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FEES Following Extubation

The 1998 Paper

Leder, Cohn and Moller investigated the incidence of aspiration following extubation in critically ill trauma patients.

The study looked at 20 patients who required oropharyngeal intubation for at least 48 hours.   All FEES were completed around 24 hours following extubation.

Remember, aspiration is when the bolus enters the airway, below the level of the true vocal cords (as defined in this study).  Silent aspiration is when there is no accompanying behavior such as a cough or throat clear with aspiration.

During this study, 9/20 (45%) of patients were found to aspirate and 4/9 (44%) were silent aspirators.   Silent aspiration was seen in 20% of this population.   8/9 of the patients that aspirated were able to resume an oral diet within 10 days of their initial FEES.

Findings during this study:

  1.  A nasogastric tube was not associated with aspiration.
  2. Traumatic intubation was noted in 5/20 patients and 4/5 of these patients aspirated.
  3. Only the Glasgow Coma Scale rating on admission exhibited a significant difference regarding aspiration status.  (Low ratings had a higher incidence of aspiration).
  4. Trauma patients have an increased incidence of aspiration.

The authors suggest that early identification of aspiration following trauma and intubation is indicated to reduce the risk of pulmonary compromise.

There are still many questions following this study, including patients intubated for shorter than 48 hours and which variables impacted aspiration (brain injury, age, traumatic intubation, sedatives, neuromuscular blockers, respiratory status).

Some newer studies indicate:

“Patients aged >55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode.”

With prolonged orotracheal intubation, patients are at risk of aspiration following extubation.  (Barquist, Brown,  Cohn,  Lundy and Jackowski)

The  incidence of aspiration determined by FEES was 56% and 25% of  patients were silent aspirators. The patients found to aspirate were intubated for a mean duration of 8 days, 7.7 days for non-aspirators.  70% of the patients who aspirated  thin liquids while 30% aspirated  puree.  63% of the patients that aspirated showed improved swallowing and tolerated an oral diet by the time of discharge.   (Ajemian, Nirmul, Anderson, Zirlen and Kwasnik)

Instrumental assessments are critical for patients, particularly after intubation 48 hours or longer.

References:

Leder, S. B., Cohn, S. M., & Moller, B. A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia13(4), 208-212.

Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Critical care medicine29(9), 1710-1713.

Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of surgery136(4), 434-437.

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Why the Dye?

The many colors of FEES

You’ve maybe witnessed a FEES exam.   It can sometimes be quite colorful.

Often, green food coloring is used during the exam.   This helps to make the bolus “stand out” in the pharynx.   You may also see blue food coloring used or even white food coloring or naturally white foods such as milk to really make the materials visible if aspirated.

Silent aspiration

Silent aspiration has been reported in over 40% of patients referred for evaluation of swallowing in a rehabilitation hospital and as many as 77% of ventilator-dependent patients have silent aspiration.   It is imperative that we are able to “see” the aspiration.

Study using blue food coloring

In a study by Leder, Acton, Lisitano and Murray (2005), 20 adults were evaluated using FEES, 9 subjects with food that was dyed blue (2 drops of blue in 60cc of pudding and 120 cc of milk) and 11 subjects with regular non-dyed food (yellow pudding, white skim milk).

The study looked at 4 areas:

  1.  the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow.
  2. evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow
  3. laryngeal penetration
  4. tracheal aspiration

Three SLPs interpreted the studies with 100% agreement in the non-dyed food and in the dyed food.

The dye was changed to green from blue after several deaths resulted from blue dye that was placed in tube feeding.

This study found that the “important variable in detecting both bolus flow to and location in the pharynx and larynx is how well a bolus reflects light (it must be brighter than the tissue it is resting on).   Therefore, the endoscopist can be assured of reliable FEES results using regular, non-dyed food trials.”

Study using green food coloring

Another study by Marvin, Gustafson and Thibeault found that the use of green food coloring improved judgement of airway invasion as compared to white foods.    

References:

Leder, S. B., Acton, L. M., Lisitano, H. L., & Murray, J. T. (2005). Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food. Dysphagia20(2), 157-162.

Marvin, S., Gustafson, S., & Thibeault, S. (2016). Detecting aspiration and penetration using FEES with and without food dye. Dysphagia31(4), 498-504.

Splaingard, M. L., Hutchins, B., Sulton, L. D., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Archives of physical medicine and rehabilitation69(8), 637-640.

Elpern, E. H., Scott, M. G., Petro, L., & Ries, M. H. (1994). Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest105(2), 563-566.

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Myths of FEES Part 2

This is going to be a big one.

This is going to maybe go against everything you’ve ever heard or known.

I mean, maybe I need a drumroll here……

FEES Myth #2 Busted………

You CAN see aspiration with FEES.

There…..i said it.

“Good agreement was found, especially for the finding of aspiration (90%).” (Regarding FEES) Schatz, Langmore, Olson 1991.  

While it is true, there is that “white-out” phase at the height of the swallow.   Although, sometimes, mine tends to look more green or black than white, you can see.

You can definitely see aspiration before the swallow.  You can see the material spill over the epiglottis and into the laryngeal vestibule.   Sometimes, when you watch close and slow down the video, you can even see the material spill into the laryngeal vestibule as the swallow occurs.

“It was concluded that the clinical examination, when compared with FEES, underestimated aspiration risk and overestimated aspiration risk in patients who did not exhibit aspiration risk.”  Leder, Espinosa 2002.

The thing with aspiration, to be considered aspiration is has to stay at the level of the vocal folds or lower in the trachea.   Now, I’ve been doing swallow studies whether it be MBSS or FEES for many years and I have very rarely seen the material just drop straight through the trachea.   There is residue that can be seen on the vocal cords or into the trachea with aspiration that is not cleared.

You can also typically see secretions or material bubble at the level of the vocal cords as the patient breaths or tries to clear the material.

“This study found that FEES was just as reliable as VFSS when using the PAS.”  Colodny 2002

References:

Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia13(1), 19-21.

Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology100(8), 678-681.

Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?. The Laryngoscope117(10), 1723-1727.

Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia17(3), 214-218.

Colodny, N. (2002). Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (Fees®) using the Penetration–Aspiration Scale: a replication study. Dysphagia17(4), 308-315.