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BackTable / ENT / Article
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in Pediatric Care: Equipment, Setup, & Clinical Outcomes
Olivia Reid • Updated Jun 7, 2024 • 56 hits
Fiberoptic endoscopic evaluation of swallowing (FEES) involves inserting a thin, flexible tube with a camera through the nose to examine and diagnose swallowing difficulties. The procedure has made significant strides in pediatric care, with advancements in equipment and improved clinical outcomes. Speech pathologist Olivia Brooks and Dr. Gopi Shah highlight the practical advantages of this emerging procedure, including financial savings, enhanced patient safety, and better adaptability for clinicians.
The increased adoption of FEES has led to reduced reliance on video swallow studies, lower labor costs, and decreased radiation exposure, resulting in savings of approximately $400-500 per procedure. Brooks emphasizes the importance of educating speech pathologists and building supportive communities to expand the use of FEES and improve patient outcomes.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• The evolution of FEES equipment, from compact setups to larger towers, highlights the need for ergonomic and space-efficient solutions, particularly in tight spaces like the NICU.
• Consistent protocols for table setup and feeding strategies are maintained across pediatric settings, with flexibility in choosing instrumental assessments based on individual patient needs. Therapeutic approaches are prioritized in the NICU before considering more invasive procedures like FEES due to the fragility of infants in the NICU.
• Enhanced awareness of neurodevelopmental care among nurses has been a positive outcome of implementing FEES, contributing to overall patient safety and care quality.
• Addressing potential complications such as nosebleeds and tachycardia, especially in cardiac ICU infants, is crucial for the successful application of FEES procedures.
Table of Contents
(1) Optimizing FEES Equipment & Setup for Pediatric Patients
(2) Advancing Pediatric Swallow Studies: Clinical Insights & Outcomes
Optimizing FEES Equipment & Setup for Pediatric Patients
The equipment used for FEES in pediatric settings has evolved in recent years from compact setups to larger towers, illustrating the importance of ergonomics and space considerations in equipment setup. In acute settings, such as the NICU, the challenges of equipment setup are heightened due to the increased machinery and staff needed for the support of the infant. Newer designs include carts that have been slimmed down for better maneuverability in these tighter spaces.
While there is consistency in the protocol for table setup and feeding strategies across pediatric settings, there is flexibility in choosing instrumental assessments based on patient history and needs, including both age and gestational considerations. Typically, a NICU baby is worked with therapeutically before considering a more invasive procedure like a FEES study because of the baby’s fragility.
[Dr. Gopi Shah]
Tell me about your equipment. When I think of a FEES, I usually think of a clinic and I think I see this big tower and we have our cameras and our lights and a big recording. It just seems so massive. Tell me the equipment that you take down there. Is it on a big cart or is it pretty easily transportable?
[Olivia Brooks SLP]
I guess this is a good point too for anybody who's interested in starting a program like this. We started with a grant from the Children's Miracle Network. That's what paid for the equipment. We started with just a C-Mac and a Schwartz-Pedes laryngoscope. That was very small and compact, I will say.
When I went to research, we had totally different equipment. We had an Olympus pistol grip scope and tower. That was very big and that was much harder to set up in the room. Again, the setup takes way longer often times than the actual study. We would have to do a lot of manipulating of monitors and IV poles and things like that to get it there, but we could make it work.
Recently, now that I'm back clinically, we've upgraded to the Telepak, which is on, I would say, it's in between those two towers that I've used. They are big and we roll them around, push them up. We have the nurses help us because, again, ergonomics are so important. I like to have it in a very specific spot whenever I'm the endoscopist. Something else that I might just be a little bit too picky about, but I like to have it in a specific spot, so we have to move some things around sometimes in the room. I'm waiting, and the stores actually reached out to me and have asked for some feedback on things they can do to help with FEES. I'm excited to do that, to just give my feedback on. That's one of the things that I would like for those companies to work on is making a little bit slimmer of a cart, especially for our acute care FEES.
[Dr. Gopi Shah]
Yes, those rooms already have so much stuff in there from all the monitors and carts. Wheeling something in, if it's not slim, it can be tight. Then you're trying to squeeze in, and you have a team of three of you. The ergonomics are so important because you need the best view. You don't have much time. To get that best view, the setup is key. That's why you're there, is to see what's going on, so I totally understand.
Tell me how this then translated to the NICU. This was a need in the CVICU. You got buy-in from the ENT, CVICU, RT, nursing. How did y'all then say, "Hey, you know what? There's a utility here for other babies. There are other inpatient babies, there are other young ones?” Those NICU babies are just as fragile. It could be the term baby that is only 10 days old and somehow had a brewie. Now we're seeing issues with their coughing and gurgling, but they went home after. That's the baby I always think about in terms of common consults that we get on the ENT side.
