How can aspiration “during the swallow” be diagnosed with FEES when you cannot see the airway during the swallow?
It is true that there is about four-tenths of a second ‘during’ the swallow known as “white-out” when the airway cannot be visualized on FEES because the pharynx squeezes around the endoscope’s camera and causes a white colored reflection on the computer screen. Evidence of the aspiration during the swallow is identified by comparing the view of the airway before the swallow and then right after the swallow. FEES allows for visualization of the anatomy in color and up close. The product of the aspiration during the swallow can be viewed immediately after the “white-out”. If a patient aspirates during the swallow, there will be an observable green color below the level of the vocal cords in the patient’s trachea (wind pipe). Remember, the FEES procedure allows for a magnified view of the airway with direct visualization of the first couple tracheal shelves by advancing the endoscope to post-swallow position.
In addition, the literature shows that aspiration occurs only about 7% of the time ‘during’ the swallow! The majority of aspiration occurs either before or after the swallow, which can be seen with amazing clarity on FEES. The ENTIRE FEES procedure is being recorded, unlike the MBSS (videoswallow) where the fluoro is turned off in between swallows to reduce radiation exposure to the patient. Literature suggests the MBSS is NOT always capturing aspiration after the swallow from residue or backflow from the esophagus. It is also important to remember that in comparison to the MBSS, the FEES procedure is better at capturing the ‘true picture’ of what is going on with pt in natural eating position self feeding, allowing for assessment of fatigue over time, identifying etiology of pill dislodgment, determining the need for ENT/GI consults for suspected laryngeal pathologies, assessing secretion management, and identifying whether unilateral weakness is impacting the swallow.
When should I request a physician’s order for FEES?
The patient is ever changing during the critical/acute care phase; therefore, the instrumental swallow report from the hospital stay may not accurately portray the patient’s current performance. Also, rather than the patient being fully upright with shoulders down and fed one bite/drink at a time by someone else during fluoroscopic assessment, the FEES procedure captures the patient in his/her ‘natural’ eating position self feeding. This type of assessment may be best suited once the patient has discharged from the hospital to a less critical level of care (LTACH, Rehab Hospital, SNF, LTC). A swallow evaluation should not solely be used as a reactionary ‘after the aspiration fact’ assessment. It is a preventative, cost effective tool, especially to determine safety of solid/liquid status and decrease re-hospitalizations for pneumonia, acute respiratory distress, UTIs, etc.
Are there any contraindications for FEES?
FEES should NOT BE completed on patients with recent facial/maxillar/nasal fractures or surgery, severe nose bleeders (epistaxis), hemophilia, bilateral nasal obstructions, or history of severe laryngospasms.
FEES CAN BE completed on patients with isolation precautions, obesity, medical complexity, pressure ulcers, dementia, nasogastric feeding tubes, other types of feeding tubes, supplemental oxygen (nasal cannula), tracheostomy tubes, speaking valves, and ventilator dependence.
Is the FEES procedure painful?
There may be slight pressure and discomfort as the scope is passed through the nose, but once the scope is in place most patients tolerate the procedure very well. Keep in mind sensation is usually decreased in the geriatric and medically complex populations, so many patients do not feel the scope the way you would! During FEES, the endoscope does not actually enter the esophagus or trachea like it does during procedures such as NG tube placement, bronchoscopy, or EGD. Based on research findings, the presence of the scope does NOT affect swallow function. Questionnaires from research studies reveal that most patients would be willing to repeat the exam. And remember, the scope does not puncture any tissue, rather follows the natural curvature of the passage from the nose to the throat.
Is there use of topical anesthetics during the FEES procedure?
We do not use topical anesthetics because in our experience patients tolerate the procedure very well. Properly trained SLPs/Endoscopists are taught to “pass the scope” in a gentle way on the floor of the nare, slightly different than the typical Ear Nose & Throat doctor using ‘numbing’ agents. The nasal passage is generally the most narrow (most uncomfortable) at the posterior section of the nare. If topical lidocaine is placed here, there is a high risk for the anesthesia to decrease sensation in the hypopharynx. We do not want to risk changing patient sensation which may alter true swallow function. We are so confident of patient tolerance, even in the dementia population, that if we do not successfully pass the scope you are not charged a penny!
What are the patient risks associated with FEES?
The risks are minimal with the most common being a slight bloody nose (epistaxis). Please refer to the Research section within this website which outlines the potential risks and associated rate of occurrence for endoscopic procedures.
Are SLPs providing accurate recommendations clinically at bedside?
NO! The literature overwhelmingly agrees that SLPs have proven to be under-estimating and over-estimating the occurrence of aspiration at bedside or in the dining room about 50% of the time. Determining the etiology of the dysphagia and providing accurate diet/liquid recommendations will:
- (1) Reduce the cost of modified or alternative intake (tube feedings, thickened liquids, pureed solids, etc.) by upgrading pt’s diet/liquid status quicker;
- (2) Decrease the cost associated with hospital re-admissions for treating pneumonia, respiratory distress, UTI, electrolyte imbalance, etc.;
- (3) Direct the facility SLP in specific treatment planning (especially for neuromuscular electrical stimulation placement of electrodes);
- (4) Increase therapeutic outcome statistics by treating the true IMPAIRMENT rather than the symptom;
- (5) Assist patient/family in decision making by providing valuable information on the true etiology of the dysphagia; and
- (6) Improve patient quality of life!
Please refer to FEES vs. MBSS section within this website to likely answer more of your questions.