The Proof is the Pudding (Part 1)

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.


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 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 and on Facebook at, as well as on Pinterest at https://


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 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.

Happy Dysphagia Awareness Month

Handy-dandy dysphagia scoring tools is a great VALIDATED questionnaire to screen new admits…at this link it’s available online and here is a link to the PDF as well…
I’ve used it even as interview questions for family members in cases where the resident can’t easily communicate and I’m trying to determine if a resident’s dysphagia has oral, pharyngeal and/or esophageal components.  It helps support our reason for evaluation and treatment in cases where an obvious supporting medial diagnosis may be lacking.    
While we’re all NOM-ed out and G-coded beyond reason, we often overlook other scores that may be useful in showing changes over time like the Functional Oral Intake Scale…
Another useful interview tool for those with esophageal complaints is the Reflux Symptom Index
Keep showing that evidence!  It makes Medicare happy and hey, they foot the bill.  

Unthicken the Thickener

When we think about thickening liquids, it’s truly important to understand how beneficial SPECIFIC diet recommendations are…Can the resident tolerate shakes and supplements that are less viscous than most pre-thickened liquids? Can they tolerate straight tomato juice or apricot nectar? What about “mixed consistencies” like pills with liquid, noodle soup or even mandarin oranges? The best way to know what is safest is to test it out…One of the primary advantages to FEES-ing in post-acute care is that you can test anything, and you can test it over multiple trials. Enjoy these resources, they certainly put levels of thickened liquids into perspective. Because thicker isn’t always better!


thickener comparisons

viscosity chart common things liquids

viscosity levels for oral enteral feedings from nutrition411

thickener image

Alzheimer’s and Dementia


There are more than 3 million cases of people being diagnosed with Alzheimer’s Disease per year in the United States. Alzheimer’s, for those who do not know, is a progressive disease that destroys memory and other important mental functions and has no cure. Similarly there are also over 3 million cases of people being diagnosed with Dementia per year in the United States and it also does not have a cure. Dementia is a group of thinking and social symptoms that interferers with daily functioning.

If your in the healthcare industry and you work closely with individuals with alzheimer’s follow the link people to find helpful tips on communicating effectively with those who suffer from alzheimer’s


feeding.tubes.advanced.dementia from American Geriatrics Society

It has been commonly seen that Alzheimer’s and Dementia can hinder the swallowing process. The link below provides details on common asked question concerning Alzheimer’s/ Dementia and feeding.

assisted_oral_tube_feeding Alzheimer’s Assoc position on feeding tubes


Patients suffering from Alzheimer’s can experience sundowning which is the restlessness, agitation, irritability, or confusion that worsens as the daylight fades. Read the article provided below on hoe to better handle sundowning






Mouth Care Tips

The topic for this weeks blog is healthcare. I have included a few youtube videos, one explains how to use the Oral Health Assessment Tool (OHAT) and the other explains mouth care training of both residents and for staff training. shows how to use the OHAT is excellent for staff training, even addresses mouth care for residents with care-resistant behaviors.

Shefali Patel which gives 101 information on mouth care. Patel is a speech therapist who is the founder and primary clinician at Ganga Learning & Rehab. She is certified in PROMPT training, Vital Stim Therapy, interactive metronome, and NICU. Patel has over seventeen years of work experience in health care. She if found of methods that include: yoga, acupressure, aromatherapy, brain gym, the listening program and among many others. Below is an article she wrote out in regards to mouth care using the lung washing method. For information on Patel visit her website at

Lung washing is actually a process, where the diseased lung is flooded with saline solution and cleansed while the healthy lung ventilates the body. This twice-a-day lung scrub is a super tip to keep your resident’s lungs cleaner and freer of harmful oral bacteria. Without further delay….here’s how to do it in three simple steps:

  1. Open your mouth
  2. Stick out your tongue
  3. Wipe it using a tongue cleaner, three scrubs.   Please do not forget to repeat at bedtime.  Oral health maintenance is so important for limiting complications associated with aspiration especially in our medically fragile elderly population.

The connection between the tongue and the lung?  First, the harmful oral bacteria (harmful enough  to cause heart disease and even kill a growing fetus) as well as the biofilm on the tongue contains toxins that our digestive system spews up onto the tongue overnight.  These toxins can easily infiltrate the lungs. In individuals with dysphagia (swallowing disorders), especially as a result of neuro- and immune-comprising diseases like Parkinson’s, Dementia, CVA, COPD and others, the risk of  pulmonary infections such as pneumonia is already high. Add to that pre-existing risk a fresh supply of bacteria infiltrating the lungs from the tongue daily and and you get pneumonia  It’s no surprise that for U.S. adults pneumonia is the most common cause of hospital admissions other than women giving birth.

Second, there is no second as important as the first.  The first is enough:  Oral hygiene is incomplete without tongue scrubbing. A couple scrapes a day keep the doctor away!  You may not want to use the underside of the metal spoon (it works, though!) so take a look at a U-shaped thin stainless steel scrapper (Ayurveda is one, available on Amazon).

In addition to scrubbing away bad breath (halitosis), increasing dental hygiene and improving your taste by better exposing those taste buds, your overall body health gets a deep acupressure massage. all by tongue scrubbing. How?

Screen Shot 2016-05-11 at 2.57.50 PM.png

The tongue is a mapped out to reflect all the internal organs just like your hand.  All energy meridians pass through the tongue and hence the Shastras of the East recommend scrubbing your lung…I mean your tongue three times, twice a day!

Shefali Patel CCC SLP


SDX Resources

The healthcare industry has a habit of releasing written work that is geared towards  professionals in the field, not taking into consideration that there are people who want to be informed that are not familiar with most medical terms. Here at SDX we have a desire to inform the public in anyway we can. While doing research there were a few articles that I found to be very informative and more importantly easy to read, I have listed them below.

