FIBER OPTIC ENDOSCOPIC EVALUATION OF SWALLOWING	ISSUE DATE:		No.	PFF-TX 145 – Vol. II
		REVISION DATE[S]:		Page 1 of 3
JOINT COMMISSION STANDARDS/DHS REGULATION:RI, PE, TX, PF, IMTitle 17 – Radiology Safety  Title 22 – Speech Language Pathologist		REVIEW DATE[S]:
		CROSS REFERENCES:  Airway Clearance Oral Care Videofluorographic Study of Oral and Pharyngeal Swallowing

DESCRIPTION

The Fiberoptic Endoscopic Evaluation of Swallowing [FEES] is a method of swallowing evaluation that offers an additional means of assessment that can help address some limitations of the Video Fluoroscopic Swallowing Study [VFSS].

Purpose of the Evaluation –

1. Assessment of anatomy and dynamic function of palate, pharynx and larynx along with sensation of the laryngopharynx.
2. To assess patients’ swallowing capabilities as they ingest various food consistencies.
3. To orient the examinees to the nature and severity of the swallowing problem.
4. To reduce reliance on X-irridiation.
5. Determine effectiveness of therapy.

STANDARD OF CARE

1. Patient can expect to receive appropriate pre-swallowing treatment to improve his/her swallowing skills.
2. Patient can expect to know what kinds of foods he/she can swallow safely.

INDICATIONS FOR PROCEDURE

1. Pharyngeal dysphagia suspected.
2. Assess for diet recommendations.
3. Need swallowing evaluation that same day.
4. Need to test for fatigue with P.O.
5. Need to repeat a swallowing examination – can diet be upgraded?
6. Patient is in the ICU – on monitors – not easily transferred to radiology.
7. Patient is in traction.
8. Patient is too large to fit into fluoro accommodations.
9. Patient is on ventilator.

10.  Need repeat exam when fluoro appears to be missing aspiration secondary to viscosity or contrast issues.

11.  Need to use real food for dementia patient or improved sensory/motor integration.

12.  Patient is on contact isolation.

13.  Patient is on respiratory isolation.

14.  Concern about excess radiation exposure.

15.  Concern about strain on patient if he/she must be transported to another facility.

16.  Need objective information on secretion management.

17.  Need to directly visualize the larynx – to assess vocal fold adduction for airway protection [paresis, chinks from in/extubation, vocal fold trauma from NG tube placement, UES edema, etc.]

18.  Need a prolonged therapeutic exam with sufficient time to try out different maneuvers, food consistencies, etc.

19.  Need to do swallowing examination in realistic feeding/eating condition.

20.  Need FEES for visual feedback.

STANDARD OF PRACTICE

1. The Physician and/or Speech-Language Pathologist will identify food the patient can eat.
2. Specific therapy and compensatory techniques will be identified to assist the patient in eating.
3. The FEES team will consist of:

• Physician trained or certified to perform FEES.
• A Speech-Language Pathologist trained or certified in FEES.
• Presence of Respiratory Therapist during the procedure is optional.

LEVEL OF PRACTITIONER

• Physician [M.D.]
• Speech-Language Phathologist [SLP]
• Respiratory Therapist [RT]

EQUIPMENT

• Fiberoptic Laryngoscope or Pediatric Bronchoscope.
• Light source.
• Video camera, VCR, and video monitor.
• Microphone/audio adapter.
• Long stem cotton swabs.

Implements Used –

• Tongue blade
• Cups
• Syringe – 1 cc
• Syringe – 3 cc
• Syringe – 10 cc
• Gloves
• Goggles/glasses
• Straw
• Size OO laryngeal mirror
• Toothette
• Toothbrush/paste
• Towels
• Masks

Food Supplies –

• Green food coloring.
• Graham crackers
• Liquids (water, ice, soda, milk) in different viscosities
• Puree.
• Other food consistencies with which the patient has difficulty.

PROCEDURE

Positioning: Patient is positioned at 90 degrees whenever possible and between the clinician and the video/monitor.

Sterilization: A disposable endosheath is typically used for each patient

A topical anesthetic can be administered superficially to the nasal passages (not sprayed) by RN or MD with MD order (Lidocaine is typically used).

Fiberoscopic endoscope is introduced transnasally by the Physician with VCR recording. Visual examination is made of the soft palate, valleculae, pyriform sinuses laryngeal, vestibule and vocal cords. The endoscope is positioned in the posterior oropharynx.

Assess velopharyngeal closure by having the patient swallow or to phonate oral and nasal sounds/sentences. Nasal reflux can be assessed by placing the scope in the nose above the pharyngeal port.

Note any anatomic anomalies that may warrant an ENT referral.  Secretion management can be observed by placing a drop of green on the tongue.  Observe the tongue base by having the patient say “kuh, kuh, kuh”.  Assess airway protection by instructing the patient to cough and then hold his breath tightly.

The SLP will administer and modify food bolus.  The following are dyed blue or green and presented in an order of least difficulty for the patient (per VFSS policy. Refer to VFSS [Video Fluoroscopic Swallowing Study] policy for details.)

1. Puree (applesauce)- given ½ teaspoon, full teaspoon, multiple trials
2. Honey thick liquids- ½ tsp, 1 tsp, cup sip, multiple sips
3. Nectar thick liquids- ½ tsp, 1 tsp, cup sip, multiple sips
4. Thin liquids- ½ tsp, 1 tsp, cup sip, multiple sips
5. Soft solids (peaches, bread)
6. Hard solids (hard cracker, bagel)

Proceed with each consistency, as indicated, until the patient is unable to tolerate safely with or without strategies.

Explain the results to the patient following the procedure.

EVALUATION

Unexpected Outcomes:

• Unable to complete the procedure due to patient’s shortness of breath, fatigue and/or severe aspiration.

Expected Outcomes:

• The patients will receive a comprehensive study in a timely and safe manner.
• The patients can expect to know the etiology for aspiration and the strategies they can learn to improve their swallowing skills.
• The patients can expect to know what kinds of food they can safely swallow.

DOCUMENTATION

1. The SLP will complete the FEES evaluation in Meditech within 24-hours of the study.
2. The Physician writes his/her report on the Progress Note.
3. The RT writes his/her report on the flow sheet.
4. Nursing staff writes its report on the flow sheet.

PATIENT/FAMILY EDUCATION

Results of the FEES shall be reviewed with patient/family and instructions regarding outcome given.

SATELLITE UNIT

Same policy and procedures apply.

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Tags: fiberoptic endoscopic evaluation of swallowing protocol, sample FEES protocol, steps to perform FEES, swallow study