The Proof is in the Pudding (Part 2)

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


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.            

  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 Med179(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.


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