STROKE AND FIBEROPTIC
ENDOSCOPIC EVALUATION
OF SWALLOWING (FEES) IN A
CANADIAN ACUTE CARE
SETTING
AJAY MYSORE NARASIMHA
Key Learning Goals
1. Appreciating the benefits of FEES in an
acute care setting
2. Usefulness of FEES in acute stroke
2
London Health Sciences Centre: Did You
Know?
• One of Canada’s largest acute care teaching
hospitals
• Serves the needs of the London- Middlesex
community
• Provides the broadest range of patient services of
any hospital in Ontario
• More than one million patient visits each year
3
LHSC: Speech-Language Pathology
(S-LP)
• 12.5 FTE S-LPs at two sites
 University
 Victoria
Hospital
Hospital
4
Pre-FEES: Assessment of Adults with
Dysphagia
• Clinical Assessment
• Instrumental Assessment:
 Modified Barium Swallow (MBS)
5
MBS: Challenges
• Exposure to radiation
• Environmental Factors:


Use of barium
? Naturalistic
• Patient factors:




Transportation
Medical fragility
Positioning
Education
• Reports
6
MBS: Challenges
• Number of appointment times


12 Victoria Hospital
11 University Hospital
• Wait times
• Limited times
• Physician consent
7
NPO: A Tough Sell
• For the patient:





Patient quality of
life
Tube feeding and
equipment
Nursing time
“Burden” of care
Discharge
destination and
timing
• For the team:
“This is holding up
discharge”
 “How are we going to
give medications?”
 “If he is aspirating, can
it be
tolerated?”

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How were we going to solve this?
9
10
Systems Thinking
“Systems thinking organizes complexity into a
coherent story that illuminates the causes of
problems and how they can be remedied in
enduring ways” ~ Peter Senge
11
Systems Thinking 101
“Integrative thinkers build models rather than choose
between them
• Consider customers, employees, competitors,
capabilities, cost structures, industry evolution, and
regulatory environment
• View the problem as a whole, rather than breaking it
down and farming out the parts
• Creatively resolve tensions without making costly
trade-offs, turning challenges into opportunities"
http://www.rotman.utoronto.ca/
•
12
So How Does this FEES Initiative Fit With
“Systems Thinking”?
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Systems Thinking and FEES
Complex Situation
Shared Reality – Shared Vision
Surfaced Assumptions
Leveraged Actions
Significant Change
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FEES: The Proposal
• Capital equipment proposal
• Collaboration with Otolaryngology and
Respirology
 Dr. Kevin Fung
 Dr. David Leasa
• Potential benefits of FEES
15
Approval…What Next?
• Finding equipment



Request for tender
Review of equipment
Procurement of a FEES system
• Establishing a process



Nasendoscopy (Delegation vs. Directive)
Nasendoscopy training…where, when, how, with whom
FEES: procedures and documentation format
• Executing the training

