J Stroke Cerebrovasc Dis. 2014 Mar;23(3):e195-200.

Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke.

Bax L1, McFarlane M2, Green E1, Miles A3.
  • 1Department of Speech Science, The University of Auckland, Auckland, New Zealand.
  • 2Waitemata District Health Board, Westlake, New Zealand; Department of Speech and Language Therapy, Northwick Park Hospital, Harrow, UK.
  • 3Department of Speech Science, The University of Auckland, Auckland, New Zealand. Electronic address: a.miles@auckland.ac.nz.



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 endoscopic evaluation of swallowing (FEES) is a safe bedside instrumental tool for detecting dysphagia and aspiration and, therefore, has the potential to inform dysphagia management. This study investigated the clinical utility of a speech-language 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 speech-language pathologist-led FEES service. The primary outcome measure was incidence of pneumonia, 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 = .037). Patients were also significantly more likely to leave hospital on standard diets (P = .004) but had longer periods of nonoral feeding (P = .013) and increased length of hospitalization (P < .001).

CONCLUSION: When used selectively, FEES services have potential for improving functional outcomes for patients after stroke.

Copyright © 2014 National Stroke Association.

KEYWORDS: Fibreoptic endoscopic evaluation of swallowing; aspiration; dysphagia; pneumonia

PMID: 24361193



Fiberoptic endoscopic evaluation of swallowing (FEES) is an established instrumental swallowing assessment tool, particularly useful due to the mobile nature of the procedure 1-3. In this study, we found the introduction of a ward-based speech-language pathologist (SLP)-led FEES service was associated with a reduction in pneumonia rates in a New Zealand inpatient stroke unit (fig 1).

Fig 1

Figure 1. Comparison of primary outcomes

 Fig 2

Figure 2. Standard diet on discharge


Interestingly, although patients in the FEES group were discharged from hospital on less restrictive diets, they had longer hospitalization and longer periods of non-oral feeding (fig 2 & 3).

 Fig 3

Figure 3. Comparison of secondary outcomes

In a concurrent study, we interviewed staff on the stroke unit about their perceptions of the FEES service 4. The themes from this study provide a deeper understanding of the impact of FEES on the service. Staff described improved patient care, increases in knowledge, improved SLP visibility on wards and increased team integration associated with the FEES service 4. However, a learning curve was described by staff with an initial over-reliance on the tool. SLPs found it hard to imagine assessing a patient at bedside without FEES to support their decisions. Over time, they described this developing into integrated decision-making where they had better abilities to decide who and when to refer for FEES 4.

We postulated that combining a ward-based FEES service with a comprehensive clinical swallowing evaluation would avoid overuse of instrumental assessment and ensure the right patients receive the additional investigation. Guidelines surrounding selection criteria of candidates for FEES may help to streamline the use of FEES and make such services more efficient.

FEES is a cost-effective tool for assessing swallowing at the bedside 1. Using an SLP-led service allows patients to receive instrumental assessment without waiting for a referral to another service or waiting for a radiology slot for a videofluoroscopy. Warnecke and colleagues have advocated for its use in acute stroke for a decade: correlating FEES findings with stroke outcomes 2, demonstrating its safety 5, developing a scoring system 6 and demonstrating to positive effect of serial FEES on patient outcomes 7. Our work adds to this field of evidence, demonstrating that pneumonia rates in this vulnerable population can be reduced with more accessible instrumental swallowing assessment.



The authors would like to acknowledge Waitemata DHB for their support in this study and for allowing researchers access their hospital databases. Louise Bax would like to acknowledge the support of a Jane and Rebecca Hulst Memorial Scholarship in her studies.



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  7. Warnecke T, Dziewas R, Oelenberg S, et al. Serial fiberoptic endoscopic evaluation of swallowing in patients with acute stroke and dysphagia: Case report and general considerations. Journal of Stroke and Cerebrovascular Diseases. 2006;15(4):172-175.

Dr Anna MilesCorrespondence

Anna Miles PhD is a full-time faculty member at The University of Auckland. Dr Miles is a researcher, lecturer and clinician in the area of swallowing and swallowing disorders. She is the New Zealand Speech-language Therapists’ Association Clinical Expert in Adult Dysphagia. a.miles@auckland.ac.nz

The Swallowing Research Laboratory at The University of Auckland, led by Dr Miles, strives to improve the lives of people with swallowing difficulties through improved assessment, treatment and medical education. The laboratory hopes to reduce the risks of pneumonia and death associated with swallowing difficulties as well as improve the quality of life of suffers.



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