FEES®: Another Tool for Dysphagia Assessment and Intervention
Idaho State University – Pocatello March 4, 2016 Presenter: John R. Ashford, Ph.D. CCC-SLP
The Clinical Picture Health Consequences (Malnutrition, dehydration, pneumonia, etc.)
SYMPTOMS
PRIMARY DISEASE
Fever Paralysis DYSPHAGIA Pain Lethargy ...
Social Consequences (stressful mealtime or eating away from home)
Psychological Consequences
(fear, anxiety, & low self-esteem suffocation, coughing, vomiting)
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12% to 30% Hospitalized Patients (Schindler et al., 2008)
44% to 87% Post-extubation Dysphagia (Leder et al, 1998; Kozlow et al, 2003)
Oropharyngeal Dysphagia 37% -78% Acute Stroke (Martino et al., 2005)
30% Multiple Sclerosis
36% Parkinson’s Disease
(Prosiegel et al., 2004)
(Mari et al., 1998)
Basic ASSESSMENT-to-INTERVENTION Paradigm Patient with Suspected Dysphagia Non-instrumental Screening Instrumental Analysis Intervention
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Non-Instrumental (Screening)
Self-Reporting Questionnaire
Instrumental (Diagnostic)
Observational Screening Test
Videofluoroscopic Swallow Study
Transnasal Video Endoscopy (FEES)
Others Poorjavad & Jalaie, 2014
Are There “Risks” For Dysphagia Present? Kertscher et al., 2014
NO – No Further Assessment or Intervention Required
YES – Proceed to Instrumental Assessment
Coughing after drinking/eating Choking episodes Wet vocal quality (?) Eye watering after drinking (?) Difficulty with some foods HX: Neurological Disorders (CVA, degenerative, trauma) • Other Complaints or DXs • • • • • •
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Newest approach: Patient self-reporting
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Patient responds to focused questions
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◦ Similar to SF-36 Health Survey- measure of functional health and well-being (Ware, 1994)
Qualitatively identifies presence, effects, & impact of disorder on patient’s quality-of-life ◦ psychosocial aspects & burdens associated with disorder New areas for intervention
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“Do you have difficulties swallowing solid food (meat, bread, etc.)?”
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“My swallowing problems frustrate me.”
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“Do you have difficulties swallowing liquid?”
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“Food sticks to the roof of my mouth when I eat.” “Do you cough while swallowing liquids?”
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Dysphagia Screening Questionnaire
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Kawashima et al., 2004 }
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The Eating Assessment Tool
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Dysphagia in Multiple Sclerosis
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Dysphagia Questionnaire
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Belafsky et al., 2008
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Hanayama et al., 2008
Dwivedl et al., 2010
RBWH Dysphagia Screening Test Cichero et al., 2009
Bergamaschi et al., 2008
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Sidney Swallow Questionnaire
Dysphapark Questionnaire Bayés-Rusiñol et al., 2011
Swallowing Quality of Life Questionnaire (SWAL-QOL) ◦ McHorney et al. 2000, 2002
Swallowing Outcomes after Laryngectomy
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Govender et al., 2012
The Deglutition Handicap Index ◦ Woisard et al., 2006
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Physical
Emotional
WHO Qualityof-Life Model
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Social/Functional }
Assessment Focus ◦ Dysphagia for certain food types; weight loss, anatomical region
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Projected Uses ◦ Identifying patient-specific concerns ◦ Determining treatment effectiveness in tandem with biomechanical functions ◦ Research: understand differences in quality of life among dysphagia subpopulations May be completed by patient, clinician, or proxy ◦ Many now translated into many different languages Short administration times ◦ 2 to 15min+ Number of questions vary per instrument ◦ 10 (Eating Assessment Tool) to 44 (SWAL-QoL) Generally use Likert Scoring Scales ◦ 0 – 3 (Swallow Disturbance Q); 0 – 5 (SWAL-QoL)
Timmerman et al., 2014; Keage et al., 2015; McHorney et al., 2000
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In practice, most do not assess adequately across all recommended WHO ICF domains ◦ SWAL-QOL is the only one ◦ Most assess “body functions & structures” ◦ Very few assess “Physical-Health condition” Keage et al., 2015
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Used as supplemental test- not adopted routinely into clinical practice Keage et al., 2015
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Difficulty reading & understanding by some patients Zraick et al. (2012)
Responses & results may be influenced by patient’s personal coping style or social support Timmerman et al., 2014
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Question sensitivity: All tools contain questions that indicate the patient is either better or worse than they really are Timmerman et al., 2014
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Screening Tool ◦ Water Screening Test usually ◦ Used to detect dysphagia only ◦ Easily administered by any medical specialist
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Clinical Examination Tool ◦ “Bedside” Exam ◦ Components
Medical History Review Physical inspection of swallow musculature Observations of swallow competence with test swallows Liquids & foods
◦ A “primarily diagnostic tool” when instrumental tools are not available Has severe limitations
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Bedside Swallowing Assessment Protocol
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Yale Swallow Protocol
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Mann Assessment of Swallowing Ability
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Gugging Swallow Screen
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(Suiter & Leder, 2014)
(Mann, 2002)
(Trapl et al., 2007)
Toronto Bedside Swallowing Screening Test
et al., 2009)
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Silent Aspiration Screening Test
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Volume-viscosity Swallowing Test
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Portable & always available
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Generally requires few tools
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Quick – 5 to 10 minutes
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Repeatable
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Very inexpensive
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Relatively safe (non-invasive)
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(Sitoh et al. 2000)
(Martino
(Wakasugi et al., 2008)
(Clave et al., 2008)
**Assist in determining if an instrumental study may be necessary
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Symptomatic only
◦ Cough, wet voice, etc.
