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.

 

We here at SDX know that an SLP can always better their craft through education which is why we asked Karen Sheffler, MS, CCC-SLP, BCS-S to share her expertise with us. 

 

Please enjoy the article “The Proof is in the Pudding: A Tribute to Steven Leder & His Contributions to FEES” which has been broken up into 3 sections.

Can you imaging not being able to safely and easily swallow a delicious chocolate pudding? How would that affect your quality of life?

June is National Dysphagia Awareness Month. Dysphagia Awareness means quickly identifying a person’s swallowing problem (dysphagia) before adverse events happen, as well as preserving that person’s quality of life.

What better way to commemorate Dysphagia Awareness Month than to honor the legacy of Steven Leder, PhD, CCC-SLP (Formerly of Yale University School of Medicine since 1991). He tirelessly promoted patient safety, by creating valid and reliable screening methods to identify a person’s risk of aspiration (Read More: Aspirations & Lessons from Steven Leder). Additionally, armed with the reliable and valid instrumental examination called the Fiberoptic Endoscopic Evaluation of Swallowing (FEES), he fought to prevent unnecessarily restrictive care, dispel “erroneous logic” (23), and remind clinicians what they can and cannot detect without instrumental evaluations. Read more from Steven Leder (2015, SIG13) on this topic with: Comparing Simultaneous Clinical Swallow Evaluations and Fiberoptic Endoscopic Evaluation of Swallowing: Findings and Consequences

Steven Leder and Joseph Murray, PhD, CCC-SLP, BCS-S (22) summarized this well:

“If the clinical (bedside) evaluation does not provide sufficient information to allow for confident patient management, an instrumental assessment should be performed (p788).”

They noted that the goal of the FEES is to evaluate the safety and efficiency of the swallow for improved nutrition and hydration and “for the maintenance and enhancement of quality of life.” Imagine being discharge from the hospital on a pureed diet with honey thickened liquids. Your first question would be: how long do I have to eat and drink this stuff? A FEES can be performed easily at your rehabilitation center or skilled nursing facility to guide your diet upgrades.

With FEES, clinicians and people with difficulty swallowing are “rewarded with an unequaled view of airway protective patterns,” and it is “a sensitive tool for detecting laryngeal penetration and aspiration,” per Leder and Murray (22, p791). When Leder wrote about a FEES exam in which he witnessed aspiration of pudding that triggered a cough reflex, which ejected a previously aspirated pill, he stated: (23, p 73)

“The proof, was literally, in the pudding.”

In 2008, Leder & Murray assured clinicians that after 20 years of research, FEES and Videofluoroscopic Swallow Studies (VFSS) have equivalent sensitivity and specificity. The VFSS is no longer considered the only gold-standard.

Goals of this article

This article will briefly explore the now 30-year history of FEES, with a special focus on Dr Leder’s work from 1997 to 2016 (references are listed chronologically to reflect history).

I will review Leder’s early contributions, research regarding the benefits of FEES, some of his work with specific populations, and finally other exam considerations (i.e., the use of dyes and the need for a residue rating scale).

This is not meant to be an exhaustive summary of FEES history, but it must start with Dr Langmore.

The Early Days of FEES: A New Procedure

In 1986, Susan Langmore, PhD, CCC-SLP, BCS-S, along with her colleagues in speech-language pathology and otolaryngology developed the Fiberoptic Endoscopic Examination of Swallowing Safety (FEESS) at the Department of Veterans Affairs Medical Center in Ann Arbor, Michigan. In 1988, they published the first article, describing this new procedure (1) and how they modified the standard otolaryngology assessment of the larynx to include the direct view of the pharyngeal stage of swallowing and aspiration. They marveled at how the clinician may see aspiration better before and after the swallow than with the VFSS, as one is not limited by the radiologist turning the camera on and off.

The team changed the procedure’s name to Fiberoptic Endoscopic Examination of Swallowing (FEES) with the 1991 publication. In this second publication (2), they studied 21 subjects, comparing FEES to videofluoroscopic (VFSS) results. However, these studies were not simultaneous, so some normal variation was to be expected when detecting penetration, aspiration, residue and premature spillage. FEES detected all patients with penetration and all but one case of aspiration and residue. Also in 1991, Langmore debated with Jeri A. Logemann in “After the Clinical Bedside Swallowing Examination: What Next?” (3). I love how Langmore practically described the game of Twister in positioning a patient for the videofluoroscopic swallow study. “We were all tired, in pain, and hot.” Additionally, she said the observed aspiration was “no more representative of his true swallowing status than if we had asked him to swallow upside down” (3, p16). Even with special swallow study chairs, Langmore noted that positioning still “requires considerable effort on the part of hospital staff” (3, p20). In response to the white-out period during the actual swallow, she stated that with training and experience, the clinician “can learn how to interpret the swallow… quite satisfactorily” (3, p17). Aspiration is predicted accurately as patients leave behind evidence in the larynx and trachea (1).

