19,20). Leder and Murray speculated that this may be due to the ability to see liquid and food particles that are too small to carry enough barium during a VFSS (22). There is a great picture of this concept in Pisegna and Langmore’s 2016 article in Dysphagia (31, p465). In their simultaneous FEES and VFSS study, residue was more obvious in the FEES picture versus the VFSS image. Clinicians noted residue in more locations on the FEES; this is especially crucial when residue is in and around the laryngeal vestibule (31). The dilemma pointed out by this study was that clinicians rated the residue as more severe when the same image was presented via FEES versus via the VFSS. This may have been due to the clinician raters were from a convenience sample of inexperienced medical professionals who just finished Langmore’s FEES training course (not experienced SLPs). Nevertheless, it does show how residue ratings have been too based on subjective impressions rather than image-based measurable benchmarks. 

Once residue is identified, we need to reliably rate the severity to make sure patients receive an accurate diagnosis regardless of instrumentation (31). Langmore (2016, February) discussed how more research is needed in the standardization of residue scales for FEES during her session at the Post-Graduate Course of the Dysphagia Research Society meeting in Tucson, AZ. She mentioned the following two measures:

1. The Boston Residue and Clearance Scale (BRACS): which regards the site, amount, and the patient’s response to residue, by Kaneoka AS, Langmore, SE, Krisciunas, GP et al (2014) in Folia Phoniatrica et Logopaedica, 65, 312-7. 
2. The Yale Pharyngeal Residue Severity Rating Scale: text by Steven Leder and Paul Neubauer, both of the Department of Surgery at the Yale School of Medicine (based on 27,30). 

Per Neubauer, Rademaker and Leder (2015), many scales do not have “adequate reliability, interpretive validity, and ease of administration to be clinically useful (p522).” They demonstrated that the anatomically defined and image-based Yale Pharyngeal Residue Severity Rating Scale is reliable and valid and only minimal training is needed to quickly achieve proficiency in rating residue in the valleculae and pyriforms. Now the proof is in the pictures and the pudding!

Neubauer, Hersey and Leder (2016) went on to perform a systematic review of all rating scales, with inclusion criteria focusing the review on “completed and generalizable pharyngeal residue severity rating scales,” which seems to have left out the BRACS (30). As Sasaki and Leder stated in Comments on Selected Recent Dysphagia Literature in the 2015 Dysphagia journal (p375): “The BRACS shows potential; however, even the authors acknowledge the impracticality of its use in the clinical setting without simplification by removing or merging redundant items.” Neubauer and team (2016) found that only The Yale Pharyngeal Residue Severity Rating Scale met all the following criteria: 

• qualitative and psychometrically reliable, 
• valid, 
• generalizable, 
• easy to learn by newer and more experienced clinicians, and
• readily useful in the clinic and in research. 

This spring 2016, Steven Leder and Paul Neubauer published the textbook, The Yale Pharyngeal Residue Severity Rating Scale, just prior to Steven Leder’s passing.

In Summary:

How do you summarize Steven Leder, a researcher who had the stamina to regularly conduct studies with hundreds if not thousands of participants. In talking with some of Dr Steven Leder’s colleagues over the last few weeks, he was certainly not done his work, but there are many amazing researchers who will carry on his legacy. His impact on our field was truly remarkable; he set quite a pace. Many will keep his energy alive remembering him as an intense researcher-friend-mentor-colleague with a great smile, sharp wisdom, incredible humor, and boundless generosity.

A memorial fund has been established to support his ongoing research collaborations with both the speech-language pathologists and the residents at Yale. Donations are tax-deductible; individuals who donate will receive a tax deduction letter.

Donations can be made to:

Yale School of Medicine, Steven B. Leder Memorial Fund.

