Updated: Apr 4, 2020
Although FEES has been around since 1986 and has been proven repeatedly to be just as valuable in the assessment of dysphagia, videofluoroscopy (MBSS) continues to be rumored as the "Gold Standard."
Luckily, that myth is slowly being put to rest with the release of new research and literature. Today, I present to you - "What is The Value of Fibre-Endoscopic Evaluation of Swallowing (FEES) in Neurological Patients?" by Dr. Tobias Braun, et al.
Dr. Tobias Braun and 8 colleagues from the Department of Neurology at University Hospital Giessen and Marburg in Giessen, Germany submitted a cross-sectional hospital-based registry study indentifying the value of FEES in neurological patients.
267 FEES were performed in 241 patients with various neurological diagnoses during their hospital stay. In 23 patients (9.5%), the procedure was repeated at least once.
Gender: 140 males and 101 females
Average Age: 73 years, with range between 61–80 years
Diagnoses Included: Ischemic Stroke - 125 Intracranial Bleeding - 27 Traumatic Brain Injury - 8 Movement Disorders - 15 Motor Neuron Disorder - 6 Intracranial Tumor - 8 Other - 52 *epileptic seizures, dementia, Guillain-Barré syndrome, degenerative changes of the cervical spine, etc
Diet Ordered Prior to FEES: NPO - 140 patients (52%) *108 were dependent on a NG tube prior to FEES and 7 patients on PEG tube Partial Oral Intake - 58 patients (24%) Full Oral Intake - 43 patients (16%)
AFTER FEES: THE OUTCOMES
FEES revealed dysphagia in 166 patients (69%) and no dysphagia in 75 patients (31%).
- It was also found that 73% of patients with no dysphagia were placed on a restricted diet prior to FEES compared to only 25% of patients with dysphagia.
- 26 patients with full oral intake prior to FEES showed critical dysphagia during the assessment and as a result, required diet modification. Out of these 26 patients, 16 were allowed only partial oral intake and 10 patients were made NPO after FEES.
- A total of 161 patients (66.8%) had a change in the oral diet. 93 of them were downgraded, but maintained an oral diet. Diet restrictions were placed on the remaining 68 patients with 47 (69%) of them being NPO.
By implementing FEES, the authors detected signs of dysphagia in 70% of neurological patients. That indicates that not only is FEES a reliable assessment for identifying dysphagia in the critically ill population, but also extremely beneficial as it can be completed at the patient's bedside in their natural eating position. Additionally, the authors noted that FEES could detect aspiration of secretions, which played a critical role in the development of pneumonia, where as MBSS could not.
Only 33% of the patients had an appropriately ordered oral diet prior to FEES. This means in 67% of patients, the SLPs either over-diagnosed or over-diagnosed dysphagia. Patients with no dysphagia were placed on unnecessarily restrictive diets and 11% of patients on a full PO diet ended up showing critical signs of dysphagia during FEES.
This further speaks to the unreliability of Clinical Bedside Exams for detection of dysphagia and aspiration. It's solidifies our responsibility as clinicians to continue to utilize instrumental exams when warranted and not overly rely on clinical judgement, especially in critically ill patient populations. The adverse consequences are never worth it and could oftentimes be fatal.
Dr. Tobias Braun is involved with the Department of Neurology at University Hospital Giessen and Marburg in Giessen, Germany. He can be reached at: firstname.lastname@example.org
This blog post is part of a multi-part series where I summarize articles and findings that have completely changed my way of thinking and altered the way I approach dysphagia treatment/management. Please subscribe to our mailing list for updates on future posts.