Use of and transition to independence
• Selecting the paradigm

Autonomy and efficiency
16
Medical Directive
• Education and skills to complete
nasendoscopy
• Indications and contraindications
• Risks, complications and solutions
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Where Are We Now?
• All SLPs achieved competency between
September 2012 - January 2013
• Continued use of FEES in the clinical
setting
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THE STROKE JOURNEY
24
ER
SWALLOWING
SCREEN WITHIN 24
HRS
HOURS
FAIL
PASS
72
SLP CONSULT
HOURS
ORAL DIET
BEDSIDE
SWALLOWING AX
FEES
MBS
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ACUTE STROKE DYSPHAGIA SCREENING TOOL
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CANADIAN BEST PRACTICE STROKE
GUIDELINES
 Patient has to be screened within first 24 hours of
admission (Evidence Level C)
 Instrumental assessment should be performed on all
patients with high risk for aspiration or based on
bedside swallowing assessment , stroke location
(brainstem stroke etc.) or other clinical features (e.g.,
multiple strokes etc.) (Evidence Level B)
 The decision to proceed with tube feeding should be
made within 72 hours/3 days of admission in
collaboration with patient, family or Substitute
Decision maker and inter-professional team.
(Evidence Level B)
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FEES IN ACUTE STROKE
DYSDYSPHAGIA
AND PNEUMONIA
 The reported incidence of dysphagia in acute stroke with
instrumental assessment is 64% to 78% . (Martino et.al
2005)
 Incidence of pneumonia in acute stroke 16% to 19%
(Martino et.al 2005)
 The risk of pneumonia dysphagia > without dysphagia,
dysphagia +confirmed aspiration > dysphagia without
aspiration (Martino et.al 2005)
 > 3 fold increase in pneumonia risk in stroke patients with
dysphagia (Martino et.al 2005)
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FEES IN ACUTE STROKE
SENSITIVITY AND SPECIFICITY
 Good inter- and intra-rater reliability between FEES
and MBS on Rosenbek Penetration and Aspiration
Scale (Kelly et al, 2007)
 Incidence of pneumonia was significantly lower with
FEES than MBS in stroke patients (Aviv, 2000)
 FEES has better outcome (behavioral and dietary) in
stroke as it readily identifies fatigue of the
pharyngeal phase and effect of fatigue (Aviv, 2000)
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FEES IN ACUTE STROKE
SAFETY
FEES could be performed within 48 hours of onset of
stroke symptoms
>80% of patients reported no or mild discomfort
during FEES
(Warnecke et.al, 2008)
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FEES IN ACUTE STROKE