The American Speech-Language Hearing Association (ASHA) endorsed the procedure and created guidelines in May of 1991. (Here is a link to the Latest ASHA Positioning Statement)

Leder’s Early Contributions to FEES:

In the mid 1990’s, Steven Leder collaborated with Clarence Sasaki, MD, Otolaryngologist to stress the importance of early identification of silent aspiration. They first presented on endoscopic evaluation at the 1996 Dysphagia Research Society Meeting (5). Did you know that they initially called the examination “FEED” for Fiberoptic Endoscopic Evaluation of Dysphagia (5)? However, by the time of their 1997-1998 publications, Leder and colleagues returned to the term FEES (6,7,8).

In 1998, Leder, Sasaki & Burrell were the first to use a large sample size, reporting on a heterogeneous population of 400 subjects (age 10 to 101). They showed that FEES was a reliable and patient-friendly method to identify silent aspiration (8). They cautioned that up to 30% of patients referred for clinical bedside evaluations of swallowing at the acute phase may be silent aspirators. Agreement between FEES and VFSS (aka, MBS or Modified Barium Swallow studies) reached 96%. Again, the studies were not simultaneous (i.e., a subject did not aspirate during a VFSS but did so silently on the FEES).

Leder, et al (1997) noted in a prospective, double-blind, randomized study that there was no significant difference in comfort levels when the nares was treated with topical anesthetics or vasoconstrictors versus a placebo or nothing at all (6). By demonstrating this, Leder proved that trained and experienced speech-language pathologists could perform FEES independently. That was a huge contribution to clinicians in the field of dysphagia.

Side Note: Recently, research has indicated that small amounts of topical nasal anesthetics do not affect swallowing. Specifically, 2% gel lidocaine applied to one nares with a cotton-tip applicator did not alter sensation in the pharynx or larynx and did not change swallowing physiology, delay the swallow response, or increase penetration or aspiration (25). O’Dea and colleagues determined that a dose of 0.2 ml of 4% lidocaine to the nares was appropriate and did not increase penetration, aspiration or residue, even in patients with dysphagia (26).

In the early 1990’s Jonathan Aviv, MD, F.A.C.S and colleagues from Columbia University added an air pulse method of testing of sensation, creating the Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST). In 2000, Aviv and team studied patient safety and tolerance without topical anesthesia in 500 consecutive examinations (11). More than 99% of the FEESST evaluations were successfully completed, and 81% of the patients rated their discomfort as none to mild. Only two patients with amyotrophic lateral sclerosis (ALS) were unable to tolerate the passage of the scope (11). However, Leder, et al (2004) studied 17 consecutive patients with ALS and only one additional patient had refused testing (16). Five out of the 17 patients even had multiple FEES as their disease progressed. He showed that FEES was “ideally suited for this particular patient population (p180)” due to the following:
      • ability to visualize pooled secretions that are predictive of aspiration on food and liquid,
      • avoidance of irradiation in order to perform a longer assessment to determine if fatigue is an issue, and
      • ability to repeat the study as often as is needed.

Langmore and Leder, among others, have written extensively about the many benefits of FEES. Langmore mentioned in 1988 that FEES is indicated for people who are in nursing facilities, but little did she know then how mobile and portable the equipment would become.

Let’s take a more detailed look at why you would evaluate with FEES.

Why FEES

As stated by Langmore in 1988, FEES is not meant to replace videofluoroscopic studies, but speech-language pathologists and healthcare providers need to know when to select FEES as the method of choice (1). Both tests help explain the nature of the dysphagia (3). As instructed by Leder and Murray in 2008, the skilled endoscopist makes appropriate referrals for further testing. For example, the VFSS better visualizes the oral and esophageal phases of the swallow, as well as the submucosal elements (22). The decision of which test to choose is based on your specific patient’s needs and your clinical questions (Read more: Good Dysphagia Evaluation Guides Treatment).

It is often pointed out that FEES avoids the need for schedule coordination with the radiology department and eliminates radiation exposure (1), but there are many more reasons to perform a FEES.