[Olivia Brooks SLP]
As goes the CVICU, so goes the NICU sometimes. Once we started doing it and I got my feet under me with it a little bit and we were getting good information and the babies were dealing with it just fine and we were progressing them and I got more confident in it, I was able to speak about it a little bit more eloquently when I would go down there. I think when you're just starting something, picking good patients for it is really important, setting yourself up for success. I didn't go down there with guns ablazing and I just want to FEES everybody, even though I might've felt that way because I was really excited about it. For speech pathologists, it's like the one procedure that we get to do. We do video fluoroscopy, but it is an interesting niche for us. Once I was up and running with it, I was really proud of it and I was excited, but I also had this thought in my brain with the NICU. NICU can be its own sort of world with its own sort of culture and a little bit more resistant to change, but I had this backing from the CVICU, which I think really helped me because that's such a skilled area too. To say, I've got data on 60 babies now that we've done these types of swallow exams. These are the benefits of it. This is the information I think I can get for us with it. Same thing. Will you let me try? Come watch, come see our safety plan and if you have any questions or if you want to add something or change something. Just being really open to hearing what they have to say, because it is different, I think helps.
I don't think we do as much in NI. I try to be very judicious with it as I think we all should. Same with video fluoroscopy because it's an invasive procedure. This is radiation. You have to really pick good patients and set yourself up for success and people just automatically buy in because it helps. It gives us good information and hopefully, we can save some patients from getting G-tubes. They don't like their very teeny tiny babies to be radiated and I don't blame them. I wouldn't either.
[Dr. Gopi Shah]
Are the protocols different at all between the NICU and the CVICU? I have a better picture in my mind of who might be the baby in the CVICU, a younger baby that had surgery. I get it. I see it. I know that baby. The NICU, you're right, it's a different culture. It's a different group of patients, all ages and stages to a certain extent. Sometimes we think, "Oh, the CVICU, they're all so sick because it's open heart," but the NICU, there's a big spectrum of complexity as well. What are those babies like, and is the protocol different?
[Olivia Brooks SLP]
The protocol is pretty much the same. I don't do any instrumental assessment of swallowing on a baby that's less than 37 weeks corrective gestation. I just think we need to work with them therapeutically. They're too young and immature to count too much against them. I think that they all aspirate a little bit. We need to practice with them, and we need to take it slow, and be cautious, and have a good feeding, a safe feeding plan. I don't jump directly to an instrumental assessment of swallowing. That is a little bit different than on the cardiac ICU where we have this very specific protocol that all these babies get instrumental assessments of swallowing per our cardiothoracic surgeons.
NICU is a different beast in that regard. It's not a one-stop shop, like these babies with this criteria get a FEES, these babies with this criteria get a videofluoroscopy. It just depends on the patient and what's going on with their history. There's a lot of GI issues happening in conjunction with learning how to feed and swallow in the NICU. That's a lot of our time. It's more of deciding, okay, this baby’s needs considering we've been working on it. They're now 38 weeks old. We're still seeing the same thing. They're not progressing. We need some more information. Okay. Which exam is going to give me that? How do we set them up for success with that? What strategies am I going to use during either one of those assessments to give me the best information so that we can make some decisions moving forward about oral feeding?
Overall, our protocol, so how we set up our table with the bottles and the nipples, or if we're doing a breastfeeding FEES, whatever, all of those things are the same, I would say. I don't really change that up very much. I like the way we do it.
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Advancing Pediatric Swallow Studies: Clinical Insights & Outcomes
FEES procedures can bring numerous advantages to pediatric care, and impact financial savings, patient safety, and clinician education. The increased use of FEES has significantly reduced the need for video swallow studies, labor costs, and radiation exposure. Each procedure saves an average of $400 to $500. Additionally, the implementation of FEES has enhanced nurses' awareness of neurodevelopmental care, contributing to improved patient safety beyond just the procedure itself.
To continue improving FEES procedure outcomes, it is essential to address and mitigate key complications such as tachycardia and nosebleeds, particularly in cardiac ICU infants on blood thinners. Ensuring patient stability and providing comprehensive education to speech pathologists through trust-building, adherence to legal requirements, and the establishment of supportive networks are pivotal steps as the procedure becomes more widespread across various practices.
[Dr. Gopi Shah]
Yes, for sure. Tell me about outcomes, meaning have y'all noticed a drop in percentage of video swallows for the inpatient infants, or have you found that, hey, there's a certain set of babies that actually benefit? These are the ones that you've been able to characterize which ones that benefit from both studies if you were to need it, or what have you found having done this now?
[Olivia Brooks SLP]
I presented on some of this data at the ESPO conference, the European Society of Pediatric Otolaryngology, this past year. I was looking at it more from a value-based care model. We found a reduction in time off units. There was a reduction in labor costs because you're not having to have respiratory and nursing and everybody, the radiologist, all of that come down to radiology. Definitely a reduction in video swallow studies and radiation exposure, barium ingestion.
We found an increase in awareness with our nurses in neurodevelopmental care, which was wonderful to see, and a decrease in cost. The cost analysis is actually interesting. In the inpatient world, it's a little tricky to look at, but I think we got a pretty good picture as far as the billing. We just took the billing codes that were for each exam. The average cost savings was like $400-500, which is not insignificant whenever you're looking at a hospital stay. That would be for one exam.
