LANGMOREADVANCED FEES COURSE · •Pryor et al, 2014 –3 MBS studeson 9 healthy, older subjects;...

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LANGMORE ADVANCED FEES COURSESUSAN E LANGMORE PHD

AGENDA FOR TODAY

• Introduction - clinical developments in protocol and miscellaneous

• Protocols – standard and customized

• Scoring - updates

• Treatment/Case studies

• Scoring practice, Interpretation

• Politics (optional)

EQUIPMENT: NEW TECHNOLOGY

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NEW FEES SYSTEMS; NEW VENDORS

WHAT IS YOUR SET-UP?

• Are you recording? Are you audio recording?

• Can you review frame by frame?

• Do you record with Manual light setting? (more)

• Are you using topical anesthesia? Decongestant?

HEY, 2015

• Reported that penetration/aspiration was detected more accurately and had higher inter rater reliability when the exam was recorded and played back frame by frame

• Hey, C, et al Penetration–Aspiration: Is Their Detection in FEESO Reliable Without Video Recording? Dysphagia, 2015.

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DO YOU RECORD WITH MANUAL LIGHT SETTING?Why is this important?

AT HEIGHT OF THE SWALLOW – FEES VIEW

Langmore fees llc ©

AFTER THE SWALLOW –


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EPIGLOTTIC INVERSION –SEEN IF MANUAL LIGHT SETTING USED


REDUCED/ABSENT EPIGLOTTICRETROFLEXION


CANNOT JUDGE EPIGLOTTIC RETURN HERE


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WHY IS IT IMPORTANT TO SEE THE RETURN OF THE EPIGLOTTIS?

• It is a direct marker for complete hyolaryngeal excursion !

• Van Daele: 20 larynges examined. Timing of movements on MBS studies analyzed. His conclusions:• 1st movement: tongue retraction and pressure on the epiglottis

• 2nd movement (down-folding) from hyoid and thyroid movement

• Both hyoid and laryngeal movement are needed for complete down-folding of the epiglottis

• Van Daele DJ, Intrinsic fibre architecture and attachments of the human epiglottis and their contributions to the mechanism of deglutition. J Anat, 1995

ARE YOU USING TOPICAL ANESTHESIA?

DECONGESTANT?

THE USE OF ANESTHESIA

• Does it compromise the swallow ?• Reduce peripheral sensation in hypopharynx

• Alter protective reflex à more aspiration?

• Does it make the patients more comfortable?

• Literature review à mixed resultsLangmore fees llc ©

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COLLABORATIVE RESEARCH: BU MEDICAL CENTER & WAKE FOREST MEDICAL CENTERThree studies…

1. Lester (2013) – normal subjects

2. Fife (2015) – patients with dysphggia

3. O’Dea (2015) – patients with dysphagia


3 COLLABORATIVE STUDIES

*Lester S, Langmore SE, Lintzenich CR, et al. The effects of topical anesthetic on swallowing during nasoendoscopy.

The Laryngoscope. 2013;123(7):1704-1708.

*Fife TA, Butler SG, Langmore SE, et al. Use of topical nasal anesthesia during flexible endoscopic evaluation of swallowing in dysphagic patients. Ann Otol Rhinol

Laryngol. 2015;124(3):206-211.

*O'Dea MB, Langmore SE, Krisciunas GP, et al. Effect of Lidocaine on Swallowing During FEES in Patients With Dysphagia. Ann Otol Rhinol Laryngol. 2015;124(7):537-544


ALL STUDIES HAD SIMILAR DESIGN

2 FEES performed• 1 exam with 4% lidocaine

• 1 exam with “sham” spray

Compared PAS scores

Compared patients’ self rating of pain


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DOSAGE VARIED WITH EACH STUDYAny difference in PAS scores in 2 conditions?

