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Isn't a Clinical "Bedside" Swallow Examination good enough?

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The clinical, "bedside" swallow examination (CSE) is a great tool for identifying potential dysphagia, and involves an SLP taking patient history, examining the structures of the mouth, and looking at a patient's responses to eating and drinking various consistencies of food and liquids.

The problem with the bedside evaluation is that SLP's CANNOT SEE two out of three phases of the swallow, which happen internally in the pharynx and esophagus.  They can only truly see the mouth before/after the "oral phase" and make inferences about what's happening during the rest of the swallow.  This includes relying on hearing a patient cough or show other outward signs to know if they are aspirating.  And about 50% of aspiration is SILENT, meaning it occurs without a cough or other visible sign... meaning around half of aspiration is missed at the bedside! This can lead to costly medical complications and re-hospitalizations. 

 

As much as we like to think we can deduce what is going on by information gathered at the bedside, clinical research has shown a 70% error rate at the bedside!  This means over-diagnosing dysphagia and costing facilities thousands of dollars in tube feeds or thickened liquids; or under-diagnosing dysphagia and missing aspiration pneumonia and aberrant anatomy/physiology that are impossible to see at the bedside (e.g. edema, zenker's diverticulum, masses). Just as a physician would never treat a broken leg without first taking an x-ray,  SLP's need access to instrumental tools to help them SEE the internal structures of the swallow and help them make critical care decisions.  

Why do we need FEES?

Compared to the SLP's clinical bedside swallowing evaluation, FEES (fiberoptic endoscopic evaluation of swallowing) is an instrumental procedure which can visualize silent aspiration when it occurs.  This means identifying and potentially reducing incidences aspiration pneumonia, which is a leading cause of death for adults over age 65.  It can save your facility money, by reducing re-hospitalizations and dependence on feeding tubes and over-use of thickened liquids.  FEES can also identify abnormal anatomy and swallow physiology, see secretions and edema, the path food/liquids take in the throat, and SEE in real-time if any therapeutic changes really help a patient have a safe swallow.  Good imaging can answer a host of clinical questions and drive sound treatment plans, which ultimately impact patient quality of life.  

How can FEES help my practice as an SLP?

Instrumental assessments help providers answer a clinical question. Some important questions SLPs may have after a bedside screen include:

  1. What physiological impairments should we target in therapy? 

  2. Is there anything wrong with the anatomy or structures of the throat that    is causing dysphagia? 

  3. Are they aspirating or are there other reasons for their cough? 

  4. Am I possibly missing silent aspiration?

  5. Why are they aspirating?

  6. Which diet is appropriate?

  7. Are the strategies we teach in therapy actually effective?  

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