SpeechLanguage Pathologist-led Fiberoptic Endoscopic

Evaluation of Swallowing: Functional Outcomes for Patients

after Stroke

Louise Bax, MSc,* Mary McFarlane, MSc, Emma Green, MSc,* and Anna Miles, PhD*

Background: Dysphagia is a common complication after stroke and is associated

with the development of pneumonia. Early detection of dysphagia and specifically
aspiration is, therefore, critical in the prevention of pneumonia. Fiberoptic endo-
scopic evaluation of swallowing (FEES) is a safe bedside instrumental tool for detect-
ing dysphagia and aspiration and, therefore, has the potential to inform dysphagia
management. This study investigated the clinical utility of a speechlanguage
pathologist-led FEES service on functional outcomes for patients after acute stroke.
Methods: A retrospective file audit was carried out on 220 patients before FEES was
introduced and on 220 patients after the implementation of a speechlanguage
pathologist-led FEES service. The primary outcome measure was incidence of pneu-
monia, and secondary outcome measures included mortality, diet on discharge,
discharge destination, duration nil-by-mouth, incidence of nonoral feeding, and
length of stay. Results: There was a significant increase in instrumental assessment
use in the group that had access to FEES (P ,.001). There was a significant reduction
of pneumonia rates in the group that had access to FEES (P 5.037). Patients were also
significantly more likely to leave hospital on standard diets (P 5.004) but had longer
periods of nonoral feeding (P 5 .013) and increased length of hospitalization
(P , .001). Conclusion: When used selectively, FEES services have potential for
improving functional outcomes for patients after stroke. Key Words: Fibreoptic
endoscopic evaluation of swallowingdysphagiaaspirationpneumonia.
2014 by National Stroke Association

Introduction pneumonia, poor functional outcomes, mortality, and

Dysphagia (difficulties swallowing) after stroke is well
established. Up to 64% of patients are likely to have
dysphagia in the acute stages.1,2 Dysphagia is asso-
ciated with increased risk of malnutrition, dehydration,
From the *Department of Speech Science, The University of Auck-
land, Auckland, New Zealand; Waitemata District Health Board,
Westlake, New Zealand; and Department of Speech and Language
Therapy, Northwick Park Hospital, Harrow, UK.
Received August 5, 2013; accepted September 30, 2013.
Declaration of interest: The authors report no conflicts of interest.
The authors alone are responsible for the content and writing of the
article.
Address correspondence to Anna Miles, PhD, Speech Science, Uni-
versity of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
E-mail: a.miles@auckland.ac.nz.
1052-3057/$ - see front matter
2014 by National Stroke Association
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.09.031
reduced quality of life.3-7 After stroke, up to one third
of patients will develop pneumonia and pneumonia
remains the leading cause of death.5,8,9 Patients who
aspirate are 10 times more likely to develop pneumonia
compared with those who have normal swallowing on
videofluoroscopic study of swallowing (VFSS; P , .0001)
and with those who silently aspirate (aspirate without
a protective cough response) 13 times more likely to
develop pneumonia (P , .0001).10 In addition to the health
implications associated with developing pneumonia,
there are significantly increased health care costs.7,11
In view of these severe consequences, there is a critical
need for accessible, reliable assessment tools for the
identification of dysphagia. Currently, the only widely
recognized methods for identifying aspiration are VFSS
and fiberoptic endoscopic evaluation of swallowing
(FEES). FEES has proven reliability for identifying the
presence of aspiration compared with VFSS.12-18 FEES

Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 3 (March), 2014: pp e195-e200 e195
e196
is safe, can be conducted at bedside, and concurs
significantly less costs than VFSS.16,19 Finally, with the
benefit of no radiation exposure, it can be repeated
multiple times if clinically indicated.17,18,20 As a result,
the use of FEES has received increasing support in acute
dysphagia assessment, specifically in the acute stroke
population.21 The aim of this study was to examine the
clinical utility of a speechlanguage pathologist (SLP)-
led FEES service in an inpatient stroke unit.
Methods
Study Design
This study received appropriate regional ethics
approval. Four hundred forty patients with a diagnosis
of stroke admitted to an inpatient stroke unit in an urban
hospital and referred to SLP for dysphagia assessment
were included in the study. A retrospective file audit
was carried out on 220 patients before FEES was intro-
duced (pre-FEES group) and 220 patients after the imple-
mentation of an SLP-led FEES service (FEES group). Each
audit group spanned 12 months of hospital admissions
with a 6-month gap between audits while the FEES ser-
vice was introduced. Twenty files were double audited
to check reliability with strong agreement (100% agree-
ment, K 5 1.0).
Referral to Instrumental Assessment
In the pre-FEES group, the stroke unit had access to on-
site VFSS in a radiology department. In the FEES group,
the stroke unit had access to a ward-based FEES service
and VFSS, with SLPs qualified to perform FEES indepen-
dently. The instigation of the FEES service was prompted
by the recruitment of an SLP experienced in FEES and the
purchase of mobile FEES equipment. There was no addi-
tion in staffing. FEES were performed at the patients
bedside using a 3.2-mm-diameter flexible video rhinolar-
yngoscope (ENF, V2; Olympus Corporation, Tokyo,
Japan), an integrated light source and video processor
(Olympus, OTV-SI; Olympus Corporation), and an LCD
Monitor (Olympus OEV203; Olympus Corporation). No
topical anesthesia was used. The endoscope was passed
through the nose and positioned in the pharynx. Patients
were administered varying quantities and consistencies
of food and fluid colored with green food dye (apple
sauce, milk, banana, cheese sandwich, continuous drink-
ing of milk from a straw, and thickened fluids if indi-
cated). The protocol was modified as required for
patient safety. The criteria for referral to instrumental
swallowing assessment did not differ between groups,
with referrals made by the treating SLP and medical
team based on individual patients clinical presentation.
Cough reflex testing had also been introduced during
the 2 recruitment periods. Cough reflex testing is a test
of airway sensitivity and is considered to indicate patients
L. BAX ET AL.
22
at risk of silent aspiration. In isolation, cough reflex
testing has not been successful in reducing pneumonia
rates, but it is assumed that it supports appropriate,
timely referrals for instrumental assessment.23
Outcome Measures
The primary outcome measure was pneumonia, using
the criteria described by Mann et al,24 where 3 or more
of the following variables constitute a diagnosis: fever
(.38 C), productive cough with purulent sputum,
abnormal respiratory examination (tachypnea [.22/
min], tachycardia, inspiratory crackles, bronchial breath-
ing), abnormal chest radiograph, arterial hypoxemia
(PO2 ,70 mm Hg), and isolation of a relevant pathogen
(positive gram stain and culture). Other outcome mea-
sures included mortality, diet on discharge, discharge
destination, length of stay (LOS), days kept nil-by-
mouth (NBM), and nonoral feeding. Diet was classified
in terms of texture as per the Australian Dietitians Guide-
lines (standard, soft, mincedmoist, puree, or NBM).25
Number and type of instrumental assessment (FEES or
VFSS) and days until instrumental assessment were re-
corded. Definitions of variables are provided in Table 1.
Data Analysis
Data were analyzed using SPSS Version 20 (SPSS,
Chicago, IL). Chi-square analyses were used for categori-
cal variables, and independent samples t tests were used
for continuous variables. Multiple logistic regressions
were applied to evaluate the efficacy of the FEES service
adjusted for confounding variables based on bivariate an-
alyses (gender, age, comorbidities, stroke severity, stroke
site, instrument assessment, LOS, days nil-by-mouth,
and days nonoral feeding) and the 2-way interactions
including FEES service and LOS, FEES service and nono-
ral feeding, and FEES service and instrumental assess-
ment. First the full model with all confounding factors
was fit, and backward selection was used to select the
main effect model. The two-way interactions were then
added to the main effect model one by one for the final
model. Multiple logistic regressions were then similarly
applied to evaluate the development of pneumonia
adjusted for confounding variables (age, LOS, gender,
stroke type, stroke severity, comorbidities, experimental
group, instrumental assessment, nonoral diet). A sample
size of 219 participants in each group was calculated to
achieve 80% power at a statistical level of .05.
Results
There were no significant differences in baseline char-
acteristics between the groups (Table 2).
SLP-LED FEES SERVICE: FUNCTIONAL OUTCOMES AFTER STROKE e197