1. Lester (normals) = 1 ml lidocaine

YES- significant difference in 2 conditions (p = 0.002)

2. Fife (dysphagic patients) – 0.5 ml lidocaine

NO signif difference, but close (p = 0.06)

3. O’Dea (patients with dysphagia) - 0.2ml lidocaine

NO signif difference. (p = .16 - .89)


STUDY #3: RESULTS (PAS SCORES)


2 conditions not significantly different

FINDINGS RE: PAIN LEVEL

• Wong-Baker FACES Pain Scale scores collected at scope insertion, during examination, and after scope removal


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ALL STUDIES HAD SAME RESULT REGARDING PATIENT COMFORT

• The exam with lidocaine was rated more comfortable than the exam with the sham spray

• When broken down into pain during insertion, pain during the exam, and pain during withdrawal…….

• Biggest difference seen during Insertion of the scope

STUDY #3: RESULTS (PAIN SCORES)


Pain scores oninsertion were signifdifferent

MY CONCLUSION

• 0.2ml of 4% lidocaine does NOT worsen PAS or residue scores in patients with dysphagia

• …but it DOES increase comfort of a FEES exam (specifically during scope insertion)


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NASAL DECONGESTANT IS USEFUL

• Afrin (oxymetazoline) or Neosynephrine (phenylephrine)

• Some avoid decongestants during pregnancy – not proven to be safe/ not cross the placenta barrier




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WHAT FOOD/LIQUID ARE YOU USING?

FOOD IDEAS


HOW DO YOU MAXIMIZE VISUALIZATION OF CLEAR LIQUIDS?

• Adding barium powder to liquid is no longer an option

• You need a liquid that coats the mucosal surface

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MILKPLUS GREEN FOOD COLOR


WHITE FOOD COLOR/- ADD TO WATER-PLUS GREEN FOOD COLOR 5ML = 4 DROPS, 15 ML=8 DROPS? PLUS ADD A LITTLE GREEN FOOD COLOR


IS IT NECESSARY TO DYE THE FOOD AND LIQUID?

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LEDER, ET AL, 2005• 20 subjects: 9 got dyed food/liquid; 11 subjects got yellow

pudding and white skim milk• 2 drops of FD&C Blue No. 1 dye in 60 cc pudding and 120 cc of

skim milk

• 3 raters scored Penetration and Aspiration

• Results: excellent agreement among the raters for both conditions

• Conclusion: Use light colored food and liquid; blue does not enhance visibility

• DISCUSSION

MARVIN, 2016: COMPARED GREEN DYE VS. NATURALLY WHITE LIQUIDS• 43 patients; 2 exams each same patients(with, without

dye; randomized)

• Thin milk and Hormel nectar thick milk with, without green food color (1 ml dye/30/20ml thin; 1 ml dye/30ml thick)

• Results: Signif difference in 2 conditions; More events of aspiration scored when bolus dyed green – for nectar thick and thin liquids, all volumes – and for scoring secretions

Marvin S, et al, Detecting aspiration and penetration using FEES with and without food dye. Dysphagia 2016.

HOW ARE YOU AND THE PATIENT POSITIONED FOR A FEES?


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IDEAL OP POSITIONING


INPATIENT EXAM


INPATIENT – BETTER POSITIONING


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CHANGES IN RECORDING – IN THE FUTURE?

• Standard now is 30fps; when slowed down, picture is series of jumpy/discontinuous shots

• High Speed camera : records 4000 fps; then replayed at 500 fps ; the picture is continuous

• Aghdam, Comparison of visual recognition of the laryngopharyngeal structures , Dysphagia 2017

AGHDAM’S STUDY

• Visualization of most movements were enhanced with high speed camera’s output (when slowed down to 500 fps)

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RELEVANT NEW RESEARCH

DOES THE PRESENCE OF AN NGT IMPAIR SWALLOWING? SHOULD YOU PERFORM THE FEES WITH OR WITHOUT THE NGT?

• Leder & Suiter 2008 – FEES: 1260 patients (similar in diagnosis, etc) ; half with NGT; half without NGT

• Results: no diff in incidence of aspiration

• Pryor et al, 2014 – 3 MBS studes on 9 healthy, older subjects; no NGT, 8French, 16Fr. NGTs

• Thin liquid, pureed, and diced fruit

• Results: Significantly worse PAS scores with small NGT (mostly

penetration)

SUITER, D., MOORHEAD, KM EFFECTS OF FLEXIBLE FIBEROPTIC ENDOSCOPY ON PHARYNGEAL SWALLOW PHYSIOLOGY, 2007.

