Information About the FEES^® Procedure

The Kay Swallowing Workstation contains a complete FEES system which is used at our facility. Although the Kay system contains additional modules (e.g., for acquisition of physiologic data), this application note focuses solely on the FEES procedure.

The use of fiberoptic endoscopy to evaluate the pharyngeal stage of swallowing is a procedure which was developed by Susan Langmore, Ph.D., Kenneth Schatz, M.A., and Nels Olsen, M.D., at the Ann Arbor VA Medical Center. This procedure is known as the Fiberoptic Endoscopic Evaluation of Swallowing or FEES (Langmore, et al., 1988). As part of their routine laryngeal examination, otolaryngologists typically use flexible endoscopy to screen for the presence of a dysphagia. Although it uses the same tool, FEES is not a screening procedure, but rather, a complete assessment of the pharyngeal stage of swallowing. It includes five components: assessment of anatomy as it affects swallowing, assessment of movement and sensation of critical structures within the hypopharynx and laryngopharynx, assessment of secretions management, direct assessment of swallowing function for food and liquid, and response to therapeutic maneuvers and interventions to improve the swallow. The purpose of the procedure is to diagnose a pharyngeal stage dysphagia, to determine the underlying anatomic or physiologic cause of the dysphagia, and to enable the examiner to make recommendations regarding the safety of the swallow, the advisability of oral feeding, and use of appropriate behavioral strategies that facilitate safe and efficient swallowing.

The FEES procedure is a portable examination, easily taken to bedside or wherever the patient needs to be examined (the Kay system has a custom-built cart which conveniently houses all components). A fiberoptic laryngoscope is passed transnasally to the hypopharynx, where the larynx and surrounding structures are viewed. The patient is then led through various tasks to evaluate the sensory and motor status of the pharyngeal and laryngeal mechanism. Food and liquid boluses are then given to the patient so that the integrity of the pharyngeal swallow can be determined. Information obtained from this examination includes ability to protect the airway, the ability to sustain airway protection for a period of several seconds, the ability to initiate a prompt swallow without spillage of material into the hypopharynx, timing and direction of movement of the bolus through the hypopharynx, ability to clear the bolus during the swallow, presence of pooling and residue of material in the hypopharynx, timing of bolus flow and airway protection, sensitivity of the pharyngeal/laryngeal structures and the effect of anatomy on the swallow. The most critical finding is aspiration, and FEES is able to detect this finding with good sensitivity (Langmore, et al., 1991; Crary et al., 1996). Patient response to residue, penetration, and aspiration of the bolus are noted and observations are made over several swallows in order to assess a more natural eating environment. Appropriate postural changes and swallowing maneuvers are attempted as soon as problems are detected so that the examiner can determine the optimal interventions to improve the safety and efficiency of the swallow. Details of the FEES procedure can be found in Langmore, et.al (1988, 1991, 1996).

The Role of Speech-Language Pathology as the Endoscopist.

Typically, a speech-language pathologist or an otolaryngologist is the endoscopist for this examination. Sometimes, the two disciplines perform the examination jointly. The FEES examination is not intended to replace the standard otolaryngological evaluation of the structural integrity of the hypopharynx/larynx. Speech pathologists are not qualified to make decisions regarding mucosal or structural abnormalities which indicate medical pathology. The FEES examination is intended solely to assess function for swallowing and speech pathologists are qualified to make functional diagnoses such as dysphagia. Physicians make medical diagnoses, such as CVA, head & neck cancer, etc., which account for the dysphagia.

In 1992, the American Speech-Language-Hearing Association published a written position paper stating that the practice of endoscopy to evaluate voice or swallowing function was within the scope of practice of speech-language pathologists (ASHA, 1992). Specific training guidelines have not been officially established by ASHA, but it is stated in the same position paper that prior to performing endoscopy, a speech-language pathologist is bound by the ASHA Code of Ethics to be adequately trained. A task force within the ASHA Special Interest Division - Dysphagia is working on the development of training and competency guidelines for this procedure which will eventually become official ASHA policy. In the meantime, speech pathologists are advised to develop their own training requirements for staff who want to perform this procedure within their institutions. As with any other semi-invasive procedure, it is imperative that any person performing this procedure seek and obtain clinical privileges, or a similar "seal of approval" from their institution before performing it independently.

