The First Step to FEES Competency: A Review of Evolutionary Education Solutions’ Intro to FEES
Author: Ainsley Martin, MS, CCC-SLP
Name of Course: Introduction to Flexible Endoscopic Evaluation of Swallowing (FEES)
Instructors: Hillary Cooper, MA, CCC-SLP & Jessica Lasky, MS, CCC-SLP
Cost: $450
Date(s) Attended: August 8-9, 2020
Number of CEUs Earned: 1.5 CEUs
Format: Live lecture via webinar due to COVID-19
Duration: 2 days
Subject: Flexible endoscopic evaluation of swallowing
Level of Difficulty: Intermediate
Applicable Patients/Disorders: Patients with suspected dysphagia requiring an instrumental evaluation of swallowing with imaging. This training is applicable to any SLPs evaluating or treating swallowing and swallowing disorders. An introductory FEES course is also required to achieve competency in performing FEES evaluations. Course attendees can find value in this course if they are just beginning their FEES journey, are familiar with FEES and need a refresher, or even SLPs who have already achieved FEES competency.
Content: Flexible endoscopic evaluation of swallowing is a gold standard instrumental evaluation of swallowing function. Developed by Dr. Susan Langmore in 1988, FEES is becoming a first-choice for instrumental swallow evaluations due to the portability of the equipment, ability to visualize pharyngeal and laryngeal structures, and assess secretions. To successfully perform a FEES evaluation, an SLP must become competent in both performing and interpreting FEES exams. The first step towards FEES competency is completing an introductory FEES course. In this course, Hillary Cooper and Jessica Lasky of Evolutionary Education Solutions provide the foundational knowledge required to begin the journey to FEES competency.
Usefulness of Resources: Resources provided in this course include detailed power point slides of all information covered in the course and a FEES report template. Trust me when I say that this template will make your instrumental swallow evaluation reports more streamlined, easier to read, and more efficient! In addition to the power point slides, attending this course also grants you access to the instructors and other course attendees through the Evolutionary Education Solutions facebook page. The course instructors frequently post interesting FEES findings on the facebook page, provide additional opportunities to practice description of laryngeal abnormalities, and are available as a FEES family support system as course attendees continue on in their FEES journeys.
Introduction to Flexible Endoscopic Evaluation of Swallowing
Time-Ordered Agenda for 8/8-8/9 Course
Day 1:
In the first section of this course, Hillary presented on personality styles and the way these styles may affect clinical communication. Prior to the course, attendees were provided with options to take personality tests such as the MBTI, Enneagram, and Kolbe A. Admittedly, I was somewhat skeptical during this portion of the course as I’m in general not a fan of personality tests. However, I kept an open mind. As I listened more, I began to realize that specific personality types can affect preferred learning styles, verbal, nonverbal, and written communication, the implementation of evidence-based practice (EBP), and even success in passing the endoscope! Who knew there was so much more to FEES??? Course attendees were then given the opportunity to analyze their own dominant learning style and personality traits. Information was also provided on setting up systems to increase success in communication, reading the room to determine how to interact with your patient, and approaches for completing FEES exams with patients with dementia.
Prior to performing a FEES exam, a clinical swallow evaluation should have been completed, either by the one performing the FEES or the referring SLP depending on the setting. In this section, Hillary reviewed what should be included in a clinical swallow evaluation, what should NOT be included, and an overview of the functions of the cranial nerves as well as how to assess them through a cranial nerve exam. Knowing the information that can be gleaned from a clinical swallow evaluation as well as the limitations can aid SLPs in advocating for the instrumental evaluations their patients need.
Jessica then provided an overview of the history of FEES, detailing how far technology has advanced this exam. From improved image quality, portability of the equipment, and size/weight of the scope, FEES has come a long way! FEES has similar sensitivity and specificity to MBSS and has been considered by the American Speech-Language and Hearing Association (ASHA) to be an appropriate tool for the diagnosis and treatment of swallowing disorders. A detailed comparison was provided about the similarities and differences between FEES and MBSS including field of view, locations exams can be administered, functional limitations, appropriate candidates and contraindications, risks, and the question of if FEES hurts that pops up in just about every FEES course.
But, which is better?
FEES or MBSS?