Table 1. Definition of variables

Variable Definition

Pneumonia Patient developed pneumonia as defined by Mann criteria at some point in their hospital admission.
Mortality Patient passed away in hospital.
Days NBM Number of days before a patient either began an oral diet or began being fed nonorally.
Nonoral feeding Patient was fed via NG or PEG tube at some point during their admission.
Days nonoral Number of days in total a patient was nonorally fed during their hospital admission.
Comorbidities Patient had pre-existing respiratory comorbidities before their hospital admission (eg, asthma,
bronchiectasis).
Instrumental assessment Patient received an instrumental assessment of swallowing (FEES or VFSS) during their hospital
admission.
Days instrumental Number of days a patient waited to have an instrumental assessment.
Stroke severity Stroke severity as rated according to NIHSS.
LOS Number of days of hospital admission.

Abbreviations: FEES, fiberoptic endoscopic evaluation of swallowing; LOS, length of stay; NIHSS, National Institutes of Health Stroke Scale;
NG, nasogastric tube; NBM, nil-by-mouth; PEG, percutaneous endoscopic gastrostomy; VFSS, videofluoroscopic study of swallowing.

Pneumonia 12%, FEES pneumonia rate 7%, proportion difference .5;

95% confidence interval [CI] .026, .05; unadjusted:
A significant association was found between experi-
c2 (1) 5 3.79, P 5 .037, adjusted: P , .001; odds ratio [OR]
mental group and pneumonia (pre-FEES pneumonia rate
5.5; 95% CI 6.27, 33.76). In the pre-FEES group, instru-
mental assessment was significantly associated with devel-
Table 2. Demographic data of pre-FEES and FEES groups
oping pneumonia (c2 5 4.5, P 5 .033; OR 5.7; 95% CI 1.15,
28.35). Conversely, in the FEES group, instrumental assess-
Pre-FEES FEES P
(%) (%) value ment was significantly associated with not developing
pneumonia (c2 5 4.977, P 5 .026; OR 3.5; 95% CI 1.166,
Age n 5 220 n 5 220 .891 10.751). Nonoral feeding was significantly associated with
Mean (SD) 76.5 (12.8) 76.3 (13.3) not developing pneumonia in both groups (pre-FEES;
Gender n 5 220 n 5 220 .923 c2 5 5.12, P 5 .024; OR 2.9; 95% CI 1.15, 7.35, FEES;
Male 95 (43.1) 93 (42.2) c2 5 6.6, P 5 .010; OR 6.88; 95% CI 1.58, 29.88).
Ethnicity n 5 220 n 5 218 .941
NZ European 150 (68.2) 151 (69.3) Functional Outcomes
NZ Maori 9 (4.1) 6 (2.7)
Pacific Island 12 (5.45) 10 (4.6) There was no significant difference between groups in
Asian 12 (5.45) 12 (5.5) the duration of NBM status (pre-FEES group 1.23 days,
Other 37 (16.8) 39 (17.9) FEES group 1.41 days, P 5 .195). There was no significant
Hemisphere n 5 215 n 5 213 .898 difference between groups in the number of patients non-
Left 106 (49.3) 106 (49.8) orally fed (FEES group 15.9%, pre-FEES group 11.4%,
Right 102 (47.4) 102 (47.9) P 5.105). In the FEES group, patients who were nonorally
Bilateral 7 (3.3) 5 (2.3) fed received nonoral feeding for significantly longer than
Type n 5 217 n 5 214 .574 patients who were nonorally fed in the pre-FEES group
Ischemic 190 (87.6) 183 (85.5) (pre-FEES group 8%, FEES group 14%, P 5 .013). If a pa-
Hemorrhagic 27 (12.4) 31 (14.5) tient left hospital on an oral diet, they were statistically
Oxford classification n 5 166 n 5 181 .868
more likely to leave hospital on standard rather than a
LACI 52 (31.3) 63 (34.8)
TACI 43 (25.9) 48 (26.5) modified diet (categorized as soft, mincedmoist, and
POCI 11 (6.7) 12 (6.6) puree) in the FEES group compared with the pre-FEES
PACI 60 (36.1) 58 (32.1) group (pre-FEES group 51%, FEES group 66%,
NIHSS stroke n 5 182 n 5 203 .520 c2 5 8.24, P 5 .005). Patients in the pre-FEES group had
Severity score, 8.53 (6.05) 8.14 (5.97) significantly shorter LOS in the hospital admission
mean (SD) (mean difference 5 2.55; 95% CI 1.23-3.85, P ,.001). There
Comorbidities n 5 210 n 5 217 .675 was no statistically significant difference between groups
Yes 27 (12.9) 31 (14.3) on discharge destination (P 5.459) or mortality (P 5.314).