How to Implement FEES in Your Practice

1. Develop and submit a policy to implement FEES in each institution where you practice.

   If FEES is not already established in an institution, the procedure needs to be approved by the medical director before it can be provided as a clinical service. A written proposal should be submitted which includes a description of the procedure, its purpose, reimbursement information, and the anticipated benefits to the patients. The use of a topical anesthetic needs to be clarified (i.e., who will administer it, what anesthetic will be used, etc.). Possible adverse reactions and medical backup that will be available during the exams needs to be specified. If FEES will be done in an institution where a physician is not immediately available, as in a nursing home or outpatient clinic, a registered nurse may provide medical backup. If a nurse passes nasogastric feeding tubes, he/she will be aware of the complications that may result from performing a FEES exam and should be capable and prepared to deal with these in the unlikely event that they occur. The nurse should be present for each exam and should monitor the patient during the exam. He/she may also serve the role of feeding the patient.

2. Obtain training in FEES.

   Suggested training for FEES recommended by S. Langmore:

   a) Completion of a seminar or workshop in the use of fiberoptic endoscopy as a procedure for investigating pharyngeal swallowing function, equivalent to those taught by Dr. Langmore. The didactic training should cover indications for a FEES exam, protocols to follow, identification of salient findings, interpretation of findings, and discussion of possible risks associated with flexible endoscopy. The instructor should be well-qualified to teach the course. A minimum of 16 hours training is suggested.

   b) Observation of one or more FEES procedures done by a clinician with full clinical privileges in this procedure. Review of the tape, discussion of findings and interpretation of results should follow the examination.

   An alternate means of satisfying (a) and (b) would be to obtain on-the-job training with an experienced speech-language pathologist who performs FEES regularly and who can teach the necessary information to the trainee.

   c) Performance of approximately 25 endoscopic procedures under the direct supervision of a person who hold clinical privileges in flexible nasoendoscopy, and preferably, who is experienced in performing FEES procedures. The suggested number given here is an average; some clinicians will need considerably more practice before they are competent; others will be competent after performing fewer than 25 examinations. Ideally, these procedures will be FEES exams done on patients with dysphagia to evaluate their swallowing function so that both the technical and cognitive skills required of this procedure can be tutored. However, if no such person is available, the technical skills can be taught by any experienced endoscopist. The first few procedures should probably be done on ‘normal volunteers’. The proctor must be physically present for each of these exams and is responsible for the patient. More than one proctor can be utilized for training.

   d) Successful completion of a certified CPR course.

3. Obtain clinical privileges to perform FEES..

Each practitioner who wishes to perform FEES needs to seek and obtain clinical privileges (or something equivalent to clinical privileges) before they can perform it independently. Clinical privileges are institution-specific and do not carry over to different settings, therefore, the application for privileges must be approved at each institution where the procedure will be done. Privileges imply independent performance of a procedure; clinicians are not privileged if they must perform the procedure under supervision. Applications for clinical privileges are reviewed and granted by a body composed of members of the medical staff at that institution and only that body can grant privileges to the applicant. In many institutions, speech-language pathologists do not generally hold clinical privileges; therefore, something equivalent to privileges, but which carries another name, may need to be obtained. It is important that some official document be produced, however, which grants approval to the clinician to perform the procedure independently in that institution.

Upon completion of the training requirements outlined above or otherwise specified, the applicant should submit a formal request for clinical privileges (or something equivalent to clinical privileges) to perform FEES procedures. The application is submitted to the appropriate medical board that reviews and grants privileges. It should document the completion of all training requirements listed above, contain a dated list of all endoscopy procedures done under supervision, and the signature of the primary clinicians(s) who directly trained the applicant in endoscopy. The primary supervisor/proctor should state in writing that he/she holds privileges in flexible endoscopy and that in his/her opinion, the applicant has demonstrated competence in both the technical and cognitive skills needed to perform FEES procedures and that he/she supports the applicant’s request for clinical privileges.

