1. The Use of Fibreoptic Endoscopic Evaluation of Swallowing (FEES) with Complex Dysphagia Vanessa Richards & Zoë Sherlock Clinical Lead Speech & Language Therapists

2. 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

3. Clinical Examination  Assessment involves:  Full case history  Oro-motor examination  Oral trials as appropriate with strategies, texture modification  Unreliable in detecting aspiration

4. 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

5. 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

7. VF- Aspiration

8. Limitations of VF  Not suitable for some patient groups e.g. critically unwell, high O 2 requirements, tracheostomy, bed-bound, severe kyphosis, claustrophobia, severe agitation/confusion  Cost and staffing  Radiation exposure  Difficulty with access  Uses barium

9. 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

13. 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

14. FEES

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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”