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)

©2016. SA Swallowing Services, PLLC.

1

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

©2016. SA Swallowing Services, PLLC.

2

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 •  •  •  •  •  • 

©2016. SA Swallowing Services, PLLC.

3

} 

Newest approach: Patient self-reporting

} 

Patient responds to focused questions

} 

◦  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

} 

“Do you have difficulties swallowing solid food (meat, bread, etc.)?”

} 

“My swallowing problems frustrate me.”

} 

“Do you have difficulties swallowing liquid?”

} 

} 

“Food sticks to the roof of my mouth when I eat.” “Do you cough while swallowing liquids?”

©2016. SA Swallowing Services, PLLC.

4

} 

Dysphagia Screening Questionnaire

} 

–  Kawashima et al., 2004 } 

} 

The Eating Assessment Tool

} 

Dysphagia in Multiple Sclerosis

} 

Dysphagia Questionnaire

} 

–  Belafsky et al., 2008

} 

–  Hanayama et al., 2008

–  Dwivedl et al., 2010

RBWH Dysphagia Screening Test –  Cichero et al., 2009

–  Bergamaschi et al., 2008

} 

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

} 

–  Govender et al., 2012

The Deglutition Handicap Index ◦  Woisard et al., 2006

} 

Physical

Emotional

WHO Qualityof-Life Model

} 

} 

Social/Functional } 

Assessment Focus ◦  Dysphagia for certain food types; weight loss, anatomical region

} 

} 

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

©2016. SA Swallowing Services, PLLC.

5

} 

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

} 

Used as supplemental test- not adopted routinely into clinical practice –  Keage et al., 2015

} 

} 

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

} 

Question sensitivity: All tools contain questions that indicate the patient is either better or worse than they really are –  Timmerman et al., 2014

} 

Screening Tool ◦  Water Screening Test usually ◦  Used to detect dysphagia only ◦  Easily administered by any medical specialist

} 

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

©2016. SA Swallowing Services, PLLC.

6

} 

Bedside Swallowing Assessment Protocol

} 

Yale Swallow Protocol

} 

Mann Assessment of Swallowing Ability

} 

Gugging Swallow Screen

} 

(Suiter & Leder, 2014)

(Mann, 2002)

(Trapl et al., 2007)

Toronto Bedside Swallowing Screening Test

et al., 2009)

} 

Silent Aspiration Screening Test

} 

Volume-viscosity Swallowing Test

} 

Portable & always available

} 

Generally requires few tools

} 

Quick – 5 to 10 minutes

} 

Repeatable

} 

Very inexpensive

} 

Relatively safe (non-invasive)

} 

(Sitoh et al. 2000)

(Martino

(Wakasugi et al., 2008)

(Clave et al., 2008)

**Assist in determining if an instrumental study may be necessary

©2016. SA Swallowing Services, PLLC.

7

} 

Symptomatic only

◦  Cough, wet voice, etc.

} 

–  Not anatomical or physiological reasons – 

} 

◦  detect structural problems ◦  assess pharynx/larynx functions well ◦  predict appropriate diet ◦  detect aspiration well – 

} 

◦  Different protocols, levels, & consistencies – 

Rosenbek et al., 2004

Cannot . . .

Not “Standardized”

} 

} 

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%

©2016. SA Swallowing Services, PLLC.

8

} 

Screening Tests:

◦  are “indirect” ◦  cannot fully appreciate the impaired swallow event. ◦  miss 40% (avg) of patients with Silent Aspiration – 

} 

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)

?

Purpose: to determine the safety & efficiency of the swallow event based upon anatomical/physiological factors } 

} 

} 

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

©2016. SA Swallowing Services, PLLC.

9

} 

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

} 

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

©2016. SA Swallowing Services, PLLC.

} 

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

10

} 

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

} 

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

©2016. SA Swallowing Services, PLLC.

11

} 

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

} 

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!

©2016. SA Swallowing Services, PLLC.

12