Application for renewal of privileges should be done annually or biannually, as the institution requires. In order to maintain clinical privileges, the applicant should perform on an annual basis a minimum of 50% of the number of procedures which were required for obtaining privileges.

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FEES^® is a registered trademark of Susan Langmore, Ph.D.

References

American Speech-Language-Hearing Association, "Instrumental Diagnostic Procedures for Swallowing." ASHA, Vol. 34 (March, Suppl .7), pp. 25-33, 1992.

American Speech-Language-Hearing Association, "Sedation and topical anesthetics in audiology and speech-language pathology." ASHA, Vol. 34 (March, Suppl. 7), pp. 41-42, 1992.

Crary, M.A. & Baron J. "Endoscopic and fluoroscopic evaluations of swallowing: Comparison of observed and inferred findings." Presented at the Dysphagia Research Society Annual Meeting, Aspen, Colorado, November 1, 1996.

Langmore, S., Schatz, K., & Olson, N. "Fiberoptic endoscopic examination of swallowing safety: A new procedure." Dysphagia, Vol. 2, pp. 216-219, 1988.

Langmore, S., Schatz, K., & Olson, N. "Endoscopic and videofluoroscopic evaluations of swallowing and aspiration." Ann Otol Rhin Laryn, Vol. 100, pp. 678-681, 1991.

Langmore, S.E. & McCulloch, T.M. "Examination of the pharynx and larynx and endoscopic examination of pharyngeal swallowing." In Deglutition and its Disorders. eds. A. Perlman and K. Schultz, Singular Press, San Diego, 1996.

Prepared by Susan E. Langmore, Ph.D.
11/15/96

Addendum - 2/28/97

A Dysphagia.SID Task Force is currently working on Training and Competency Guidelines for persons interested in performing FEES. This draft document should be ready mid-1997 and will be published in the SID newsletter for peer review. In the meantime, the training outlined above can be used as a guide. There are relatively few formal FEES workshops currently being offered, but several sites are interested in sponsoring FEES workshops. You are welcome to call the VA Medical Center for information about workshops offered there or elsewhere at (313) 761-7579, ask for Tim McGuigan, or e-mail: langmore.susan@ann-arbor.va.gov.

Indications for a FEES or Fluoroscopy Examination

The first step in the process of assessing a patient with dysphagia is to perform a clinical examination. The chart review, providing a medical history and current status and a patient/caregiver interview constitutes the preliminary steps, followed by a sensory-motor examination and cognitive screening. If the patient is eating a PO diet, the speech-language pathologist will want to observe him/her during a meal. Otherwise, swallowing can be assessed with trial foods or with ice chips, water, flavored swabs added to the patient’s saliva, or with no external bolus at all (saliva swallows).

If, following the clinical examination, the speech-language pathologist decides that an instrumental examination is indicated, she/he must decide whether to perform a fluoroscopy or FEES examination. The indications listed below give practical and clinical indicators for each examination. Of course, this is a matter of clinical judgment and exceptions will always be found. In many situations, either examination will be effective. The goal of both procedures is to determine the presence of an oropharyngeal dysphagia, to reveal the nature of the dysphagia, and to determine under what conditions, if any, the patient is able to take different consistencies orally, without undue risk for aspiration and in sufficient quantity to meet caloric needs.

In some settings, fluoroscopy is not readily available, whereas a portable FEES unit can be done that same day. In those cases, a FEES examination may be utilized simply because it is more convenient. This may be acceptable for many cases, however, convenience must never be the total determining factor. If the clinical picture indicates the need for fluoroscopy, this examination should be done. Perhaps, depending on your billing situation, a FEES could be done as an interim procedure until the fluoroscopy procedure can be performed. Although it is the rare case that needs both examinations, we do have the following rule of thumb: whenever the problem is not fully explained by one procedure, we follow it with the other. Invariably, this has answered our questions.