In short, NEITHER! FEES is not any better or worse than a MBSS. Since this is a FEES course, you may have thought the presenters would be biased towards FEES over MBSS. You couldn’t be further from the truth! Hillary and Jessica were very forthcoming about the pros and cons of each assessment. While different tests may be more appropriate for a patient dependent on the situation and that particular patient’s presentation, the best exam is the one you are able to access and will provide you the information you need to help your patient.
Information was also provided at the end of this section re: ways to describe a FEES exam to your patients and resources for state specific information about performing FEES.
At this point in the course, it already felt like so much information had already been covered. In this section, Jessica moved into the meat of Day 1: anatomy and physiology.
“A flexible endoscope is passed through the nose. At the back of the nose, it is angled inferiorly, then advanced into the pharynx to view the vocal cords.”
Image attribution to James P. Thomas, MD
As you can see from the image above, anatomy observed during a FEES exam include the nose, pharynx, base of tongue, larynx, and the trachea. A solid understanding of anatomy and physiology involved in swallowing is essential in dysphagia assessment and treatment.
Diagrams and multiple images from actual FEES exams were used to highlight the anatomy and introduce the presenters to normal vs abnormal anatomy.
Throughout the course, Hillary and Jessica took occasional periods to review the anatomy to provide additional practice in identifying structures.
After providing a solid foundation on anatomy, Jessica then presented on physiology and how these different events may appear during a FEES exam. For example, the white-out period that occurs when the endoscope is often positioned between the tongue and posterior pharyngeal wall.
A brief introduction was also made to anatomical abnormalities that can be observed during FEES exams including; velopharyngeal insufficiency, trauma following extubation, lesions, granuloma, and many more.
Not all FEES scopes are the same. There are mobile systems vs tower systems, distal chip vs fiber scopes, and differences in image quality, portability, durability, function buttons, trigger and handle, and price. Before purchasing FEES equipment, it is helpful to know the pros and cons of the different equipment. You can do this by talking to reps from different FEES companies, visiting vendor booths at conferences to get a feel for the equipment, and reaching out to other SLPs who perform FEES.
While you won’t necessarily have to balance a book on your head, awareness of proper body mechanics is essential to be a successful FEES provider.
You can be the best at identifying anatomic deficits and swallowing pathophysiology, but if you can’t maintain an appropriate position to complete a study because your back hurts, the study is useless. (I may or may not be speaking from personal experience.) In this section, Hillary placed great emphasis on detailing proper body mechanics with picture examples of both “good” and “needs improvement” body mechanics.
Additional considerations addressed in this section include; setting up the room so that you have adequate view of your montior while the person assisting in feeding has easy access to the patient, items on the tray for food trials, types of food coloring, use of lubricant to increase comfort during the exam vs anesthesia or nasal spray, and cleaning the scope after an exam is complete.
In the last section of this presentation, Hillary detailed the interdisciplinary team that may be involved when considering FEES for a patient, marketing our knowledge and expertise in dysphagia to increase buy-in, and considerations for developing your “elevator pitch” including; creating a script, being aware of body language, and explaining how FEES can benefit members of the interdisciplinary team, being mindful of how documentation can be interpreted (e.g., reactionary vs descriptive), and making appropriate referrals. You seriously don’t want to be that SLP who makes an ENT referral when a uvual or the superior horns of the hyoid make a cameo appearance during an exam.
In the last course section for the day, Jessica covered what to do when actually performing an exam. The first step is to actually pass the scope. Making the patient feel relaxed, or at the very least distracted, is key. Once the scope is successfully passed you want to maintain your home position (“there’s no position like home position”). After the swallow, you want to hop over the epiglottis to get a view of the larynx for your money shot (view of the trachea). You can also pop into the nasopharynx to assess for possible nasal regurgitation. Keep in mind, when performing a FEES exam, you will not always be in a clean pharynx. The camera may be covered by secretions, food, or fog. Jessica gave the presenters expert tips on clearing the scope and maintaining a clean view.
Performing a FEES exam is challenging at best. While maintaining the scope’s position, you are also calling for trials, assessing physiology in real time, thinking on your feet for compensatory strategies you may trial, and, in some cases, dealing with a combative or agitated patient. In my post about completing my FEES competency, I said my FEES mentor (Hillary) compared performing a FEES exam to juggling knives in the dark while you're set on fire.
(Image by Ulrike Mai from Pixabay)
Forming your own FEES protocol of pre-swallow tasks, trials, when compensatory strategies will be assessed, observations and physiologic assessment will set you up for success and assist in identifying improvements in swallowing function if you complete a repeat study. This so so helpful, especially when a FEES provider is just starting out.
