The Use of Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

with Complex Dysphagia

Vanessa Richards &Zoë Sherlock

Clinical Lead Speech & Language Therapists

Considerations…

Over 123,000 patients admitted with a primary or secondary diagnosis of dysphagia in 20013/14

Mean LOS = 7 days Dysphagia and

aspiration highly associated with pneumonia and death

Clinical Examination

Assessment involves: Full case history Oro-motor

examination Oral trials as

appropriate with strategies, texture modification

Unreliable in detecting aspiration

Tools to Bedside Assessment

Cervical auscultation (Stroud et al 2002, Leslie et al 2003)

Pulse oximetry (Wang et al 2005, Higo et al 2004)

Both unreliable in detecting aspiration

Videofluoroscopy

Dynamic fluoroscopic imaging procedure Assessment of oral, pharyngeal and oesophageal

stages Views in lateral and antero-posterior planes Uses barium Exposure to radiation Conducted in radiology dept. Medically unwell or immobile patients unsuitable

VF- Aspiration

Limitations of VF

Not suitable for some patient groups e.g. critically unwell, high O2 requirements, tracheostomy, bed-bound, severe kyphosis, claustrophobia, severe agitation/confusion

Cost and staffing Radiation exposure Difficulty with access Uses barium

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

Flexible nasendoscopy used Assessment of pharyngeal and laryngeal anatomy

and physiology Assessment of secretions Uses real food Minimal risks and contraindications Repeatable Can be done at bedside

Advantages of FEES

Very high risk of aspiration Evaluation of secretion management Visualisation of altered laryngopharyngeal

anatomy/physiology Suspected impairment of sensation Extended assessment possible Uses real food/fluid Biofeedback Repeatable Can be done on unit

FEES

Case Study

71 year old lady admitted with peritonitis due to C. diff. Transfer to GICU post total colectomy & ileostomy

PMHx: L thyroid lobectomy (diffuse large B cell

lymphoma) L TVF palsy. Dysphagia and dysphonia Post op. pharyngo-cutaneous fistula requiring

NBM and PEG

Case History Cont.

FEES 1 - ++ upper airway secretions. No pooled secretions in pharynx/larynx. L TVF palsy. Poor compensation from R. Silent aspiration

Return to theatre & surgical tracheostomy Pseudomonas in sputum No air leak around trache with cuff ↓ on

bedside ax

Case History Cont.

FEES 2 ↑ airway closure but weak SP and BOT with pre-swallow loss on all oral trials with silent aspiration. Remain NBM with dysphagia exercises

Tolerating SV. Good voice FEES 3 Much improved. No overt aspiration

with thin and soft but silent aspiration on puree. Started on ‘tasters’ due to fatigue

Case History Cont

Failed mini-trache trial due to copious secretions

FEES 4 Not suitable for VF due to secretions and infection. Occasional pre-swallow loss. Residue build-up with thicker consistencies. Poor sensation on-going. Left on ‘tasters’ chilled water only

Decannulated

Case History Cont.

FEES 5 Reduced sensation but improved movement and cough. Diet ‘tasters’ introduced using strategies

Diet increased to half portions FEES 6 Laryngeal penetration with

increased amounts fluid. Improved with chin tuck and double swallow. Soft/normal diet

Discharged after monitoring at bedside In hospital for 4 months

In Summary…

FEES essential because: silent aspiration bed-bound, O2 and suction reliant infection status bio-feedback for pt. and husband implementation of strategies and therapy repeatable risk management in view of acuity and complexity of

presentation informed MDT management

To Conclude…

FEES is an essential part of dysphagia management for in and out-patients with complex dysphagia

“Just wanted to say a quick thank you for your help today. You really helped me understand what is happening functionally in my throat, & more importantly, what I can do to alleviate the situation. I can’t begin to convey what a relief it is to know that things can be under ‘my’ control again after your excellent explanations & guidance.  Really appreciated being shown the images too seeing what is actually happening with explanations that this layman can understand”