• 14 patients examined via fluoro, with & without a 3.5 mm laryngoscope in place (same patient) Randomized order• 2x 10ml liquid barium

• Laryngeal elevation duration, PAS measures• Results: No signif difference in 2 conditions in

swallow duration measures (total swallow duration, pharyngeal delay, duration of laryngeal elevation; # of swallows to clear the bolus) or PAS


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ADACHI 2017: VIDEOENDOSCOPY WORSENS SWALLOWING FUNCTION: A VIDEOFLUOROSCOPYSTUDY

37 patients given fluoro, with/without endoscope in place (random order)

10 ml liquid; 2 swallows total

Scored pharyngeal delay, PAS, and residue

Results: PAS signif worse; residue score signif worse with scope in place!

WHY THE DISCREPANCY? Hard to compare the 2: different consistencies, methods

• More studies needed.


DZIEWAS R, DO NASOGASTRIC TUBES WORSEN DYSPHAGIA IN PATIENTS WITH ACUTE STROKE? BMC NEUROLOGY, 2008

• 125 acute stroke patients; FEES to observe placement of NGT• Their NGTs were (4.7mm or 5.3mm; 14, 16 French) They

noted the position of the tube: Correct (down lateral wall) or misplaced (over midline of epiglottis or coiled)• 5/100 patients had misplaced NGT; better swallow

when re-positioned


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DZIEWAS, CONT’D

• Part 2: 18 patients got FEES without and with NGT• Results: no difference in penet, asp, or residue except for

patients with malpositioned NGT where residue stuck to the NGT and fell into the piriforms or laryngeal vestibule• More residue and penetration with misplaced tube • This was attributed to material sticking to the feeding tube

(=residue) and penetrating the laryngeal vestibule after the swallow

3 Videos: Scoring Abnormal FindingsResidue NGT food on FT; residue NGT applesauce; residue NGT cracker

RECENT STUDY ON SAFETY AND IMPACT OF FEES

Dziewas, et al (2019) (not yet published)

• Safety: 2401 patients from 25 hospitals in Germany: missc diagnoses• 2% complications - self limiting, all resolved

• Impact: in >50% of exams, feeding strategies were changed; most patients had upgrade in diet

•Conclusions: FEES is very safe!

RECENT STUDY ON PHYSIOLOGY OF SWALLOWING: WHITE OUT: WHAT DOES IT TELL US?

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ANALYZING WHITE OUT DURATION• 30 healthy volunteers ages 21 – 74

• FEES with different volumes, consistencies

• Raters scored duration of white out: from the first totally white frame until the WO was lost and the HP and laryngeal structures became again clearly visible

• (25 frames/sec, so not as precise as 30 fps)

• Mozzanica et al, Effect of age, sex, bolus volume, and bolus consistency on whiteout duration in healthy subjects during FEES. Dysphagia, 2018

WHAT CAUSES WHITE OUT DURATION?

Closure of airspace around tip of laryngoscope

Represents the height of the swallow;

as the base of tongue contacts pharyngeal walls + pharyngeal

constrictors close off the airspace;

bolus is moving through the pharynx

Time of closure of pharynx

Duration of pharyngeal phase?

Duration of pharyngeal pressure wave

RESULTS: DURATION OF WHITEOUT

Range = 591 +/- 113ms. (478 – 704 ms)

• Longer as bolus size increases

• Longer with more solid consistencies

• Longer in men than women

• Longer in old than young

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ANALYZING WHITE OUT DURATION

1 sec = 1000ms = 30 frames

½ sec = 500ms = 17 frames

Each frame = .333 sec

(Normal = 591 ms (=20 frames) +/-113 ms (478-704 msWhat if white out is shorter than 478 ms (16 frames)?

What does it mean?

PINK – OUT

REDUCED PHARYNGEAL SQUEEZE FOR SWALLOWING

LANGMOREADVANCED FEES COURSE · •Pryor et al, 2014 –3 MBS studeson 9 healthy, older subjects;...

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