I think sometimes we leave any exam, whether it be a video swallow study or a FEES, with more questions than answers, and we might have to do some more work. That does happen, but generally, we're getting good information from the studies to where we can at least start some PO safely and get some practice going, even if it's small volumes or it's with some compensations or diet modifications. It's nice to have that option to reassess without being so stressed about spacing the time of those reassessments out because you're worried about radiation exposure. That's been really nice. Obviously, I'm not going to go every day and re-scope a baby, but even if it's a week after, that's better than the videofluoroscopy. Just having those more interval assessments and having the option to do both should we need them. We had a baby two weeks ago now where I did a FEES. He was in the NICU, and he was grossly aspirating. His airway looked beautiful, and I went to the neonatologist, and I was like, "I can tell you that this baby is grossly aspirating, but I cannot tell you why.” Neurodevelopmentally, he looked beautiful. Timing was beautiful. He had beautiful closure. I said, “Dr. Birchfield, I don't know. I'm just telling you that he's aspirating. Now, I want to do a videofluoroscopy.” I need to see the height of the swallow, which we get that right out during the FEES. He was gracious enough to let me, and the baby had a very large H-type TEF. I could have just gone to fluoro, I think, and found that, but the FEES made that case, I think, that we needed to keep digging because I couldn't figure it out just from the FEES. That's why I think they complement each other really well and how we can use both there.
[Dr. Gopi Shah]
Yes, and it sounds like from a complication standpoint, you have a robust safety protocol. An occasional nosebleed, which is usually scant in these infants. As ENTs, we scope all the time, and a little bit of bleeding happens. It's not common, and it's usually a very small amount in infants and NICU, CBIC babies. Are there any other complications or considerations that we need to have in mind?
[Olivia Brooks SLP]
I will just add as a caveat, on the cardiac ICU, a lot of those babies on blood thinners, and so they will bleed a little bit more.
[Dr. Gopi Shah]
Do you use Afrin or just see how things go?
[Olivia Brooks SLP]
I don't have access to that. Thankfully, the one that we did have, it was a pretty good nosebleed, but the baby recovered very quickly. That was very early on, and I think that had a little bit to do with my scoping, if I'm just being honest. I learned from that, poor baby. I've made adjustments, and that hasn't happened since. I am cautious of that, especially if the baby's on blood thinners, we keep a close eye on that.
I think the biggest other thing that I have seen is tachycardia. If they get very upset during the passing of the scope, or if you're going very slow during training or while you're learning, sometimes they can get very agitated. If they're very narrow and it might be a little bit painful, even though I'm just really trying to ride the floor as best I can, but you can tell it might be pinching or whatever. As with any procedure, their heart rate tends to go up, and with our cardiac infants, we just want to watch that very closely. I think, maybe twice, I know for sure once, I had a baby who became pretty tachycardic and wasn't calming quickly, and we were trying to do the pacifier sucks and give him a little sugar water. She just was so angry and she just wouldn't calm down. I ended up removing the scope and giving her a minute to calm down. Then we tried again, and on the other side, I got much quicker, and I think we were okay. That did happen.
This is why I think it's so important, too, to set yourself up for success and make sure that your baby is stable, because I can think of another time from a respiratory perspective, the baby, they weren't dropping their sets crazy, but they were desatting some with the scope in and trying to eat at the same time. Then I was thinking to myself, I think maybe they just really need that space to breathe and eat, and maybe a videofluoroscopy would be a better option. Maybe we can get some better information, because I felt like they were aspirating from poor respiratory reserve and drive, and I wanted to see their swallow with that unoccluded. That can be in my mind, too, sometimes.
Other than that, the babies are so resilient, and they're so strong, and they tolerate it very well, typically. They might fuss a little bit while I'm passing the scope, but then once we go in and you offer them food, they go to town, and their vitals stay fine, and we monitor that at close. I'm always impressed with them. They tolerate it better than my adults, often.
[Dr. Gopi Shah]
Cool. Olivia, as we start to round this out, I learned a ton. Thank you so much. Any final pearls or anything you want to leave our listeners with?
[Olivia Brooks SLP]
I think for any speech pathologists that might be listening, find your people. If you're interested in starting something like this, build some trust. Check your laws, too, because I think different laws have different states, and your institution might have different things that they want. I think, for example, up in Atlanta, if the child's less than three, ENT has to be there is my understanding. Just check on all of that. Build your community and have people around you that support you.
If you're an ENT listening, I would say, I hope that things like this help you guys in the long run, even though it's some work up front. I know I'm forever appreciative to the physicians that trusted me with this and guided me and mentored me and taught me. It's made me a better speech pathologist, so I'm forever grateful for that. That's what I would like to leave them with.
Podcast Contributors
Olivia Brooks, SLP
Olivia Brooks is a pediatric speech-language pathologist at UF Health in Gainesville, Florida.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, April 2). Ep. 165 – Implementing FEES for Infants in CVICU & NICU [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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