800 Howard Ave., 4th Floor, Room 422

New Haven, CT  06510

FEES References (listed chronologically):

1. Langmore, S.E., Schatz, K. & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2, 216-219.
2. Langmore, S.E., Schatz, K. & Olson, N. (1991). Endoscopic anad videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100 (8), 678-681. 
3. Langmore, S.E. & Logemann, J.A. (1991). After the clinical bedside swallowing examination: What next? AJSLP, September, 13-20.
4. Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103. 
5. Leder, S.B. & Sasaki, C.T. (1997). Identifying silent aspiration with a fiberoptic endoscopic evaluation of dysphagia (FEED). Dysphagia, 12, 117.
6. Leder, S.B., Ross, D.A., Briskin, K.B. & Sasaki, C.T. (1997). A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy. JSLHR, 40, 1352-1357. 
7. Leder, S.B. (1998). Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phys Med Rehabil, 79, 1264-1269.
8. Leder, S.B., Sasaki, C.T. & Burrell, M.I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13, 19-21. 
9. Leder, S.B., Cohn, S.M. & Moller, B.A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13, 208-212. 
10. Leder, S. (1999). Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury. Journal of Head Trauma Rehabilitation, 14 (5), 448-453. 
11. Aviv, J.E., Kaplan, S.T., Thomson, J.E., Spitzer, J., Diamond, B. & Close, L.G. (2000). The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): An analysis of 500 consecutive evaluations. Dysphagia, 15, 39-44. 
12. Leder, S.B., & Karas, D. (2000). Fiberoptic endoscopic evaluation of swallowing in the pediatric population. The Laryngoscope, 110, 1132-1136. 
13. Leder, S.B. & Sasaki, C.T. (2001). Use of FEES to assess and manage patients with head and neck cancer. In Langmore, S.E., editor. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 201-212. 
14. 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.
15. Leder, S.B. (2002). Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheostomy. Chest, 122, 1721. 
16. Leder, S.B. Novella, S. & Patwa, H. (2004). Use of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in patients with Amyotrophic Lateral Sclerosis. Dysphagia, 19, 177-181. 
17. Leder, S.B., Acton, L.M., Lisitano, H.L., Murray, J.T. (2005). Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food. Dysphagia, 20, 157-162. 
18. Leder, S.B. & Ross, D.A. (2005). Incidence of vocal fold immobility in patients with dysphagia. Dysphagia, 20, 163-167.
19. Kelly, A.M., Leslie, P., Beale, T, et al. (2006). Assessing endoscopic evaluation of swallowing and videofluoroscopy: Does examination type influence perception of pharyngeal severity? Clinical Otolaryngol, 31, 425-432.
20. Kelly, A.M., Drinnan, M.J. & Leslie, P. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope, 117, 1723-1727.
21. Leder, S.B., Sasaki, C.T. & Bayar, S. et al. (2007). Fiberoptic endoscopic evaluation of swallowing in the evaluation of aspiration following transhiatal esophagectomy. J Am Coll Surg, 205, 581-585. 
22. Leder, S.B. & Murray, J.T. (2008). Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am, 19, 787-801. 
23. Leder, S.B. (2012). Nil per os except medications order in the dysphagic patient. QJM: An International Journal of Medicine, 106 (1), 71-75.
24. Leder, S.B., Suiter, D.M., Duffey, D. & Judson, B.L. (2012). Vocal fold immobility and aspiration status: A direct replication study. Dysphagia, 27, 265-270. 
25. Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M. & Schluteman, K. (2014). Effects of topical nasal anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST). Dysphagia, 29(1), 33-43. 
26. O’Dea, M.B., Langmore, S.E., Krisciunas, G.P., Walsh, M. Zanchetti, L.L., Scheel, R., et al (2015). Effect of lidocaine on swallowing during FEES in patients with dysphagia. Ann Otol Rhinol Lanryngol, 124(7), 537-44. doi: 10.1177/0003489415570935
27. Neubauer, P.D., Rademaker, A.W. & Leder, S.B. (2015). The Yale Pharyngeal Residue Severity Rating Scale: An anatomically defined and image-based tool. Dysphagia, 30, 521-528. 
28. Leder, S.B., Siner, J.M., Bizzarro, M.J., McGinley, B.M. & Lefton-Greif, M.A. (2016). Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia, 31, 154-159. 
29. Marvin, S., Gustafson, S. & Thibeault, S. (2016). Detecting aspiration and penetration using FEES with and wtihout food dye. Dysphagia, Published online: 18 March 2016. DOI 10.1007/s00455-016-9703-0 
30. Neubauer, P.D., Hersey, D.P. & Leder, S.B. (2016). Pharyngeal residue severity rating scales based on Fiberoptic Endoscopic Evaluation of Swallowing: A systematic review. Dysphagia, 31, 352-359.
31. Pisegna, J.M. & Langmore, S.E. (2016). Parameters of instrumental swallowing evaluations: Describing a diagnostic dilemma. Dysphagia, 31, 462-272.            
    