Follow this link to read more about medications and swallowing with regard to Dysphagia. Articles are from the American Speech- Language and Hearing Association

Here is a list of medications that impact swallowing and why. The list was put together by the state of Connecticut, you may want to consider posting the flyer throughout your facility to keep yourself and others informed.


Important points for the SLP: Beers now includes proton pump for inhibitors as potentially in appropriate due to increased risk for bacterial infection….Why? Low acid means a bacteria-friendly environment! Aspirators of refluxate on PPIs are likely to get pneumonia because their stomach content is HIGH in bacteria. Read more below

Beer Criteria



Mouth Care Tips

Does mouth care stress you out? Follow these tips for better mouth care in  your  facility.

    • Talk about MOUTH care instead of oral care.
  • Talk about FACTS
    • Good mouth care can PREVENT 1 in 10 pneumonias***
    • Brush 2 mins 2x a day
    • By writing GOALS for mouth care, you can spend BILLABLE TIME training staff
      • Example,”Pt will spit two times during mouth care with cues from assisting staff to reduce the risk of developing aspiration pneumonia.”
      • YOUR SKILL is the skill of assessing:
        • who is at risk to develop PNA
        • how that risk can be reduced
  • And don’t forget to PICK AND CHOOSE your battles…
    • Soak dentures, BUT STILL BRUSH THEM
    • FLOSSING makes MORE OF A DIFFERENCE than brushing
    • BAN TOOTHETTES for residents with teeth
    • If you have to skip the toothpaste, so be it.  BRUSHING is what makes the difference.
  • Train staff to be patient—Not every resident will allow mouth care right away.  Relationship building is a huge part of successful mouth care programming.  Other helpful hints:
    • Sing to the resident
    • Use a mirror so they can watch
    • Use hand over hand to facilitate participation and carryover

See the evidence with SDX

You know that an SDX FEES gives you the freedom of testing REAL food right in the resident’s room, in their typical eating position, allowing the resident to eat independently or even to be fed by staff or family members.  You know an SDX FEES is the optimal test for a resident when you are concerned about fatigue.
But do you know…
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A FEES provides that perfect top-down view that lets us actually view the tissue, identifying atypical redness, edema and cobblestoning that accompany reflux.  Because we are able to view after the swallow, we can keep monitoring for cricopharyngeal backflow as long as needed during a FEES.  When backflow occurs, we can then assess for the resident’s reaction, looking for the triggering of a reswallow and backflow clearance, or identifying the resident’s inability to clear the backflow.  Unlike an MBS, an SDX FEES lets you see what happens CONTINUOUSLY, with no “on and off” switch.
Know what’s really happening even after the swallow with SDX FEES!
 If you think your resident is having pharyngeal dysphagia complications with an underlying reflux, call your SDX FEES Specialist to review the case.
An SDX FEES can help identify strategies that work to minimize the impact of backflow.  Full-color photos actually show tissue irritation, facilitating MD diagnosis and treatment of reflux.


Alzheimer’s and Caregiving

alzheimers-fb I am getting on my soapbox and talking about the role of the SLP as a primary caregiver to residents with dementia and dysphagia.  When our resident stops eating, what do we do? What do we recommend when we do a FEES and see that nearly all consistencies are aspirated?  How do we document these recommendations?
To tube or not to tube is not our decision to make, but it is within our scope to provide education to residents, their caregivers, and our facility staff.  ASHA provides guidance to the SLP through Frequently Asked Questions About Alternative Nutrition and Hydration, a document created by Special Interest Group 13, Swallowing and Swallowing Disorders.  Click here to visit ASHA’s resource page for end of life issues in SLP.
There are references galore that instruct residents, families, and other professionals to use the support of the interdisciplinary team to assist in decision making, and most importantly in this process, to be guided by the facts.  Three stellar position papers are linked below:
The American Geriatrics Society presented an updated Feeding Tubes in Advanced Dementia Position Statement  in July of this year.  It gives strong rationales for its position that feeding tubes are not recommended for older adults with advanced dementia, and that careful oral (hand) feeding should be offered because it is “at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort.”
From the Alzheimer’s Association, 

be shared with a resident’s decision maker and other family members, as well as other professionals.  It emphasizes the benefits of assisted oral feeding over a PEG, and discusses the importance of advanced directives planning for residents with dementia.  

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.


More Success by Saying Less


Those of you who know me know how much I talk…I’m a speech therapist right?  Well, turns out saying less CAN mean more. I had the pleasure of participating in LSVT LOUD.  It is a very dynamic training with research to support its success.  It really got me thinking, how can I help my dysphagia clients with what I just learned?  I can do a FEES, I can establish how to make a difference, but how do I invest my patient in therapy?  If I can make therapy meaningful to my resident, carryover can be successful!
Next time you are getting frustrated with training swallowing strategies, ask yourself:

Why does this matter to the resident?

  • Make it a point to connect therapy to their wants and needs…do they want to eat without being embarrassed by their coughing?  Do they want to stay healthy for the next 6 months to attend a grandchild’s wedding?  Do they want to be able to eat prime rib at that event?
Take a step back.  Think about what you are asking of the resident.  Focus on their abilities and teach to their abilities.
“Do what I do” are 4 of the most powerful words in teaching a skill.  Remove the thinking about what they need to do, stop talking about what they need to do, and teach the skill by example–SHOW what they need to do by doing it yourself first. Show it over and over again, and aim to make it automatic.  Be persistent, and be consistent! Gandhi’s wisdom can be taken literally when you practice being the change you wish to see.