Abbreviations: FEES, fiberoptic endoscopic evaluation of swal- Instrumental Assessment Use

lowing; NIHSS, National Institutes of Health Stroke Scale; LACI,
lacunar infarct; TACI, total anterior circulation infarct; POCI, poste- Patients in the FEES group were significantly more
rior circulation infarct; PACI, partial anterior circulation infarct. likely to receive an instrumental assessment (FEES or
e198 L. BAX ET AL.
26
VFSS) than the pre-FEES group (pre-FEES group 6%, population. Both specialized stroke units and nurse
FEES group 38%, P , .001; Table 3). In the FEES group, dysphagia screens are known to lead to improved out-
35 patients (16%) received multiple instrumental assess- comes for patients after stroke, and these were both pre-
ments during their admission. In the pre-FEES group, sent at the research site.27 However, these services were
only 1 patient received a repeat VFSS. Patients in the already present during the pre-FEES group data collec-
FEES group waited significantly fewer days between tion. Although patients after the implementation of the
admission and instrumental assessment taking place FEES service were significantly less likely to develop
(pre-FEES group mean 5 10.5, FEES group mean 5 2.3, pneumonia if they received an instrumental assessment,
P 5 .008; Table 3). the opposite was true for the pre-FEES group. Miles
et al23 recently described similar findings. They report
that no patients in their control group received an instru-
Discussion
mental assessment until they developed pneumonia. This
Pneumonia rates were lower for the group with access wait-and-see approach to dysphagia management is
to the SLP-led FEES service. The incidence of pneumonia concerning and suggests that SLPs are hesitant to refer
in both groups is well below recent national data from a patients for instrumental assessment perhaps because of
multisite randomized clinical trial of 311 patients with lack of accessibility. Ward-based FEES may be an efficient,
dysphagia after stroke (27% pneumonia rate).23 Further- fast means of instrumental assessment, therefore, avoid-
more, the 7% pneumonia rate in the FEES group is below ing patients developing pneumonia while they wait for
the national rate of 10% reported in the general stroke VFSS and minimizing the inconvenience of waiting for a
radiology procedure. The visibility and collaborative na-
ture of FEES are also thought to lead to a better team un-
Table 3. Comparison of clinical decision making and
derstanding of dysphagia and, perhaps, in turn stricter
functional outcomes between groups
adherence of SLP recommendations.28
Pre-FEES FEES P The introduction of cough reflex testing in conjunction
(%) (%) value with the FEES service may have allowed more informed
decisions regarding referral criteria for instrumental
Instrumental n 5 220 n 5 220 ,.001 assessment as those who fail a cough reflex test are more
assessment likely to be referred for VFSS or FEES. Cough reflex testing
Yes 14 (6.4) 84 (38.2) has been shown to increase instrumental assessment rates
Instrumental n 5 14 n 5 84 .008 in the stroke population.23 Combining a ward-based FEES
assessment
service with a comprehensive clinical swallowing evalua-
Days until; 10.5 (9.8) 2.3 (4.9)
tion including cough reflex testing may avoid overuse of
mean (SD)
Nonoral feeding n 5 220 n 5 220 .211 instrumental assessment and ensure the right patients
PEG or NG 25 (11.4) 35 (15.9) receive the additional investigation.
Nil-by-mouth n 5 215 n 5 208 .195 The FEES group, where pneumonia rates were lower,