    OTHER REFERENCES
32. Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16, 140–16.Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16,140–16. 
33. Gross, R. D., Atwood, C. W.Jr., Ross, S. B., Olszewski, J. W., & Eichhorn, K. A. (2009). The coordination of breathing and swallowing in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 179(7), 559–565. doi: 10.1164/rccm.200807-1139OC
34. Gross, R.D. (2014). Lung volumes and their significance for pharyngeal and esophageal swallowing function. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23, 91-99. doi:10.1044/sasd23.3.91
35. Martin-Harris, et al. (2014). Respiratory-swallow training in patients with head and neck cancer. Arch Phys Med Rehabil, 96, 885-893.

We continue with Part 2 of “The Proof is in the Pudding” by Karen Sheffler.

Leder’s FEES Research with Specific Populations

Acute care

FEES has a dual purpose, especially in acute care, seemingly on the two ends of the spectrum from conservative to liberal measures:

1. Identify dysphagia, aspiration and patients with the inability to protect their airway. This directs the plan of care to be more cautious, which has been found to prevent pulmonary complications (i.e., after extubation) (9).
2. Re-instate oral intake with immediate instrumental testing, when appropriate. This prevents being overly cautious and restrictive, potentially allowing a person to eat far earlier than conventional wisdom may have dictated. This can drastically reduce the patient’s length of stay and hospital costs (9). Leder studied patients who required mechanical ventilation with tracheotomies less than 2 months old, and he found that two-thirds of them could actually swallow safely. However, with high-risk patients, it is crucial to base diet recommendations on instrumental evaluations, as 82% of those who aspirated did so silently (15).

Steven Leder was such a proponent of patient safety in acute care. In his 2012 case report, he showed how sometimes benefits do not outweigh the risks (23). A 71 year old patient was referred to his service due to suspected aspiration risk; however, the patient was made nil per os (NPO) except pills in applesauce. Leder performed a FEES and watched the patient aspirate on puree. Fortunately, this did elicit a cough response, and out popped an enteric coated aspirin! Leder cautioned that if significant aspiration risk is suspected, then the team should make the patient fully NPO and wait for the dysphagia evaluation to determine the safest manner of medication delivery.

COPD & Respiratory Compromise

How often have you had the radiologist turn off the camera too soon after the swallow on a VFSS, preventing that post-swallow monitoring? For people with chronic obstructive pulmonary disease (COPD), it is especially important to monitor the time periods before and after the swallow due to their potential difficulty coordinating breathing and swallowing.

There is a plethora of research regarding the coordination of respiration and swallowing. One resource is this review article by Dr Bonnie Martin-Harris, PhD, CCC-SLP, BCS-S. 

In healthy adults, it is most common and safest to swallow interrupting the exhalation phase (i.e., exhale-swallow-exhale). However, many studies have shown that patients with COPD have a higher rate of inhaling after the swallow (see Gross, et al, 2009 for one such study). This means that the person with COPD (and potentially any individual trying to eat when short-of-breath with a rapid respiratory rate) is at high risk to aspirate after the swallow. A quick inhale after the swallow-apneic period can suck in any potential residue that is sitting near the airway. Langmore recommended continuous monitoring of post-swallow pharyngeal residue for 1-2 minutes after the swallow during FEES testing (1).