FEES Benefits: Why and When FEES is Needed

• Transport to the radiology suite, mobile swallow study van, or hospital for the VFSS may be impossible due to:
      ◦Fatigue, anxiety and agitation with transport may hinder swallowing performance (3)
      ◦Positioning issues: essentially bedridden, kyphotic, severe arthritis, bariatric, too weak/paralyzed, quadriplegic, contracted, pressure sores/ulcers causing pain, or when the shoulder blocks the hypopharynx and upper esophagus (1,2,3,22)
      ◦ Many tubes and lines tethered to the patient (e.g., on a ventilator) (1,2,3,22)
      ◦ Critically ill and cannot leave the intensive care unit (1,2,9,22)
      ◦ Poor respiratory status: patient cannot tolerate aspirating even a trace of barium      in foods and liquids. A FEES can evaluate secretion management, ability to phonate and cough, and protect the airway. You can carefully assess only ice chips (1,2,4,22). Patients with pooled secretions, especially in the laryngeal vestibule, have an increased likelihood for aspiration of food and/or liquid (4).
      ◦ Minimally alert: again, the clinician can assess if the patient is pooling and aspirating secretions (1).
• Answer the question: “Can my patient swallow with safety,” in an immediate or at least timely fashion, especially when discharge is eminent (1,3).
• Identify aspiration and dysphagia early to reduce pulmonary complications. If the FEES does find that a patient can swallow safely, then oral feeding will not be delayed, which reduces length of stay and lowers medical costs (9).
• Examine at bedside, especially important for critically ill trauma patients (9).
• Test without the need for specific directions for patients with significantly reduced mental status (1). Pt is allowed to swallow spontaneously without any commands to swallow, which can alter function and timing (32).
• View actual structures and pharyngeal and laryngeal anatomy (1,2,3,31).
• Assess for velopharyngeal incompetence, nasal regurgitation and identify the source of perceived hypernasality (22).
• Assess pharyngeal and laryngeal sensation for airway protection. Note the patient’s reaction to the scope and the movement of the structures in reaction to the bolus (1,2).
• Localize secretions, bolus position and residue with great precision (1,2,3,4).
• Assess vocal fold movement (1,2,3,18,24). Vocal fold immobility can be noted by the SLP. “Natural airway protection becomes a real entity.” (3, page 17)
• Assess vocal cord adduction and anterior arytenoid tilt prior to the swallow. This can be an anticipatory protective mechanism in response to large bolus sizes (3).
• Monitor time period before and after the swallow closely. Whereas, during the VFSS, you only see a few swallows, and the camera may be turned off too quickly or not back on fast enough (1).
• Serial retesting may be necessary to document progress or decline in function (7,8,22).
• Provide real-time visual feedback during swallowing therapy (22).
• Digitally record the videoendoscopy for careful frame-by-frame review (8). You can also educate your patient, family and medical team, showing them the video after the study.
• Test many therapeutic interventions without a time limit. Whereas, during a VFSS, the study must be fairly short to limit radiation exposure. Testing many strategies in a longer study is especially helpful when the patient’s intake and quality of life depend on a diet upgrade (22).
• Use regular food and not barium-laced foods and liquids. Barium paste may add too much moisture to foods when you may want to assess crumbly textures. Barium can be constipating. Additionally, barium may affect the viscosity, familiarity, flavor, and palatability (8).
• Assess at a meal in a functional, real-life situation (poor positioning and all). You can see not only if fatigue increases as the meal progresses, but also if positioning, rate of intake, and method of feeding will impact safety (22).

Contraindications to FEES:

• Immediate post-op and recovering from general anesthesia (11)
• Acute facial fractures (22)
• Recent refractory epistaxis (nose bleeds) (22)
• Bilateral obstruction of nasal passages (22)
• Severe agitation or inability to cooperate (1, 22)

Stay Tuned for Parts 2 and 3.

More About Karen:

Karen Sheffler, MS, CCC-SLP, BCS-S graduated from the University of Wisconsin-Madison in 1995 with her Master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr John (Jay) Rosenbek, Dr JoAnne Robbins, and Dr James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. 

Karen is a medical speech-language pathologist. She worked in skilled nursing facilities and rehabilitation centers in the 1990’s, and has been in acute care in the Boston area since 1999. She trained graduate student clinicians during their acute care internships for over 10 years. Special interests are too numerous to list, but they include neurological conditions, geriatrics, end-of-life considerations, oral hygiene and aspiration pneumonia and patient safety/risk management. She has lectured on dysphagia in webinars, at hospitals, at the MGH Institute of Health Professions, at Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society (DRS), the National Foundation of Swallowing Disorders (NFOSD), and the Special Interest Group 13: Swallowing and Swallowing Disorders. 

Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. Karen embraced the world of social media in 2014 when she founded SwallowStudy.com: a Dysphagia Resource for Professionals and Patients. She was the official dysphagia blogger for the ASHA convention in 2014 and was the official blogger for the Dysphagia Research Society’s annual meetings in 2015 and 2016. You can follow her on Twitter at https://twitter.com/swallowstudySLP and on Facebook at https://facebook.com/swallowstudySLP, as well as on Pinterest at https:// http://www.pinterest.com/swallowstudySLP/

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.