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Not anatomical or physiological reasons
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◦ detect structural problems ◦ assess pharynx/larynx functions well ◦ predict appropriate diet ◦ detect aspiration well
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◦ Different protocols, levels, & consistencies
Rosenbek et al., 2004
Cannot . . .
Not “Standardized”
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Poorjavad & Jalaie, 2014
Poor Reliability ◦ 44%
(McCullough et al, 2000)
Cannot detect silent aspiration well
Linden et al., 1983; Logemann, 1983; Lim et al., 2001.
Rosenbek et al., 2004
Bours et al. 2009-Systematic Review ◦ 11 of 407 studies accepted. ◦ Water Tests: (5 studies)
Sensitivity Range: 27%-85% Specificity Range: 63%-88%
◦ Viscosity Tests: (4 studies)
Conclusions • Best: Water test using mix of endpoints (coughing, choking, voice combined with pulse Oximetry)
Sensitivity Range: 41%-100% Specificity Range: 57%-82%
◦ Swallow test with oxygen desaturation (2 studies) Sensitivity Range: 94%-98% Specificity Range: 63%-70%
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Screening Tests:
◦ are “indirect” ◦ cannot fully appreciate the impaired swallow event. ◦ miss 40% (avg) of patients with Silent Aspiration
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Linden et al., 1983; Logemann, 1983; Splaingard et al., 1988.
Water screening tests (alone) are “not a good tool for detecting silent aspiration.” (Lim et al. 2001)
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Purpose: to determine the safety & efficiency of the swallow event based upon anatomical/physiological factors }
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Videofluoroscopic Swallow Study Transnasal Endoscopic Swallow Study ◦ FEES or FEEST
Other Procedures ◦ Dual-Axis Accelerometry ◦ High Resolution Manometry ◦ Ultrasound ◦ Electromyography ◦ 320-Row Area Detector CT
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U"lity
◦ Visualizes oral, pharyngeal & cervical esophageal structures
Limita"ons
◦ Requires radiaNon exposure ◦ Administered in a hospital radiological suite
◦ Visualizes oropharyngeal swallow event
◦ Limited exposure Nme
◦ Determines biomechanical & temporal measures
◦ Uses barium sulfate
◦ Limited frequency of retesNng
◦ Unnatural head posiNoning
◦ May demonstrate treatment effects
◦ Radiologist or technician required
◦ Administered to most paNents, not all
◦ Referring SLP not always acNve parNcipant ◦ Higher Expense
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U"lity
◦ Administered at bedside to most paNents, not all in natural head posiNon Portable equipment
◦ May be repeated frequently ◦ Visualizes pharynx/larynx & nonswallow funcNons well ◦ Helps determine biomechanical causes ◦ May demonstrate treatment effects ◦ Staff SLP acNvely parNcipates; other staff not required ◦ Less expense
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Limita"ons
◦ Does not visualize oral cavity or cervical esophagus ◦ “White-out period ◦ Rare, but potenNal for
PaNent discomfort Gagging Nose bleeds Allergic reacNons to anesthesia (if given) Laryngospasm or vasovagal response
◦ Endoscopic equipment/special training required
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FEES has better sensitivity for detecting aspiration (87.5% v. 87%) & penetration (90% v. 81.3%)
Zhonghya et al., 2009; Gerek et al., 2005; da Silva et al., 2010; Rao et al., 2002
◦ Aspiration & penetration perceived to be greater (more severe) with FEES than VFSS Kelly et al., 2007
◦ Pharyngeal residue consistently perceived as greater with FEES. Kelly et al., 2006
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Advantages:
◦ FEES – detecting aspiration ◦ VFSS – dynamic evaluation of oral & esophageal phases of swallowing Gerek et al., 2005
Factors Criteria FEES VFSS Swallow safety evaluaNon*§ > SensiNvity 1 2 Oral anatomy View Quality 2 1 Larynx/Pharynx Anatomy* View Quality 1 2 Dynamic Physiology* Quality/sensiNvity 1 1 Comprehensive Study* 3 phases/relaNonship 2 1 Accessibility* Transport/available 1 2 Efficiency* Time/staff needed 1 2 PaNent Safety* RadiaNon/Invasion 1 2 Repeatability MulNple tests 1 2 Biofeedback Training* Live vs Recorded 1 2 *Wu et al. (1997) The Laryngoscope, 107(3), 396-401 § Kelly et al. (2007) The Laryngoscope, 117(10), 1723-1727
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Screening for dysphagia is a necessity
◦ Quickly identifies at-risk patients ◦ Prevents unnecessary assessment & treatments ◦ Self-Reporting Questionnaires should become an integral part of overall assessment process ◦ Use valid screening tests; no need to re-invent
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Instrumental tests: Only sure means . . .
◦ to determine safety & efficiency of swallowing; use them, when possible ◦ to determine effectiveness of some treatments ◦ Now-TWO Gold Standards-FEES AND VFSS!
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