Persons with COPD benefit from being evaluated for disordered breathing and swallowing patterns and trained to coordinate swallowing at optimal lung volumes (34). Training protocols with visual feedback have been shown to encourage optimal coordination (35). As Leder noted, FEES is perfectly designed to assess the time period after the swallow and use the real-time video images for biofeedback (8, 22).

Langmore stated early on that FEES is ideally suited for people with COPD, and not only for residue monitoring and biofeedback. If the person with COPD is very ill and compromised, he may not tolerate even a small amount of aspiration of food/liquid. The clinician could start oral trials with ice chips and 1 ml of water with blue or green dye added to determine if it is safe to progress to other liquids and foods (1). Even prior to oral intake, the clinician gathers information on laryngeal function and sensation. FEES directly assesses laryngeal function for respiration (with vocal cord abduction) and airway protection (with vocal cord adduction), by observing voicing, coughing and breath-holding tasks prior to oral trials. (1,2,3). Langmore noted that if a patient cannot sustain a breath-hold for a minimum of 3 seconds, then the clinician could suspect poor airway protection for safe swallowing (3). In Leder’s large 1998 study, there were 45 patients with COPD and other pulmonary complications. Thirty out of 45 showed aspiration on FEES, and 17 out of 30 aspirated silently (8).

More recently, Leder, et al (28) studied the impact of high-flow oxygen via nasal cannula on the safety of oral alimentation. It is important to note that 11 out of the 50 adults were excluded from all testing and kept NPO per the team’s judgement, due to the severity of their respiratory issues. However, with the use of their Yale Swallow Protocol and FEES (when the protocol was failed), Leder and his team were able to successfully advance 39 out of the 50 adults to oral alimentation (with 5 requiring nectar thick liquid) (28).They found that the issue of high-flow oxygen alone did not elevate risks. Rather, it was the bigger picture. Safe swallowing depended more on the following underlying medical conditions and patient-specific factors.

• Resolution of respiratory condition (i.e., stable respiratory status, requiring 10-50 L/min of high-flow oxygen or less)
• Resolution of medical compromise
• Improvements in mental status to participate at meal-times
• Ability to handle oral secretions
•  Increased overall strength
• Passing the Yale Swallow Protocol. This includes screening orientation, command following and simple oral-motor movements, in addition to drinking 90 ml without stopping and starting. (Read More: Aspiration & Lessons from Steven Leder)

These factors are readily transferable to many of our patients who are critically ill and have respiratory compromise. If the patient with respiratory compromise is not reaching these goals above, then instrumental testing with FEES is certainly indicated.

Leder, S.B., Warner, H.L., Suiter, D.M., Bhattacharya, B., Rosenbaum, S.H. and Schuster, K. presented a poster at the 2016 Dysphagia Research Society’s annual meeting in Tucson, AZ. The poster was titled: How and When to Begin Safe Oral Alimentation in Post-Extubation Intensive Care Unit Patients. The study had similar inclusion criteria as noted in the bulleted patient-specific factors section above when selecting the 139 subjects. All patients were 18 or older (mean age of 57.3) with intubation durations from 4 hours to 15 days (median 2 days). Results showed that in stable patients, the combination of the Yale Swallow Protocol and FEES lead to safe oral intake recommendations. Specifically, if a person repeatedly failed the swallow screen protocol in the first 24 hours, then FEES was performed by the speech-language pathologist prior to recommending a diet. Fourteen people out of 139 required the FEES, and 6 people were placed on a diet, but 8 remained NPO. This poster showed the benefit of the Yale Swallow Protocol, but also the benefit of immediate access to testing with FEES. I see that as 6 people who did not have to wait to enjoy a meal. However, it was also 8 people who avoided potential adverse respiratory complications. I look forward to more details in the future publication.

