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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”
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