d; mean (SD) 1.23 (1.4) 1.41 (1.5) had significantly longer hospitalization. In contrast, simi-
Days nonoral feeding n 5 25 n 5 34 .013 larly designed international studies have associated the
NG; mean (SD) 7.6 (6.5) 13.5 (11.1) development of pneumonia with longer hospitaliza-
Discharge diet n 5 186 n 5 192 .005 tion.8,11 It could be hypothesised that the introduction
Standard 95 (48.5) 126 (61.8) of the FEES service has provided SLPs with greater
Soft 50 (25.5) 31 (15.2) input into the rehabilitation process for patients and
Mincedmoist 18 (9.2) 16 (7.8)
subsequently led to patients remaining in hospital for
Puree 23 (11.7) 19 (9.3)
swallowing rehabilitation before being discharged. This
Length of stay n 5 220 n 5 220 ,.001
Mean (SD) 17.34 (15.2) 23.67 (20.2) theory is supported by the higher percentage of patients
Discharge destination n 5 220 n 5 220 .459 in the FEES group leaving hospital on standard diets.
Home 96 (43.6) 102 (46.4) This has positive repercussions in terms of quality of life.
Rehabilitation 43 (19.5) 36 (16.4) Diet restrictions have been associated with reduced
Rest home 14 (6.4) 10 (4.5) quality of life.29 Modified foods lose nutritional value
Private hospital 41 (18.6) 54 (24.5) through the process of modification, and therefore, diet
Death 23 (10.5) 16 (7.3) modification leads to a risk of malnutrition and dehydra-
Other 3 (1.4) 2 (.9) tion.29 Discharging with diet modifications may necessi-
Mortality n 5 220 n 5 220 .314 tate further community follow-up and, therefore, concur
Yes 23 (10.5) 16 (7.3)
additional and, perhaps, unnecessary health care costs.
Abbreviations: FEES, Fiberoptic endoscopic evaluation of swal- Nonoral feeding was significantly associated with not
lowing; NG, nasogastric tube; PEG, percutaneous endoscopic gas- developing pneumonia, although the effect size was
trostomy. much larger in the FEES group. Yet, previous research
SLP-LED FEES SERVICE: FUNCTIONAL OUTCOMES AFTER STROKE
has suggested a higher incidence of pneumonia in pa-
tients who are nonorally fed, with 1 study reporting
that 41% of tube-fed patients after stroke developed pneu-
monia.30 It is possible that the FEES service allowed clini-
cians to be more assertive and confident in making earlier,
objectively informed management decisions regarding
nonoral feeding options.
Limitations
The retrospective nature of the research means that data
collection is reliant on access to, and accurate, documenta-
tion by health professionals. Similarly, the auditors are
required to be both accurate and consistent in their inter-
pretation. Both documentation and interpretation are sus-
ceptible to human error. Additionally, the between-group
study design over 2 time periods means that confounding
variables such as changes to hospital protocol or personnel
cannot be accounted for.
Conclusions
Introduction of an SLP-led FEES service was associated
with a reduction in pneumonia rates in an inpatient stroke
unit. Patients were discharged from hospital on less
restrictive diets but following longer hospitalization and
longer periods of nonoral feeding. Guidelines surround-
ing selection criteria of candidates for FEES may help to
streamline the use of FEES and make such services
more efficient. This would provide further strength to po-
tential benefits of FEES in reducing pneumonia rates and
improving functional outcomes for patients after stroke.
Acknowledgment: The authors would like to acknowl-
edge Waitemata DHB for their support in this study and
for allowing researchers access their hospital databases.
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