This concludes Day 1. But there is so much more excellent FEES knowledge to be obtained in…
Day 2:
For intro to FEES courses, the second day is usually reserved for completing “normal passes” or practicing passing the scope on either course volunteers or your fellow participants to get a greater understanding of normal variances in anatomy while also practicing in a safe environment before performing FEES on actual patients. With consideration for the increased number of COVID cases in certain areas of the country, conservation of PPE, physical distancing, and the health and safety of course attendees and their home communities, the course presenters made the difficult (but responsible) decision to hold the course entirely online. This meant participants would not have the opportunity to complete normal passes. However, participants were provided with additional solutions such as finding a qualified FEES provider in the area or even shadowing with an ENT.
As a consolation for not being able to complete normal passes, Hillary and Jessica gave in-depth presentations on FEES interpretation, documenting FEES findings, and identifying and describing laryngeal abnormalities.
The day began with case studies and basic FEES interpretation. Hillary reviewed the oral and pharyngeal stages of the swallow and various impairments that can be identified via FEES. Photos and video examples were provided to demonstrate how these impairments may present. While the esophageal phase cannot be viewed with FEES, strategies to screen for possible esophageal issues were also detailed. A handy chart was also provided detailing physiologic causes of observations (e.g., reduced BOT movement or strength resulting in residue in the vallecula) and recommended compensatory strategies to trial during the exam. The importance of reviewing the study in slow-motion or frame by frame was also emphasized.
Documentation. After making your observations and interpretation, you want to document your findings in a way that is clear, concise, and emphasizes the most important part of the evaluation first (hint: it’s the physiology).
Additionally, you may want to include scales such as secretions ratings, reflux finding scores, and functional measurements for pre- and post-evaluation. Hillary completely revamped her entire report template to reflect physiology first documentation. As a benefit to course participants, Hillary provided her documentation template which had rave reviews from other SLPs and physicians!
However, when performing FEES exams, you will eventually encounter a laryngeal abnormality. When this happens, it is up to the FEES provider to describe and refer on, without diagnosing as this is outside of our scope of practice.
“But, how do I describe this?”
This is a very common question following introductory FEES courses.
Never fear! Jessica has you covered. With real-life case studies for advanced interpretation, videos, and images detailing various laryngeal abnormalities, participants were provided with numerous opportunities for practice. Images of common findings with descriptions were also provided for future reference.
The course ended with a Q&A for all things FEES. Hillary and Jessica also both emphasized that this is not the end towards achieving FEES competency, but this is the beginning. Taking one introductory course provides an excellent foundation to be built upon by taking additional coursework, completing normal passes, and completing abnormal passes under the guidance of a qualified competency mentor. It is also not possible for one person to know everything. Having a network of other FEES providers is invaluable in getting support, asking questions, and further developing skills as an endoscopist. To continue to provide support, mentorship, and community beyond this course, members were granted access to a private facebook community for additional support, networking, and interpretation practice.
Impressions:
I completed my basic FEES course in 2017 and completed my competency training in 2019. Even though I had already taken basic and advanced FEES courses as well as having completed my FEES competency, I knew I needed to take this course! Hillary and Jessica have years of experience in performing FEES exams across a variety of settings and providing competency training. In developing this course, they sought to fill in the gaps of information missing from most introductory FEES courses. I was able to take away new information and appreciated the review of information I’d already learned. Course attendees varied in all levels of FEES proficiency from beginners to those like myself who have already completed FEES competency. Each FEES course reflects the experience of the instructor, so taking multiple courses can only expand your knowledge base. An additional benefit of this course was having two presenters who were able to share their similarities and variations in approach. Even though this course was loaded with functional information and the latest research evidence, the presentation style was very interactive and laid back. I felt like I was having a conversation with two good friends! The resources provided including access to the presentation slide, pictures of laryngeal abnormalities, the physiology-first documentation template, and access to the Evolutionary Education Solutions facebook page were the cherry on top! If you are looking to being your FEES journey or if you are looking to expand your knowledge base, I highly recommend this course!
Please visit Evolutionary Education Solutions if you want information about registration, upcoming courses, or if you just want to know more about Hillary and Jessica.
*Disclosure: The author received a waived registration fee to attend this course.