 AADVANTAGES OF FEES
Immediate and repeated assessments
Better visualization and information regarding
sensory/afferent component compared to MBS (Aviv
2000)
Can be used as a bio-feedback tool
Able to assess secretion management
Visualization of anatomic soft tissue , anomalies (e.g.,
vocal cord paralysis etc.)
Portable to bedside
Test patients who are difficult to position or transport
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FEES Truisms
FEES TRUISMS
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Discharge Facilitated
CASE STUDY 1
• 71 year old female with history of kyphosis from NH
• Right Middle Cerebral Artery (MCA) stroke, dense left hemiplegia,
unilateral Upper Motor Neuron (UMN) dysarthria on Thursday night
• Not a TPA candidate
• Failed dysphagia screening due to left facial droop
• Seen by SLP Friday a.m. for a clinical swallowing assessment inconsistent clinical signs of penetration/aspiration therefore NPO
recommended
• Kyphosis preclude positioning for an MBS
• Also, no MBS slot until Tuesday
• FEES completed Friday afternoon – patient initiated on a pureed solids
with regular thin liquids
• NG tube was avoided
• Discharged to stroke rehab – day 5
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Bio-Feedback Tool in Treatment
CASE STUDY 2
• 55-year-old man post brainstem stroke with subsequent
tracheostomy due to aspiration of secretions
• Admitted to the ICU
• Dysphagia managed by nasogastric tube
• Able to follow directions and participate in therapy to rehabilitate the
swallow
• Repeated FEES studies completed with the goal of providing
biofeedback/visualization
• First step, learning to swallow secretions and utilizing a volitional
cough to laryngeal vestibule
• Decannulation in one week with improvement in secretion
management
• Second step, within two week, patient learned chin tuck maneuver
and initiated a full fluid diet
• Nasogastric tube removed
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The Story So Far….
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Questions
1. How has FEES influenced the number of
patients receiving MBSs?
2. How has FEES influenced the number of
swallowing referrals?
3. How has FEES impacted the use of
instrumental assessments?
4. How has FEES impacted inter-professional
care ?
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Why?
 Fees fever picture
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How has FEES impacted interprofessional care ?
• Results perceived as more “credible”
• Greater agreement with recommendations
• Better understanding of the swallowing
impairment
• Recognition for contributing towards access
and flow
•
“You can do that today?!”
• Enhanced professional profile
empowerment
staff
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Future Directions for our Department
Related to:
1. FEES
2. Clinical Excellence
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Future Directions
Related to FEES:
1. Setting up our tool kit with on site staff
training
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Future Directions
Related to FEES:
1. Incorporation into the student placement
experience
2. New staff: A different training model
3. Data collection: Trends through statistics
4. Research opportunities
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Future Directions
Related to Clinical Excellence:
1. Carry over to other disorders
•
Continue case studies
2. Carry over to other projects
•
Model
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In Summary
• Fees proven to be a useful method of performing instrumental
assessments in in and outpatients across multiple patient
populations especially in Acute Stroke.
• FEES has been found to be an alternative to MBS and can be
utilized effectively in the acute care setting
• FEES may allow for early optimal assessment for stroke patients
with medical fragility, dependence on the ventilator, difficulty with
positioning, or fatigability
• Quicker instrumental assessment for stroke patients resulting in
earlier swallowing/nutrition plans and facilitating discharge to
most appropriate medical setting (e.g., rehab)
• The initiation of FEES has influenced MBS usage at LHSC
• The reduction of MBS usage has the potential to reduce costs for
the organization
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Acknowledgments
• Drs. Fung and Leasa who provided tremendous
support, expertise, and time in assisting us with the
introduction of “FEES” at LHSC
• Dr. Vanessa Burkoski for recognizing the impact of
FEES on patient care and supporting this significant
financial investment
• Donna Bandur for seeing the potential in FEES and
championing this initiative
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References
• Acceptance of Delegation of a Acceptance of Delegation of a. (2008). Retrieved
September 1, 2013, from CASLPO OAOO:
http://www.caslpo.com/Portals/0/positionstatements/mpsdeleg.pdf
• A Guide to Medical Directives and Delegation. (n.d.). Retrieved September 1,
2013, from Federation of Health Regulatory Colleges of Ontario:
http://www.regulatedhealthprofessions.on.ca/WHOWEARE/default.asp
• Aviv JE. Prospective, randomized outcome study of endoscopy versus modified
barium swallow in patients with dysphagia. Laryngoscope. 2000;110:563-574
• Kelly AM, Drinnan MJ, Leslie P. Assessing penetration and aspiration: How do
videofluroscopy and fiberoptic endoscopic evaluation of swallowing compare?
Laryngoscope. 2007; 117:1723-1727.
• Leder SB, Sasaki CT, Burrell MI. Fiberoptic endoscopic evaluation of dysphagia
to identify silent aspiration. Dysphagia. 1998;13:19-21
• Lindsay, M. P., Gubitz, G., Bayley, M., & Philips, S. (2013). Canadian Best
Practices and Recommendations for Stroke Care. Canadian Stroke Best
Practices and Standard Group. Retrived from
http://www.strokebestpractices.ca/wpcontent/uploads/2010/10/Ch4_SBP2013_Acute-InpatientCare_22MAY13_EN_FINAL4.pdf.
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References
• Langmore SE, Schatz K, Olsen N. endoscopic and videofluoroscopic evaluation
of swallowing and aspiration. Ann Otol Rhinol Laryngol. 1991;100:678-681
• Langmore, S. E. (2001). Endoscopic Evaluation and Treatment of Swallowing
Disorders. New York: Thieme NewYork.
• Leder, S. A. (2005). Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with
and without Blue-Dyed Food. Dysphagia, 157-162.
• Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia
after stroke: Incidence, Diagnosis, and Pulmonary Complications. Stroke.
2005;36:2756-2763.
• Senge, P. (1990). The fifth discipline: the art and practice of the learning
organization. New York: Doubleday.
 Steele, C. M. (2008). Practice Standards and Guidelines for Dysphagia
Intervention by Speech-Language Pathologists. Retrieved September 1, 2013,
from CASLPO OAOO: http://www.caslpo.com/Portals/0/ppg/Dysphagia_PSG.pdf
 Wu CH, Hsaio TY, C CJ, Chang YC, Lee SY. Evaluation of swallowing safety with
fiberoptic endoscope: Comparison with videofluoroscopic technique.
Laryngoscope. 1997;107:396-401
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