Vocal Fold Immobility

Is your patient’s voice breathy, hoarse, or easily fatiguable? Has your patient been coughing on liquids ever since her recent intubation and/or surgery? FEES is the perfect way to see if deficits in laryngeal valving or airway closure are affecting your patient’s swallowing. Speech-language pathologists do not diagnose a pathology in the true vocal cords (TVC), but we can identify if they are mobile or immobile.

In 2005 and 2012, Leder, et al used FEES to study the incidence of vocal fold immobility (VFI) in people referred acutely for dysphagia evaluations and the relationship of VFI to aspiration (18,24). In 2005, after examining 1,452 consecutively accrued participants, they noted that 29.3% of the total had aspiration and 5.6% had unilateral or bilateral VFI (left fold immobility was the most frequent due to surgical trauma). Of the subjects with VFI, 44% had aspiration, but age and side of immobility were not significant factors. Vocal fold immobility was associated with a 15% increased incidence of aspiration, particularly with liquids greater than purees.

In the 2012 direct replication study, Leder and colleagues tested an additional 2,650 participants, creating a combined data set of 4,102 subjects. Data was consistent across the 2005 and 2012 studies. Therefore, using a combined data set, the risk for aspiration in people with unilateral or bilateral vocal fold immobility is increased by 17%. For example, your patient with left vocal cord paresis or paralysis after cardiac surgery has a 2.50 times greater odds of aspirating (2.41 specifically with liquids and 2.08 with purees). Let’s remember that when that patient is made “NPO except medications and sips!”

Stay Tuned for Part 3

References

FEES References (listed chronologically):