Indications for a FEES Exam (Practical Indications; Clinical Indications)

Need exam that day

Positioning in fluoroscopy problematic - e.g., patient bedridden, weak, has contractures, in pain, has decubitis ulcers, quadriplegic, wearing neck halo, obese, on ventilator.

Transportation to fluoroscopy problematic - medically fragile/unstable patient (in ICU; cardiac or other monitoring in place; on ventilator; nursing/medical care must be with patient)

Transportation to hospital problematic - nursing home issues, including cost of transportation, resources needed to accompany patient, strain on patient, patient fearful of leaving familiar surroundings, etc.

Concern about excess radiation exposure

Severe dysphagia with very weak or possibly absent swallow reflex and/or very limited ability to tolerate any aspiration; e.g., brainstem stroke, patient tube fed for prolonged period, very poor pulmonary status, poor immunologic status. Concern about aspiration of barium, food, and/or liquid in these patient indicates the need for FEES which can give you a more conservative examination.

Post-intubation or post-surgery - esp. CABG, carotid endarterectomy, or any surgery where RLN was vulnerable) Endoscopy can visualize larynx directly for signs of trauma or neurologic damage and assess laryngeal competence.

Tracheostomy if you suspect laryngeal competence may be compromised

Need to assess fatigue or swallow status over a meal

Repeat exam to assess change; to assess effectiveness or need for maneuvers

Therapeutic exam that requires time to try out several maneuvers, several consistencies, etc.; you want to try real foods; you want caregiver to hold baby in several positions, etc. or you want to try biofeedback

When these clinical symptoms are present:

- Hypernasal voice

- Hoarse, breathy voice

- Wet voice quality

- Rapid respiratory rate; effortful breathing

- Inability to handle saliva/secretions - wet breathing, need for suctioning, drooling

Indications for Fluoroscopy (Practical Indications; Clinical Indications)

Patient will not accept/tolerate endoscopy

Suspected oral stage problem that should be imaged

Esophageal stage problem or GER suspected; want to visualize esophageal motility and GE reflux

Globus complaints; possible CP dysfunction

Vague symptomotology from patient; need comprehensive view

Need to identify which bolus propulsion force/ structural movement is weak (e.g., tongue vs. laryngeal elevation)

Need to verify aspiration of thin liquids during the swallow

Need to get better impression of amount of aspiration

What Findings are Revealed Better Endoscopically and Fluoroscopically?

The following list is a summary of my observations after using both tools for several years. I think the two tools really complement each other, simply because you are imaging different structures, from a different orientation, and at different points in time.

Clinical findings better revealed endoscopically:

Anatomical relations; alterations in anatomy, edema

Effect of large bore feeding tube or recent endotracheal tube on anatomy and swallowing

Velopharyngeal closure; nasal reflux

Frequency of spontaneous or dry swallows

Status of secretions; ability to sense, swallow, or clear secretions

Respiratory rate, rhythm and effect of respiratory problems on swallowing

Ability to achieve and maintain airway closure to protect airway

Pharyngeal/laryngeal sensation

Status of airway protection during bolus spillage (before the swallow)

Location of spillage; penetration of spillage

Vocal fold/arytenoid movement at onset of swallow

Amount, location of residue (after the swallow)

Residue build-up, patient response to residue

Aspiration of residue after the swallow

Fatigue over a meal, possibly leading to aspiration

Effectiveness of postural change to alter path of bolus flow.

Ability to hold breath volitionally or sustain breath holding.

Effect of different bolus consistencies, temperatures, taste on the swallow.

Esophageal- to- pharynx reflux

Laryngeal signs of GERD

Clinical findings revealed better fluoroscopically:

Tongue containment, mastication of the bolus

Tongue propulsion at onset of swallow

Coordination of oral and pharyngeal movements

Arytenoid contact to epiglottis during the swallow

Completeness of epiglottic retroflexion during the swallow

Hyoid elevation

Laryngeal elevation

Cricopharyngeal opening; timing of CP opening

Airway closure at level of arytenoid to epiglottal contact

Aspiration during the height of the swallow

Esophageal clearance

Gastroesophageal reflux

Ability to produce effortful swallow and Mendelsohn maneuver