1. Langmore, S.E., Schatz, K. & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2, 216-219.
2. Langmore, S.E., Schatz, K. & Olson, N. (1991). Endoscopic anad videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100 (8), 678-681. 
3. Langmore, S.E. & Logemann, J.A. (1991). After the clinical bedside swallowing examination: What next? AJSLP, September, 13-20.
4. Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103. 
5. Leder, S.B. & Sasaki, C.T. (1997). Identifying silent aspiration with a fiberoptic endoscopic evaluation of dysphagia (FEED). Dysphagia, 12, 117.
6. Leder, S.B., Ross, D.A., Briskin, K.B. & Sasaki, C.T. (1997). A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy. JSLHR, 40, 1352-1357. 
7. Leder, S.B. (1998). Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phys Med Rehabil, 79, 1264-1269.
8. Leder, S.B., Sasaki, C.T. & Burrell, M.I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13, 19-21. 
9. Leder, S.B., Cohn, S.M. & Moller, B.A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13, 208-212. 
10. Leder, S. (1999). Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury. Journal of Head Trauma Rehabilitation, 14 (5), 448-453. 
11. Aviv, J.E., Kaplan, S.T., Thomson, J.E., Spitzer, J., Diamond, B. & Close, L.G. (2000). The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): An analysis of 500 consecutive evaluations. Dysphagia, 15, 39-44. 
12. Leder, S.B., & Karas, D. (2000). Fiberoptic endoscopic evaluation of swallowing in the pediatric population. The Laryngoscope, 110, 1132-1136. 
13. Leder, S.B. & Sasaki, C.T. (2001). Use of FEES to assess and manage patients with head and neck cancer. In Langmore, S.E., editor. Endoscopic evaluation and treatment of swallowing disorders. New York: Thieme; 201-212. 
14. 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.
15. Leder, S.B. (2002). Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheostomy. Chest, 122, 1721. 
16. Leder, S.B. Novella, S. & Patwa, H. (2004). Use of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in patients with Amyotrophic Lateral Sclerosis. Dysphagia, 19, 177-181. 
17. Leder, S.B., Acton, L.M., Lisitano, H.L., Murray, J.T. (2005). Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food. Dysphagia, 20, 157-162. 
18. Leder, S.B. & Ross, D.A. (2005). Incidence of vocal fold immobility in patients with dysphagia. Dysphagia, 20, 163-167.
19. Kelly, A.M., Leslie, P., Beale, T, et al. (2006). Assessing endoscopic evaluation of swallowing and videofluoroscopy: Does examination type influence perception of pharyngeal severity? Clinical Otolaryngol, 31, 425-432.
20. Kelly, A.M., Drinnan, M.J. & Leslie, P. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? Laryngoscope, 117, 1723-1727.
21. Leder, S.B., Sasaki, C.T. & Bayar, S. et al. (2007). Fiberoptic endoscopic evaluation of swallowing in the evaluation of aspiration following transhiatal esophagectomy. J Am Coll Surg, 205, 581-585. 
22. Leder, S.B. & Murray, J.T. (2008). Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am, 19, 787-801. 
23. Leder, S.B. (2012). Nil per os except medications order in the dysphagic patient. QJM: An International Journal of Medicine, 106 (1), 71-75.
24. Leder, S.B., Suiter, D.M., Duffey, D. & Judson, B.L. (2012). Vocal fold immobility and aspiration status: A direct replication study. Dysphagia, 27, 265-270. 
25. Kamarunas, E.E., McCullough, G.H., Guidry, T.J., Mennemeier, M. & Schluteman, K. (2014). Effects of topical nasal anesthetic on Fiberoptic Endoscopic Examination of Swallowing with Sensory Testing (FEESST). Dysphagia, 29(1), 33-43. 
26. O’Dea, M.B., Langmore, S.E., Krisciunas, G.P., Walsh, M. Zanchetti, L.L., Scheel, R., et al (2015). Effect of lidocaine on swallowing during FEES in patients with dysphagia. Ann Otol Rhinol Lanryngol, 124(7), 537-44. doi: 10.1177/0003489415570935
27. Neubauer, P.D., Rademaker, A.W. & Leder, S.B. (2015). The Yale Pharyngeal Residue Severity Rating Scale: An anatomically defined and image-based tool. Dysphagia, 30, 521-528. 
28. Leder, S.B., Siner, J.M., Bizzarro, M.J., McGinley, B.M. & Lefton-Greif, M.A. (2016). Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia, 31, 154-159. 
29. Marvin, S., Gustafson, S. & Thibeault, S. (2016). Detecting aspiration and penetration using FEES with and wtihout food dye. Dysphagia, Published online: 18 March 2016. DOI 10.1007/s00455-016-9703-0 
30. Neubauer, P.D., Hersey, D.P. & Leder, S.B. (2016). Pharyngeal residue severity rating scales based on Fiberoptic Endoscopic Evaluation of Swallowing: A systematic review. Dysphagia, 31, 352-359.
31. Pisegna, J.M. & Langmore, S.E. (2016). Parameters of instrumental swallowing evaluations: Describing a diagnostic dilemma. Dysphagia, 31, 462-272.            
    
    OTHER REFERENCES
32. Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16, 140–16.Daniels S.K., Schroeder M.F., DeGeorge P.C., Corey D.M. & Rosenbek J.C. (2007). Effects of verbal cue on bolus flow during swallowing. J Am Speech Lang Pathol, 16,140–16. 
33. Gross, R. D., Atwood, C. W.Jr., Ross, S. B., Olszewski, J. W., & Eichhorn, K. A. (2009). The coordination of breathing and swallowing in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 179(7), 559–565. doi: 10.1164/rccm.200807-1139OC
34. Gross, R.D. (2014). Lung volumes and their significance for pharyngeal and esophageal swallowing function. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23, 91-99. doi:10.1044/sasd23.3.91
35. Martin-Harris, et al. (2014). Respiratory-swallow training in patients with head and neck cancer. Arch Phys Med Rehabil, 96, 885-893.